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Garzelli L, Dufay R, Tual A, Corcos O, Cazals-Hatem D, Vilgrain V, Nuzzo A, Ben Abdallah I, Ronot M. Predictors of Survival Without Intestinal Resection after First-Line Endovascular Revascularization in Patients with Acute Arterial Mesenteric Ischemia. Radiology 2024; 311:e230830. [PMID: 38860892 DOI: 10.1148/radiol.230830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Background Acute arterial mesenteric ischemia requires emergency treatment and is associated with high mortality rate and poor quality of life. Identifying factors associated with survival without intestinal resection (hereafter, intestinal resection-free [IRF] survival) could help in treatment decision-making after first-line endovascular revascularization. Purpose To identify factors associated with 30-day IRF survival in patients with acute arterial mesenteric ischemia whose first-line treatment was endovascular revascularization. Materials and Methods Patients with acute arterial mesenteric ischemia whose first-line treatment was endovascular revascularization because of a low probability of bowel necrosis were included in this single-center retrospective cohort (May 2014 to August 2022). Patient demographics, laboratory values, clinical characteristics at admission, CT scans, angiograms, and endovascular revascularization-related variables were included. The primary end point was 30-day IRF survival, and secondary end points were 3-month, 1-year, and 3-year overall survival. Factors independently associated with 30-day IRF survival were identified with binary logistic regression. Results A total of 117 patients (median age, 70 years [IQR, 60-77]; 53 female, 64 male) were included. Within 30 days after revascularization, 73 of 117 patients (62%) survived without resection, 28 of 117 (24%) survived after resection, 14 of 117 (12%) died without resection, and two of 117 (2%) underwent resection but died. The 30-day IRF survival was 63% (74 of 117). The 3-month, 1-year, and 3-year mortality rate was 18% (21 of 117), 21% (25 of 117), and 27% (32 of 117), respectively. Independent predictors of 30-day IRF survival were persistent bowel enhancement at initial CT (odds ratio [OR], 0.3; 95% CI: 0.2, 0.8; P = .013) and C-reactive protein (CRP) level less than 100 mg/L (OR, 0.3; 95% CI: 0.1, 0.8; P = .002). The 30-day IRF survival was 86%, 61%, 47%, and 23% in patients with both favorable features, persistent bowel enhancement but CRP level greater than 100 mg/L, no bowel enhancement but CRP level less than 100 mg/L, and both unfavorable features, respectively. Conclusion Independent predictors associated with 30-day IRF survival in patients with acute arterial mesenteric ischemia whose first-line treatment was endovascular revascularization were persistent bowel wall enhancement at initial CT and CRP level less than 100 mg/L. © RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Lorenzo Garzelli
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Raphael Dufay
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Arnaud Tual
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Olivier Corcos
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Dominique Cazals-Hatem
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Valérie Vilgrain
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Alexandre Nuzzo
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Iannis Ben Abdallah
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Maxime Ronot
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
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Garzelli L, Felli E, Al-Taher M, Barberio M, Agnus V, Plaforet V, Bonvalet F, Baiocchini A, Nuzzo A, Paulatto L, Vilgrain V, Gallix B, Diana M, Ronot M. MRI for the Detection of Small Bowel Ischemic Injury in Arterial Acute Mesenteric Ischemia: Preclinical Study in a Porcine Model. J Magn Reson Imaging 2023; 57:918-927. [PMID: 35852296 DOI: 10.1002/jmri.28344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND MRI is the reference for the diagnosis of arterial cerebral ischemia, but its role in acute mesenteric ischemia (AMI) is poorly known. PURPOSE To assess MRI detection of early ischemic bowel lesions in a porcine model of arterial AMI. STUDY TYPE Prospective/cohort. ANIMAL MODEL Porcine model of arterial AMI obtained by embolization of the superior mesenteric artery (seven pigs). FIELD STRENGTH/SEQUENCE A 5-T. T1 gradient-echo-weighted-imaging (WI), half-Fourier-acquisition-single-shot-turbo-spin-echo, T2 turbo-spin-echo, true-fast-imaging-with-steady-precession (True-FISP), diffusion-weighted-echo-planar (DWI). ASSESSMENT T1-WI, T2-WI, and DWI were performed before and continuously after embolization for 6 hours. The signal intensity (SI) of the ischemic bowel was assessed visually and quantitatively on all sequences. The apparent diffusion coefficient (ADC) was assessed. STATISTICAL TESTS Paired Student's t-test or Mann-Whitney U-test, significance at P < 0.05. RESULTS One pig died from non-AMI-related causes. The remaining pigs underwent a median 5 h53 (range 1 h24-6 h01) of ischemia. Visually, the ischemic bowel showed signal hyperintensity on DWI-b800 after a median 85 (57-276) minutes compared to the nonischemic bowel. DWI-b800 SI significantly increased after 2 hours (+19%) and the ADC significant decrease within the first hour (-31%). The ischemic bowel was hyperintense on precontrast T1-WI after a median 87 (70-171) minutes with no significant quantitative changes over time (P = 0.46-0.93). The ischemic bowel was hyperintense on T2-WI in three pigs with a significant SI increase on True-FISP after 1 and 2 hours. DATA CONCLUSION Changes in SI and ADC can be seen early after the onset of arterial AMI with DWI. The value of T2-WI appears to be limited. EVIDENCE LEVEL 1 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Lorenzo Garzelli
