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CT of Acute Bowel Ischemia¹

¹ From the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115. Received September 17, 2001; revision requested November 15; revision received December 21; accepted January 22, 2002. Address correspondence to P.R.R. (e-mail: pros@partners.org).

View larger version (113K): [in a new window]   Figure 1. Unenhanced transverse CT scan shows mild thickening of descending colon (arrowheads). Note pronounced circumferential calcification of infrarenal abdominal aorta and inferior mesenteric artery at its origin (arrow).

View larger version (126K): [in a new window]   Figure 2. Contrast material-enhanced transverse CT scan shows subtotal thrombosis of superior mesenteric artery (arrowheads). Note small well-perfused residual lumen dorsolaterally (arrow) and well-perfused branch, which prevented acute mesenteric infarction in this case.

View larger version (123K): [in a new window]   Figure 3a. (a) Contrast-enhanced transverse CT scan shows several infarcted small-bowel loops (arrows), which manifest with dilatation and air-fluid levels but no wall thickening, due to transmural small-bowel necrosis. (b) Contrast-enhanced transverse CT scan shows large cholesterol embolus (arrows) in the superior mesenteric artery, confirmed at surgery, which caused acute mesenteric infarction.

View larger version (135K): [in a new window]   Figure 3b. (a) Contrast-enhanced transverse CT scan shows several infarcted small-bowel loops (arrows), which manifest with dilatation and air-fluid levels but no wall thickening, due to transmural small-bowel necrosis. (b) Contrast-enhanced transverse CT scan shows large cholesterol embolus (arrows) in the superior mesenteric artery, confirmed at surgery, which caused acute mesenteric infarction.

View larger version (117K): [in a new window]   Figure 4a. Unenhanced transverse CT scans show sigmoid colon infarction after aortic stent placement. (a) Stent can be seen in an infrarenal aortic aneurysm (arrows). The stent caused occlusion of the inferior mesenteric artery and subsequent ischemia of the sigmoid colon. (b) Note moderate wall thickening of sigmoid colon (arrows), which has undergone transmural infarction.

View larger version (128K): [in a new window]   Figure 4b. Unenhanced transverse CT scans show sigmoid colon infarction after aortic stent placement. (a) Stent can be seen in an infrarenal aortic aneurysm (arrows). The stent caused occlusion of the inferior mesenteric artery and subsequent ischemia of the sigmoid colon. (b) Note moderate wall thickening of sigmoid colon (arrows), which has undergone transmural infarction.

View larger version (138K): [in a new window]   Figure 5. Unenhanced transverse CT scan shows pneumatosis (arrowheads) along the left-sided colon, due to transmural colonic infarction. The patient had low cardiac output, but the wrong position of the intraaortic balloon (arrow), which occluded the inferior mesenteric artery at its origin, might have been the main reason for the critical underperfusion of the left side of the colon.

View larger version (105K): [in a new window]   Figure 6. Contrast-enhanced transverse CT scan shows segmental small-bowel with pronounced wall thickening (arrowheads) and mild periserosal haziness involving ileum and colon in a patient with generalized autoimmune vasculitis due to systemic lupus erythematosus.

View larger version (125K): [in a new window]   Figure 7. Contrast-enhanced transverse CT scan shows mesenteric venous infarction with massive small-bowel wall thickening (arrows), total absence of bowel wall enhancement, pronounced edema of mesenteric fat (arrowheads), and ascites () in a patient with polycythemia vera who developed multiple thromboses of distal and intramural mesenteric veins.

View larger version (141K): [in a new window]   Figure 8. Contrast-enhanced transverse CT scan shows ischemia of the ileum, with pronounced bowel wall thickening (arrows) and mesenteric fat stranding (arrowheads) in a patient with strangulated closed-loop obstruction. Note mural edema of strangulated bowel segment and mild perfusion of mucosal-submucosal and serosal-subserosal layers, causing a target sign.

View larger version (143K): [in a new window]   Figure 9. Contrast-enhanced transverse CT scan shows ischemia of several small-bowel loops, with mild thickening and diffuse hyperemia of bowel wall (arrows), as well as mesenteric fluid (arrowheads) adjacent to ischemic bowel segments, in a case of strangulated small-bowel herniation due to a congenital defect in the mesosigmoid.

View larger version (106K): [in a new window]   Figure 10. Unenhanced transverse CT scan shows parastomatal herniation of left-sided colon (large arrow) causing mechanical obstruction and prestenotic dilatation of right-sided colon. Massively distended right-sided colon shows mild (but on the basis of distention, abnormal) wall thickening (arrowheads), as well as pneumatosis (small arrows) due to ischemic colitis.

View larger version (124K): [in a new window]   Figure 11. Contrast-enhanced transverse CT scan shows mild homogeneous wall thickening (arrows) of the splenic flexure. The homogeneously hypoattenuating appearance is caused by pronounced mural edema.

