Transmural Bowel Necrosis From Acute Mesenteric Ischemia and Strangulated Small-Bowel Obstruction: Distinctive CT Features

Background: Acute arterial occlusive mesenteric ischemia with transmural intestinal necrosis (TIN) is a fatal disease, which is difficult to diagnose on multidetector computed tomography (MDCT). The aim of the present study was to determine the relationship of superior mesenteric artery (SMA) thrombus density with TIN on MDCT in patients with acute mesenteric ischemia (AMI) due to SMA thromboembolism.Methods: In this retrospective study, 33 patients who underwent abdominal MDCT and angiography for AMI due to SMA thromboembolism were divided into two groups: the AMI with TIN group and the AMI without TIN group. We analyzed the relationships of clinical characteristics, qualitative MDCT signs, and SMA thrombus density with TIN. The SMA thrombus density was measured on non-contrast MDCT.Univariate and multivariate analyses were performed to determine the risk factors for predicting TIN. The diagnostic performances of risk factors were evaluated by receiver-operating characteristic (ROC) curve analysis.Results: Of the patients with AMI enrolled in this study, 33.3% (11/33) were diagnosed with TIN. Peritonitis (P=0.042), bowel wall thinning (P=0.033), and pneumatosis/portomesenteric gas (P=0.010) were significantly associated with TIN. AMI patients with TIN exhibited a higher SMA thrombus density than AMI patients without TIN [41.2±6.1 vs. 34.2±3.0 Hounsfield unit (HU), P=0.003]. Multivariate analysis showed that SMA thrombus density was an independent predictor of TIN [P=0.044, hazard ratio (HR): 1.82, 95% confidence interval (CI): 1.02-3.25]. For diagnosing AMI with TIN, the area under the ROC curve (AUC) of SMA thrombus density (0.83) was larger than those of peritonitis (0.68), bowel wall thinning (0.66), and pneumatosis/portomesenteric gas (0.71).Conclusions: In patients with AMI, erythrocyte-rich thrombus blocking the SMA trunk which has a higher density on MDCT is prone to the occurrence of TIN compared with erythrocyte-scarce thrombus with a lower density. SMA thrombus density could be an independent risk factor for TIN in patients with AMI due to SMA thromboembolism.

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“…Previous studies have indicated that some MDCT signs are associated with intestinal necrosis in patients with AMI (12,21,22 (23).…”

Section: Discussionmentioning

confidence: 99%

Relationship of superior mesenteric artery thrombus density with transmural intestinal necrosis on multidetector computed tomography in acute mesenteric ischemia

Tang¹,

Zhang²,

Kuang³

et al. 2021

Quant Imaging Med Surg

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“…Our patient presented three years after his initial surgery decreasing the likelihood of these complications being the cause of his symptoms. For transmural bowel necrosis, the risk factors in our patient are embolic acute mesenteric ischemia from chronic AF and small-bowel obstruction from previous CRS and HIPEC [ 9 ].…”

Section: Discussionmentioning

confidence: 99%

“…In the setting of acute abdomen, leukocytosis, electrolyte derangements, and lactic acidosis may be suggestive of many causes, including sepsis, bowel ischemia, or perforation [ 13 ]. Furthermore, imaging studies like abdominal X-ray series are quick, low-cost, and 50%-70% sensitive in identifying even small amounts of pneumoperitoneum and small and large bowel obstructions [ 9 ]. However, CT scans of the abdomen and pelvis are the most sensitive and specific tests to diagnose a perforation and ascertain the most likely etiology.…”

Section: Discussionmentioning

confidence: 99%

Role of Imaging Studies in Evaluating Patients Post Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Fayed¹,

Angappan²,

Oyibo³

et al. 2021

Cureus

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A 77-year-old male presented to the ED with a new onset of acute abdominal pain, nausea, and vomiting. He had a previous surgical history of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for an appendiceal tumor. Despite the repeated reassuring abdominal examinations, CT abdomen showed high-grade bowel obstruction and perforation. He was urgently taken to the operating room and underwent resection of 70 cm segment of small ischemic bowel with primary anastomosis. His postoperative course was complicated with atrial fibrillation (AF) requiring cardioversion and medical therapy. Later, he was discharged home under stable conditions. Relying on abdominal signs, an abdominal exam in a patient with a previous history of extensive peritonectomy and post-HIPEC surgery is challenging due to the altered peritoneal anatomy. As a result, the abdominal examination findings can be benign and misleading. This can lead to delayed surgical intervention, thereby increasing morbidity and mortality significantly. Therefore, a detailed evaluation with a low threshold for abdominal imaging studies like abdominal X-rays and CT abdomen series is warranted in this subset of patients.

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“…The absence of intestinal necrosis and securing sufficient operating space are prerequisites for laparoscopic surgery. Various approaches such as computed tomography 11 and scoring using clinical, laboratory, and radiological parameters, [12][13][14] have been evaluated for their utility in determining the presence of intestinal necrosis prior to surgery. Advanced studies have attempted to use magnetic resonance imaging 15,16 to measure intestinal fatty acid-binding protein.…”

Section: Analysis Of Risk Factors For Laparotomymentioning

confidence: 99%

Age, blood urea nitrogen, and lactate: Preoperative risk factors of laparotomy for strangulated small bowel obstruction

Hayakawa

Uehara

et al. 2021

Asian J Endoscop Surgery

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Introduction: Despite increasing reports of laparoscopy for strangulated small bowel obstruction (SSBO), there is no consensus on outcomes in patients with SSBO. We evaluated the safety and utility of laparoscopy for SSBO and investigated the preoperative risk factors for laparotomy. Methods: This retrospective study included 107 patients who underwent emergency surgery for SSBO over a period of 6 years. Patients' characteristics and surgical parameters were compared between 27 patients undergoing laparoscopy alone (group L) and 80 patients undergoing laparotomy (group O, including conversion). Univariate and multivariate analyses were performed to determine risk factors for laparotomy.Results: Compared with group L, group O had significantly shorter operation time (59 vs 115 minutes, P < .001), shorter postoperative hospital stay (6 vs 10 days, P < .001), and fewer complications (3 vs 40 cases, P < .001). Age ≥ 68 years (odds ratio [OR] 3.970, P = .021), blood urea nitrogen (BUN) ≥ 14.6 mg/dL (OR 4.360, P = .012), and lactate ≥2.80 mmol/L (OR 12.90, P = .023) were independent risk factors for laparotomy. Conclusion: Prognosis was better in patients with SSBO undergoing complete laparoscopy than in patients undergoing laparotomy; however, age, BUN, and lactate were independent preoperative risk factors for laparotomy.

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Transmural Bowel Necrosis From Acute Mesenteric Ischemia and Strangulated Small-Bowel Obstruction: Distinctive CT Features

Cited by 36 publications

References 27 publications

Relationship of superior mesenteric artery thrombus density with transmural intestinal necrosis on multidetector computed tomography in acute mesenteric ischemia

Relationship of superior mesenteric artery thrombus density with transmural intestinal necrosis on multidetector computed tomography in acute mesenteric ischemia

Role of Imaging Studies in Evaluating Patients Post Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Age, blood urea nitrogen, and lactate: Preoperative risk factors of laparotomy for strangulated small bowel obstruction

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