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France.,IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Eric Felli
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France.,Hepatology, Department of Biomedical Research, Inselspital, University of Bern, Bern, Switzerland
| | - Mahdi Al-Taher
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Manuel Barberio
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Vincent Agnus
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Vincent Plaforet
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Fanny Bonvalet
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Andrea Baiocchini
- Department of Pathology, San Camillo Forlanini Hospital, Rome, Italy
| | - Alexandre Nuzzo
- Université Paris Cité, Paris, France & Structure d'Urgence Vasculaire Intestinales (SURVI), Nutritional support, Gastroenterology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Luisa Paulatto
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Valérie Vilgrain
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Benoit Gallix
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Michele Diana
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France.,IRCAD, Research Institute against Digestive Cancer, Strasbourg, France.,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, France.,ICube Lab, Photonics for Health, Strasbourg, France
| | - Maxime Ronot
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
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Tateno K, Motegi Y, Ogawa H, Suga K, Okada T, Osone K, Katoh R, Ubukata Y, Saito H, Hara K, Sakai M, Ogata K, Sohda M, Murakami C, Shirabe K, Saeki H. Gangrenous ischemic colitis localized to the cecum: a case report. Surg Case Rep 2023; 9:9. [PMID: 36689043 PMCID: PMC9871088 DOI: 10.1186/s40792-023-01587-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 01/06/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Ischemic colitis affects the left colon in elderly individuals and localization on the right side, especially in the cecum, is rare. We report a case of gangrenous ischemic colitis localized in the cecum of a patient undergoing hemodialysis. CASE PRESENTATION A 73-year-old man had been undergoing hemodialysis for chronic renal failure caused by diabetic nephropathy. He experienced frequent vomiting, diarrhea, and abdominal pain. Contrast-enhanced computed tomography revealed thickening of the cecal wall, poor enhancement, dilation of the cecum, and intrahepatic portal emphysema. No obvious abnormal findings were observed in the appendix. The patient was diagnosed with cecal necrosis and ileocecal resection was performed. Histopathological examination revealed gangrenous ischemic colitis of the cecum. He was discharged 12 days after surgery without postoperative complications. CONCLUSION It is important to consider the possibility of ischemic colitis of the right colon in the event of renal failure requiring dialysis, to ensure that opportunities for surgical intervention are not missed.
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Affiliation(s)
- Kohei Tateno
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Yoko Motegi
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Hiroomi Ogawa
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Kunihiko Suga
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Takuhisa Okada
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Katsuya Osone
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Ryuji Katoh
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Yasunari Ubukata
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Hideyuki Saito
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Keigo Hara
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Makoto Sakai
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Kyoichi Ogata
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Makoto Sohda
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Chiaki Murakami
- grid.256642.10000 0000 9269 4097Department of Human Pathology, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Ken Shirabe
- grid.256642.10000 0000 9269 4097Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
| | - Hiroshi Saeki
- grid.256642.10000 0000 9269 4097Division of Gastroenterological Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan
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Chou CK. CT manifestations of small bowel ischemia due to impaired venous drainage-with a correlation of pathologic findings. Indian J Radiol Imaging 2021; 26:342-351. [PMID: 27857460 PMCID: PMC5036332 DOI: 10.4103/0971-3026.190426] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute abdominal pain may result from a wide variety of medical and surgical diseases. One of these diseases is small bowel ischemia, which may result in a catastrophic outcome if not recognized and treated promptly. Computed tomography (CT) by its faster image acquisition, thinner collimation, high resolution, and multiplanar reformatted images has become the most important imaging modality in evaluating the acute abdominal conditions. In this article, the author presents a description of the histology of the small bowel, pathophysiology of small bowel change, and a correlation of the pathologic and CT findings of the small bowel injuries due to impaired venous drainage. A convincing correlation of the microscopic mucosal condition with the enhancement pattern of the thickened small bowel wall on CT is useful in definitely describing the mucosal viability.
