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Helical CT Signs in the Diagnosis of Intestinal Ischemia in Small-Bowel Obstruction

¹ Department of Radiology, C. U. B. Hôpital Erasme, 808, Route de Lennik, 1070 Bruxelles, Belgium.
² Department of Gastrointestinal Surgery, C. U. B. Hôpital Erasme, 1070 Bruxelles, Belgium.

View larger version (141K): [in a new window]   Fig. 1A. —50-year-old woman with strangulating small-bowel obstruction and infarction. Contrast-enhanced CT scan shows dilated and fluid-filled bowel loops in right flank (i). Small amount of fluid is present in mesentery (m).

View larger version (126K): [in a new window]   Fig. 1B. —50-year-old woman with strangulating small-bowel obstruction and infarction. Contrast-enhanced CT scan slightly more caudal reveals that wall of ischemic dilated loops is not clearly visible (white arrowheads), and proximal collapsed loops enhance normally (black arrowheads). Patient underwent surgery 24 hr later; she had complete volvulus of distal meter of small bowel caused by tight adhesive band. One meter of necrotic small bowel was resected.

View larger version (143K): [in a new window]   Fig. 2A. —54-year-old man with history of appendectomy, aortic surgery, and previous laparotomy for adhesive bands. Unenhanced CT scan shows dilated and fluid-filled jejunal loops (j). Veins in adjacent mesentery are enlarged (arrowheads).

View larger version (135K): [in a new window]   Fig. 2B. —54-year-old man with history of appendectomy, aortic surgery, and previous laparotomy for adhesive bands. Unenhanced CT scan reveals fluid in mesentery around congested veins (m). Note pseudothickening of bowel wall (arrowheads) caused by transverse scanning of Kerckring's folds. Gas bubbles in intestinal lumen (arrow) must not be confused with pneumatosis. Also note large amount of fluid in pelvis. Patient, who was immediately treated by nasogastric suction and fully recovered without surgery, was one of nine false-positive cases in our series.

View larger version (143K): [in a new window]   Fig. 3. —85-year-old woman with reversible ischemia. Contrast-enhanced CT scan shows signs of mechanical obstruction of small bowel with dilated and fluid-filled loops in left fossa iliaca (i). Note fluid in mesentery (m) and congestion of small mesenteric veins (arrowheads). Wall of segment of small bowel is barely visible (arrows). Small gas bubble is present in unenhanced loop. Patient underwent surgery same day and had surgical evidence of ischemic bowel due to secondary volvulus. After devolvulation, ischemic bowel regained normal coloration and resection was not necessary. Patient left hospital 7 days after admission.

View larger version (116K): [in a new window]   Fig. 4A. —67-year-old woman with thrombosis of superior mesenteric vein who presented with clinical signs of intestinal obstruction. Contrast-enhanced CT scan reveals thrombus (arrowhead) in superior mesenteric vein. Second portion of duodenum (d) and proximal jejunum (i) are dilated and fluid-filled.

View larger version (117K): [in a new window]   Fig. 4B. —67-year-old woman with thrombosis of superior mesenteric vein who presented with clinical signs of intestinal obstruction. Contrast-enhanced CT scan more caudal shows absence of enhancement (white arrowheads) of dilated jejunal loop, and more proximal loop enhances normally (black arrowheads). Note that nonenhancing loop has no evidence of wall thickening.

View larger version (98K): [in a new window]   Fig. 4C. —67-year-old woman with thrombosis of superior mesenteric vein who presented with clinical signs of intestinal obstruction. Contrast-enhanced CT scan more caudal than B. Jejunal loops have thickened wall with reduced enhancement (arrowheads). Mesentery (m) is hazy. Patient was treated medically with anticoagulant therapy and had uneventful evolution. Months later she developed fibrotic stricture but did not undergo surgery.

View larger version (136K): [in a new window]   Fig. 5A. —65-year-old man with history of allergy to iodine contrast agent. Unenhanced CT scan shows dilated and fluid-filled small-bowel loops (i) occupying left flank. Mesentery (m) is hazy because of presence of triangular-shaped fluid adjacent to dilated loops.

View larger version (148K): [in a new window]   Fig. 5B. —65-year-old man with history of allergy to iodine contrast agent. Unenhanced CT scan 3 cm more cephalad than A reveals presence of congested mesenteric veins (arrowheads). Surgery performed 6 hr later confirmed diagnosis of strangulation. It was caused by internal hernia, and 1.20 m of necrotic bowel was resected.

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