Intestinal ischemia (summary)

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This is a basic article for medical students and other non-radiologists

Intestinal ischemia refers to vascular compromise of the bowel which in the acute setting has a very high mortality if not treated expediently. Diagnosis is often straight forward provided appropriate imaging is obtained. The disease can be arbitrarily classified into broad groups according to the time of onset, or the portion of bowel involved or the underlying cause.

Reference article

This is a summary article; read more in our article on intestinal ischemia.

Summary

  • epidemiology
    • conditions that predispose to ischemia
    • tends to be more likely in older populations
  • presentation
    • variable, but often with pain and distension
    • acute symptom onset might point towards arterial occlusion
  • pathophysiology
    • anything that results in reduced blood flow and metabolites to the bowel
      • general hypotension, hypoxemia or sepsis
      • arterial occlusion (SMA, IMA)
      • bowel obstruction
      • venous outflow obstruction (SMV)
  • investigation
    • CT angiography it the test of choice
    • CTA requires rapid contrast infusion and therefore, an appropriate cannula
  • treatment
    • first line treatment is often resuscitation
    • depends on the cause of ischemia and its severity
    • necrotic bowel needs to be resected

Role of imaging

  • look for evidence of ischemia
  • look at the blood supply - arterial and venous
  • assess of any complication, e.g. perforation
  • look for any other cause of symptoms

Radiographic features

CT has replaced catheter angiography as the gold standard for assessment for intestinal ischemia. It allows assessment of the whole abdomen in multiple vascular phases, e.g. arterial, portal venous, delayed. It also has the added advantage of being able to diagnose alternative causes of acute abdominal pain.

CT

Imaging features can vary depending on the time course and etiology. A number of features are common to most advanced acute cases and result from the bowel wall necrosis and perforation:

The bowel wall is not always thickened - in fact, it may be thinned where there is complete arterial occlusion or bowel obstruction.

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