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Affiliation(s)
- Chung Kuao Chou
- Department of Radiology, Yuan's General Hospital, Kaohsiung, Taiwan, Republic of China
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Ding J, Zhang W, Wang L, Zhu Z, Wang J, Ma J. Idiopathic mesenteric phlebosclerosis: clinical and CT imaging characteristics. Quant Imaging Med Surg 2021; 11:763-771. [PMID: 33532275 DOI: 10.21037/qims-20-301] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background The aim of our study was to evaluate the clinical characteristics and computed tomography (CT) imaging findings of idiopathic mesenteric phlebosclerosis (IMP). Methods From January 2013 to May 2019, the clinical data of 10 patients diagnosed with IMP were analyzed retrospectively. Computed tomography angiography (CTA) and colonoscopy were performed in all 10 patients. All CT imaging findings were evaluated by three radiologists, including the form and distribution of calcification, the bowel's thickness, and the surrounding fat gap. The calcification score was calculated according to the extent of the involved mesenteric veins. The colonic wall thickness was defined as the average value of the thickest and thinnest regions of the intestinal wall. The correlation between the calcification scores and the colonic wall thickness was analyzed using Spearman's correlation analysis. Results All 10 patients were male with an average age of 59.6 years (range, 51-83 years). The average smoking index was 712 (range, 0-1,800). Among them, 7 patients had a history of long-term excessive daily intake of medicinal liquor or Chinese herbal medicine. Clinical symptoms of abdominal pain, diarrhea, bloating, and nausea were found. Colonoscopy showed dark purple discolorations of the edematous mucosa, engorged blood vessels, extensive erosion, ulceration, and multi-focal nodular surface in all patients. CT demonstrated colonic wall thickening, calcification along the mesenteric vein, and blurry surrounding fat gap in all 10 patients. Mesenteric venous calcification involved the terminal ileum, the ascending and transverse colon in all patients, and the descending colon and sigmoid colon's involvement in two patients. A total of 33 segments of the intestinal wall were involved. The median calcification score was 6 points, the mean thickness of the colonic wall was 10.73±3.22 mm, and there was no significant correlation (P=0.782) between calcification score and thickness of the colonic wall. Conclusions The main features of IMP are mesenteric venous calcification, colonic wall thickness, and pericolic fat stranding, and there is no correlation between calcification score and colonic wall thickness. Therefore, CT imaging combined with colonoscopy can improve the diagnostic accuracy of IMP.
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Affiliation(s)
- Jian Ding
- Department of Radiology, the First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Weiqiang Zhang
- Department of Radiology, the First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Lizhang Wang
- Department of Radiology, the First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Zefeng Zhu
- Department of Radiology, the First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Jia Wang
- Department of Radiology, the First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Jianbing Ma
- Department of Radiology, the First Hospital of Jiaxing, The Affiliated Hospital of Jiaxing University, Jiaxing, China
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6
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Mothes H, Mueller-Mau V, Lehmkuhl L, Lehmann T, Settmacher U, Teichgräber U, Ludewig S. The role of computed tomography in the diagnostic pathway of acute mesenteric ischemia: a nested case-control study. Acta Radiol 2020; 61:1444-1451. [PMID: 32077303 DOI: 10.1177/0284185120905086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Computed tomography (CT) can be used as the primary screening modality for the evaluation of patients suspected of having acute mesenteric ischemia known to show high sensitivity and specificity rates. PURPOSE To prove the value of CT in patients with pathological abdominal findings following cardiac surgery. MATERIAL AND METHODS In a retrospective case-control study, 12 different CT scan parameters of patients with or without mesenteric ischemia following cardiac surgery were compared using univariate and logistic regression analyses. RESULTS Of 14,176 patients, 133 (0.9%) received an abdominal CT scan during postoperative care due to pathological abdominal findings. Sixty-eight patients were diagnosed with acute mesenteric ischemia. In-hospital mortality was 73.5% for this group. CT parameters with the highest specificity for indicating colonic ischemia were intestinal (99%) or porto-venous (96%) pneumatosis, abnormal contrast medium enhancement (89%), and occlusion of the proximal inferior mesenteric artery (81%). All of those parameters showed low sensitivity levels in the range of 15%-23%. A statistically significant association between acute mesenteric ischemia and CT appearance was obtained for contrast medium enhancement (odds ratio [OR] 12.2, 95% confidence interval [CI] 1.5-99.2) and intestinal pneumatosis (OR 21.0, 95% CI 2.7-165.2) only. CONCLUSION The typical CT criteria indicating mesenteric ischemia lose their accuracy in patients under critical clinical conditions. As CT remains the first-line diagnostic imaging modality for abnormal abdominal findings following cardiac surgery, negative signs should not prevent early laparotomy if clinical suspicion remains high.