View larger version (133K): [in a new window]   Figure 12. Contrast-enhanced transverse CT scan shows diffuse mild wall thickening and prolonged bowel wall enhancement (arrowheads) in several dilated small-bowel loops. Also present are mesenteric and peritoneal fluid (arrow) and ascites () in this patient with cardiac shock who was treated with a high dose of intravenous blood pressure drugs. At autopsy, diffuse mucosal and submucosal necrosis was revealed throughout the intestine, but no transmural bowel infarction was found.

View larger version (114K): [in a new window]   Figure 13. Unenhanced transverse CT scan shows mild wall thickening (small arrows) of left-sided colon, with mild paracolic fat stranding. Note much more pronounced bowel wall thickening (large arrows) and paracolic fat stranding along the right side of the colon, which, in addition to nontransmural ischemic bowel wall damage, also showed marked bacterial superinfection and subsequent inflammation.

View larger version (132K): [in a new window]   Figure 14. Contrast-enhanced transverse CT scan shows moderate thickening of ileum (arrows), as well as mild mesenteric fat stranding (arrowheads), representing acute radiation-induced enteritis. Patient had undergone radiation therapy to treat inoperable retroperitoneal metastasis (not shown) from colon cancer initially treated with right hemicolectomy.

View larger version (128K): [in a new window]   Figure 15. Unenhanced transverse CT scan shows pronounced homogeneous cecal wall thickening (arrows), representing transmural necrosis with superinfection in a patient with isolated cecal infarction.

View larger version (137K): [in a new window]   Figure 16. Unenhanced transverse CT scan shows pronounced circumferential thickening of rectal wall (arrows) and pararectal fat stranding (arrowheads) in a patient with nonocclusive ischemic proctitis, which is well depicted following rectal administration of contrast material and luminal distention.

View larger version (128K): [in a new window]   Figure 17. Contrast-enhanced transverse CT scan shows pronounced heterogeneous colonic wall thickening (arrows), as well as mild pericolic fat stranding along the splenic flexure due to diffuse intramural hemorrhage in a patient with nontransmural ischemic colitis with diffuse intramural hemorrhage.

View larger version (148K): [in a new window]   Figure 18. Unenhanced transverse CT scan in a patient with ischemic colitis of descending and sigmoid colon shows marked heterogeneous wall thickening of sigmoid colon (small arrows) and mucosal and submucosal hyperattenuation (large arrows) due to hemorrhage.

View larger version (137K): [in a new window]   Figure 19. Contrast-enhanced transverse CT scan in a patient with ischemic colitis shows hypoattenuating colonic wall thickening with enhancement of mucosa and submucosa and serosa and subserosa, causing a target sign (arrows). Despite absence of transmural infarction, mild pericolic streakiness and fluid are present along the anterior pararenal and lateroconal fasciae (arrowheads).

View larger version (122K): [in a new window]   Figure 20. Contrast-enhanced transverse CT scan in a patient with occlusive transmural colonic infarction shows widely dilated colon with (based on the degree of distention) mildly thickened colonic wall, mesenteric gas, and mixed bubblelike (arrowheads) and bandlike (arrows) pneumatosis.

View larger version (130K): [in a new window]   Figure 21. Unenhanced transverse CT scan in a patient with embolic transmural small-bowel infarction shows massive circumferential and bandlike pneumatosis (arrows) of multiple necrotic loops and pronounced edema () of mesenteric fat.

View larger version (131K): [in a new window]   Figure 22. Unenhanced transverse CT scan in a patient with embolic transmural small-bowel infarction shows collection of mesenteric venous gas (arrows) in a branch of the superior mesenteric vein. The infarcted small bowel was dilated without wall thickening.

View larger version (100K): [in a new window]   Figure 23. Contrast-enhanced transverse CT scan in a patient with embolic transmural small-bowel infarction shows mesenteric venous gas with an air-contrast material level in the superior mesenteric vein (arrow). The infarcted small bowel shows minimal pneumatosis (arrowhead) but no wall thickening.

View larger version (147K): [in a new window]   Figure 24. Contrast-enhanced transverse CT scan in a patient with acute transmural mesenteric infarction shows pronounced intrahepatic portal venous gas (branching hypoattenuating areas) extending into the periphery of both liver lobes.

View larger version (153K): [in a new window]   Figure 25a. Contrast-enhanced multi-detector row CT scans (coronal reconstructions) in a patient with nonocclusive ischemic colitis of descending colon nicely show (a) mesenteric vessels (arrows), which proved to be normal, and (b) thickened descending colon (arrowheads).

View larger version (150K): [in a new window]   Figure 25b. Contrast-enhanced multi-detector row CT scans (coronal reconstructions) in a patient with nonocclusive ischemic colitis of descending colon nicely show (a) mesenteric vessels (arrows), which proved to be normal, and (b) thickened descending colon (arrowheads).