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Affiliation(s)
- Henning Mothes
- Department of General, Visceral and Vascular Surgery, Sophien- und Hufeland-Klinikum, Weimar, Germany
| | - Vetlana Mueller-Mau
- Department of General, Visceral and Vascular Surgery, Robert-Koch-Krankenhaus, Apolda, Germany
| | - Lukas Lehmkuhl
- Rhön-Klinikum Campus Bad-Neustadt, Department of Diagnostic Radiology, Bad Neustadt, Germany
| | - Thomas Lehmann
- Institute of Medical Statistics, Informatics and Documentation, University Hospital, Jena, Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Ulf Teichgräber
- Department of Diagnostic and Interventional Radiology, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Stefan Ludewig
- Department of General, Visceral and Vascular Surgery, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
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Abstract
OBJECTIVE. The purpose of this article is to provide an overview of the diagnostic and prognostic roles of CT in the management of acute mesenteric ischemia. CONCLUSION. Acute mesenteric ischemia is defined as inadequate blood supply to the gastrointestinal tract resulting in ischemic and inflammatory injury. The prognosis is poor without treatment. Contrast-enhanced CT has become the cornerstone of diagnosis to identify features of vascular disorders and of intestinal ischemic injury and to visualize bowel necrosis.
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Yeh CM, Chou CM. Transmural gangrene of stomach caused by isolated left gastric artery thrombosis. Asian J Surg 2020; 43:517-518. [PMID: 32059942 DOI: 10.1016/j.asjsur.2019.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 11/27/2022] Open
Affiliation(s)
- Chou-Ming Yeh
- Taichung Hospital, Ministry of Health and Welfare, Executive Yuan, Taichung, Taiwan, ROC; Department of Healthcare, Central Taiwan University of Science and Technology, Taichung, Taiwan, ROC
| | - Chia-Man Chou
- Division of Pediatric Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC; National Yang-Ming University, Taipei, Taiwan, ROC.
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Shieh AC, Guler E, Tirumani SH, Dumot J, Ramaiya NH. Clinical, imaging, endoscopic findings, and management of patients with CMV colitis: a single-institute experience. Emerg Radiol 2020; 27:277-284. [DOI: 10.1007/s10140-020-01750-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 01/03/2020] [Indexed: 12/12/2022]
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10
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Copin P, Zins M, Nuzzo A, Purcell Y, Beranger-Gibert S, Maggiori L, Corcos O, Vilgrain V, Ronot M. Acute mesenteric ischemia: A critical role for the radiologist. Diagn Interv Imaging 2018; 99:123-134. [DOI: 10.1016/j.diii.2018.01.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 12/13/2022]
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Zekria D, Boavida P. Paroxysmal nocturnal haemoglobinuria (PNH) manifesting on CT as a pathologic segment of small bowel. Radiol Case Rep 2017; 12:706-709. [PMID: 29484054 PMCID: PMC5823304 DOI: 10.1016/j.radcr.2017.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/09/2017] [Indexed: 10/25/2022] Open
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12
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Yang XY, Wei MT, Jin CW, Wang M, Wang ZQ. Unenhanced Computed Tomography to Visualize Hollow Viscera and/or Mesenteric Injury After Blunt Abdominal Trauma: A Single-Institution Experience. Medicine (Baltimore) 2016; 95:e2884. [PMID: 26945375 PMCID: PMC4782859 DOI: 10.1097/md.0000000000002884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
To identify and describe the major features of unenhanced computed tomography (CT) images of blunt hollow viscera and/or mesenteric injury (BHVI/MI) and to determine the value of unenhanced CT in the diagnosis of BHVI/MI. This retrospective study included 151 patients who underwent unenhanced CT before laparotomy for blunt abdominal trauma between January 2011 and December 2013. According to surgical observations, patients were classified as having BHVI/MI (n = 73) or not (n = 78). Sensitivity, specificity, P values, and likelihood ratios were calculated by comparing CT findings between the 2 groups. Six significant CT findings (P < 0.05) for BHVI/MI were identified and their sensitivity and specificity values determined, as follows: bowel wall thickening (39.7%, 96.2%), mesentery thickening (46.6%, 88.5%), mesenteric fat infiltration (12.3%, 98.7%), peritoneal fat infiltration (31.5%, 87.1%), parietal peritoneum thickening (30.1%, 85.9%), and intra- or retro-peritoneal air (34.2%, 96.2%). Unenhanced CT scan was useful as an initial assessment tool for BHVI/MI after blunt abdominal trauma. Six key features on CT were correlated with BHVI/MI.
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Affiliation(s)
- Xu-Yang Yang
- From the Department of Gastrointestinal Surgery, West China Hospital, Sichuan University (X-YY, M-TW, MW, Z-QW) and Department of Gastrointestinal Surgery, The Fifth People's Hospital of Chengdu (C-WJ), Chengdu, Sichuan, China
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13
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Cruz C, Abujudeh HH, Nazarian RM, Thrall JH. Ischemic colitis: spectrum of CT findings, sites of involvement and severity. Emerg Radiol 2015; 22:357-65. [PMID: 25732355 DOI: 10.1007/s10140-015-1304-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 02/13/2015] [Indexed: 02/06/2023]
Abstract
To summarize the frequency of findings on IV contrast, enhanced computer tomography (CT) in 335 patients with pathologically proven ischemic colitis (IC) determine the most frequent locations and patterns of involvement and establish the correlation of these findings with the severity of IC. 231 patients were excluded for not having a concomitant CT or for having underlying comorbidities. 104 cases were analyzed. Scans were evaluated for abnormal wall enhancement (AE), bowel wall thickening (BWT), bowel dilatation (DIL), mesenteric fat stranding (FS), venous engorgement (VE), pericolonic free fluid (FF), and pneumatosis (PN) and portomesenteric venous gas. Segmental versus pancolonic involvement was noted. Severity was determined by histopathology criteria. Data obtained are as follows: female to male incidence, 69 % (70) vs. 31 % (34); average age, 64.5; and positive CT, 102/104 (98.1 %). The most frequent findings include FS (88 %), BWT (88 %), and AE (82 %) regardless of severity of involvement. Statistically significant increased risk ratio and likelihood of severe ischemia for PN, DIL, and FF individually. BWT, DIL, FS, FF, VE, and PN together have a probability for severe IC of 91.8 %. A correlation between fewer findings and milder IC was found (R (2) = 0.6771). The most frequently involved segments: descending (64 %) and sigmoid colon (54 %). Splenic flexure (SF) was infrequently involved (n = 8, 7.84 %). Females had two times higher incidence of IC. The most frequent CT findings in IC are FS, BWT, and AE regardless of the severity. PN is suggestive of severe IC. Segmental involvement is the predominant pattern. The distal colon is more frequently involved. SF contrary to the conventional literature is not disproportionately involved in IC.
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Affiliation(s)
- Cinthia Cruz
- , 25 New Chardon Street 449A, Boston, MA, 02114, USA,
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Rubin GD. Computed tomography: revolutionizing the practice of medicine for 40 years. Radiology 2015; 273:S45-74. [PMID: 25340438 DOI: 10.1148/radiol.14141356] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Computed tomography (CT) has had a profound effect on the practice of medicine. Both the spectrum of clinical applications and the role that CT has played in enhancing the depth of our understanding of disease have been profound. Although almost 90 000 articles on CT have been published in peer-reviewed journals over the past 40 years, fewer than 5% of these have been published in Radiology. Nevertheless, these almost 4000 articles have provided a basis for many important medical advances. By enabling a deepened understanding of anatomy, physiology, and pathology, CT has facilitated key advances in the detection and management of disease. This article celebrates this breadth of scientific discovery and development by examining the impact that CT has had on the diagnosis, characterization, and management of a sampling of major health challenges, including stroke, vascular diseases, cancer, trauma, acute abdominal pain, and diffuse lung diseases, as related to key technical advances in CT and manifested in Radiology.
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Affiliation(s)
- Geoffrey D Rubin
- From the Duke Clinical Research Institute and Department of Radiology, Duke University School of Medicine, PO Box 17969, 2400 Pratt St, Durham, NC 27715
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15
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François CJ. Noninvasive Imaging Workup of Patients with Vascular Disease. Surg Clin North Am 2013; 93:741-60, vii. [DOI: 10.1016/j.suc.2013.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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16
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Oliva IB, Davarpanah AH, Rybicki FJ, Desjardins B, Flamm SD, Francois CJ, Gerhard-Herman MD, Kalva SP, Ashraf Mansour M, Mohler ER, Schenker MP, Weiss C, Dill KE. ACR Appropriateness Criteria ® imaging of mesenteric ischemia. ABDOMINAL IMAGING 2013; 38:714-9. [PMID: 23296712 DOI: 10.1007/s00261-012-9975-2] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Mesenteric ischemia is a rare disease associated with high morbidity and mortality. Acute mesenteric ischemia is most commonly secondary to embolism followed by arterial thrombosis, nonocclusive ischemia, and less commonly venous thrombosis. Chronic mesenteric ischemia is almost always caused by atherosclerotic disease, with rare causes including fibromuscular dysplasia and vasculitis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Patients with mesenteric ischemia usually present with nonspecific abdominal symptoms and laboratory findings. This document evaluates and rates the appropriateness of imaging to evaluate patients with clinically suspected mesenteric ischemia. While catheter-based angiography has been considered the reference standard and enables diagnosis and treatment, advances in computed tomography have made it a first-line test in many patients because it is a fast, widely available, and noninvasive study. Abdominal radiographs and ultrasound have a limited role in diagnosing mesenteric ischemia but are commonly the first ordered tests in patients with abdominal pain and may diagnose more common pathologies.
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Somma F, Berritto D, Iacobellis F, Landi N, Cavaliere C, Corona M, Russo S, Di Mizio R, Rotondo A, Grassi R. 7T μMRI of mesenteric venous ischemia in a rat model: timing of the appearance of findings. Magn Reson Imaging 2012; 31:408-13. [PMID: 23102942 DOI: 10.1016/j.mri.2012.08.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 08/18/2012] [Accepted: 08/30/2012] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The aim of this study is to analyze the chronological development of macroscopic, microscopic and magnetic resonance imaging (MRI) findings in a rat model of Superior Mesenteric Venous (SMV) ligation, and to evaluate the role of MRI in the diagnosis of mesenteric venous thrombosis. METHODS Thirty adult Sprague-Dawley rats were used and divided in two different groups that underwent a different surgical model and a different monitoring of ischemic damage. Group I underwent macroscopical and histological observation; Group II underwent 7T μMRI evaluation and histological analysis. RESULTS The first alterations occurred 30 min after SMV ligation and progressively worsened until the eighth hour. The morphological and MRI findings showed the same course. CONCLUSIONS This study provides a systematic evaluation of early anatomopathological and MRI findings following the SMV ligation. MRI allows to identify the early pathological findings of venous mesenteric ischemia and allows to correlate those to the histopathological features. Our data suggest a relevant role of MRI in the diagnostic management of mesenteric venous thrombosis, allowing to non-invasively identify and characterize the histopathologic findings. So, thanks to these skills, its future application in early diagnosis of human mesenteric venous ischemia is supposable.
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Affiliation(s)
- Francesco Somma
- Institute of Radiology, Second University of Naples, Piazza Miraglia 2, Naples, Italy
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18
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Alturkistany S, Artho G, Maheshwari S, Blaichman J, Kao E, Mesurolle B. Transmural colonic ischemia: clinical features and computed tomography findings. Clin Imaging 2012; 36:35-40. [PMID: 22226441 DOI: 10.1016/j.clinimag.2011.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 02/10/2011] [Indexed: 12/12/2022]
Abstract
Our purpose was to describe the computed tomography features of transmural colonic ischemia in correlation with clinical, laboratory and histopathological findings of 14 patients who underwent colectomy (9 female and 5 male; mean age, 68 years). Seven patients died (50%). Transmural necrosis involved the right colon in 10 patients (10/14, or 72%). Eleven patients showed thickened colonic wall (11/14, or 79%), 10 pneumatosis (10/14, or 71%), 5 gas in the portal venous system (5/14, or 36%), and 14 fat stranding (14/14, or 100%).
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Affiliation(s)
- Samira Alturkistany
- Department of Radiology, McGill University Health Center, Royal Victoria Hospital, 687 Pine Avenue West, Montreal, PQ, Canada
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19
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Pneumatosis intestinalis after liver transplantation. Eur J Radiol 2011; 80:629-36. [DOI: 10.1016/j.ejrad.2010.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Revised: 07/21/2010] [Accepted: 08/02/2010] [Indexed: 12/18/2022]
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20
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Seven-Tesla micro-MRI in early detection of acute arterial ischaemia: evolution of findings in an in vivo rat model. Radiol Med 2011; 116:829-41. [PMID: 21509555 DOI: 10.1007/s11547-011-0676-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 10/11/2010] [Indexed: 12/13/2022]
Abstract
PURPOSE Acute mesenteric ischaemia (AMI) is a life-threatening vascular emergency with a high mortality rate. Early diagnosis is the key to reducing its mortality rate and improving the quality of life. Although computed tomography (CT) is still the gold standard for acute intestinal disorders, over the last few years, magnetic resonance imaging (MRI) has become a useful alternative tool. An animal model of AMI was developed in order to study the effectiveness of MRI in early detection of this condition and to observe lesion evolution. METHODS Thirty Sprague Dawley rats were randomly divided into two groups (n=15): in the first group, after laparotomy, the animals underwent ligation of the superior mesenteric artery (SMA), followed by macroscopic monitoring and histological evaluation; in the second, ischaemia was induced by squeezing a loop around the SMA 3 days before evaluation with 7-T micro-MRI. RESULTS Macroscopically, a reflex spastic ileus followed by reflex hypotonic ileus and colour changes in some of the loops were detected. MRI evidenced luminal dilatation with air-fluid levels, free intraperitoneal fluid and bowelwall oedema. Histological analysis confirmed ischaemia and earlier damage involving the central portion of the ileum. CONCLUSIONS This model shows the correct sequence of events during arterial AMI and demonstrates that MRI can be recommended for early diagnosis of these lesions.
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Elsayes KM, Al-Hawary MM, Jagdish J, Ganesh HS, Platt JF. CT enterography: principles, trends, and interpretation of findings. Radiographics 2011; 30:1955-70. [PMID: 21057129 DOI: 10.1148/rg.307105052] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Computed tomographic (CT) enterography is an emerging alternative to traditional fluoroscopy for the assessment of disorders of the small bowel. The greatly improved spatial and temporal resolution provided by multidetector CT scanners, combined with good luminal distention provided by negative oral contrast agents and with good bowel wall visualization, have made CT enterography the main imaging modality not only for investigating proved or suspected inflammatory bowel disease but also for detecting occult gastrointestinal tract bleeding, small bowel neoplasms, and mesenteric ischemia. CT enterography is particularly useful for differentiating between active and fibrotic bowel strictures in patients with Crohn disease, thus enabling selection of the most appropriate treatment (medical management or intervention) for an improved outcome. CT enterography allows excellent visualization of the entire thickness of the bowel wall and depicts extraenteric involvement as well, providing more detailed and comprehensive information about the extent and severity of the disease process.
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Affiliation(s)
- Khaled M Elsayes
- Department of Radiology, University of Michigan Health System, Ann Arbor, Mich., USA.
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22
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Wasnik A, Kaza RK, Al-Hawary MM, Liu PS, Platt JF. Multidetector CT imaging in mesenteric ischemia--pearls and pitfalls. Emerg Radiol 2010; 18:145-56. [PMID: 21132342 DOI: 10.1007/s10140-010-0921-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 11/10/2010] [Indexed: 12/18/2022]
Abstract
Mesenteric ischemia is a complex and devastating disease which still remains a diagnostic challenge to the clinicians due to non-specific clinical and laboratory findings. Several imaging features have been described with multidetector computed tomography which allows the diagnosis of mesenteric ischemia with high sensitivity and specificity. However, there are imaging features which overlap with other pathologies including benign inflammation and infection. Knowledge of imaging findings in mesenteric ischemia and its potential mimics is important in early and definitive diagnosis.
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Affiliation(s)
- Ashish Wasnik
- Division of Abdominal Imaging, Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Drive, Taubman Center, B1-132 F, Ann Arbor, MI 48109, USA.
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23
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Yikilmaz A, Karahan OI, Senol S, Tuna IS, Akyildiz HY. Value of multislice computed tomography in the diagnosis of acute mesenteric ischemia. Eur J Radiol 2010; 80:297-302. [PMID: 20719444 DOI: 10.1016/j.ejrad.2010.07.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 07/15/2010] [Accepted: 07/19/2010] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To define the value of multislice computed tomography (CT) in the diagnosis of acute mesenteric ischemia (AMI). MATERIALS AND METHODS Two hundred patients (age range: 20-92 years) who were referred to the emergency CT department with a clinical suspicion of AMI were prospectively included in the study. CT examinations were performed with a multislice (16) CT scanner and the protocol included pre-contrast, arterial and venous phase acquisitions. Images were evaluated by using multiplanar reconstruction, maximum intensity projection and volume-rendering techniques at the CT workstation. RESULTS Ninety-four patients (47%) underwent surgery for AMI or for other causes of acute abdominal pain. One hundred-six patients (53%) were followed conservatively according to clinical, radiologic and laboratory findings. Of the 94 patients who underwent surgery, 49 (25%) were found to have AMI. All of these 49 patients with a proven AMI diagnosis were diagnosed with CT. In the other 45 patients who underwent surgery, CT findings were negative for AMI. None of the patients, who were followed conservatively, were eventually diagnosed as having AMI except 1 patient. This patient was unfit for surgery although his clinical and radiologic findings were consistent with AMI and died in 3 days. The sensitivity and specificity values of CT for the detection of AMI were calculated to be 100% for each. CONCLUSIONS Multislice CT is an effective imaging technique for the diagnosis of AMI with excellent sensitivity and specificity values.
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Affiliation(s)
- Ali Yikilmaz
- Erciyes University, School of Medicine, Gevher Nesibe Hospital, Department of Radiology, Talas Yolu, 38038 Melikgazi, Kayseri, Turkey.
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Rosenblat JM, Rozenblit AM, Wolf EL, DuBrow RA, Den EI, Levsky JM. Findings of Cecal Volvulus at CT. Radiology 2010; 256:169-75. [DOI: 10.1148/radiol.10092112] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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25
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El Hennawy HM, Abdalla MF, El-Osta A, Bedair EMA. Isolated ileocolic artery occlusion presented with segmental bowel infarction: a case report. CASES JOURNAL 2009; 2:9153. [PMID: 20062670 PMCID: PMC2803950 DOI: 10.1186/1757-1626-2-9153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Accepted: 12/07/2009] [Indexed: 11/12/2022]
Abstract
Acute mesenteric ischemia is a serious acute abdominal condition requiring early diagnosis and intervention to improve the outcome. Although transmural acute bowel infarction represents about 1% of all cases of acute abdomen, it has a higher annual mortality rate than colon cancer. It tends to affect the colon in segmental fashion, mostly the splenic flexure and rectosigmoid portions of the colon. Isolated ischemia of the right side of the colon is rarely reported, especially in association with shock. Diagnosis of acute colonics ischemia is challenging as it may easily be confused with other non ischemic conditions both clinically and radiologically. Surgical resection is still the main curative approach. We present a case of segmental terminal ileum, cecum and part of ascending colon infarction due to isolated IleoColic artery thrombosis.
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Affiliation(s)
- Hany M El Hennawy
- Department General Surgery, Al Khor Hospital, Hamad Medical Corporation, Doha, PO Box 3050, Qatar
| | - Mohamed Fahmy Abdalla
- Department General Surgery, Al Khor Hospital, Hamad Medical Corporation, Doha, PO Box 3050, Qatar
| | - Abdelrahman El-Osta
- Department General Surgery, Al Khor Hospital, Hamad Medical Corporation, Doha, PO Box 3050, Qatar
| | - Elsaid MA Bedair
- Department of Radiology, Al Khor Hospital, Hamad Medical Corporation, Doha, PO Box 3050, Qatar
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Abstract
This article presents the differential diagnosis for small bowel ischemia. Clinical presentation of small bowel ischemia is variable, presenting with a myriad of specific or nonspecific clinical and laboratory findings. The imaging findings associated with small bowel ischemia are variable and combinations of findings may be necessary for definitive diagnosis. More specific imaging findings in patients with acute small intestine ischemia include bowel wall gas, mesenteric vessel occlusion, mesenteric venous gas, portal venous gas, or absence of bowel wall enhancement. Less specific imaging findings include small bowel wall thickening, mesenteric stranding, and mesenteric fluid. Further complicating the issue, several small intestinal disease processes may mimic ischemia both clinically and radiographically. These alternate diagnoses include infectious, inflammatory, and infiltrative processes.
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Abhishek K, Kaushik S, Kazemi MM, El-Dika S. An unusual case of hematochezia: acute ischemic proctosigmoiditis. J Gen Intern Med 2008; 23:1525-7. [PMID: 18521689 PMCID: PMC2518031 DOI: 10.1007/s11606-008-0673-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2007] [Revised: 12/04/2007] [Accepted: 05/01/2008] [Indexed: 12/01/2022]
Abstract
Acute ischemia of the rectum is uncommon and usually occurs after aorto-iliac surgery. In this report, we present a case of acute ischemic proctosigmoiditis that developed from a brief episode of hypotension. An 85-year-old male presented to the emergency room with hypotension, mental confusion, and passage of maroon-colored stool. He was resuscitated and treated for presumed sepsis. Computerized tomography of the abdomen and pelvis displayed signs of acute inflammation of the distal colon and rectum. Endoscopic findings and microscopic examination of the rectal biopsy revealed changes consistent with acute ischemic proctosigmoiditis. An evaluation for infectious etiologies was negative. The patient's clinical condition improved over the next 24 h with supportive care. Involvement of the rectum is rare in ischemic colitis because of its abundant collateral blood supply. Acute ischemic proctosigmoiditis should be considered in the differential diagnosis of elderly patients with multiple co-morbidities presenting with hematochezia.
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Affiliation(s)
- Kumar Abhishek
- Department of Internal Medicine, Carilion Clinic, Roanoke, VA, USA
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30
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Alqahtani S, Coffin CS, Burak K, Chen F, MacGregor J, Beck P. Hepatic portal venous gas: a report of two cases and a review of the epidemiology, pathogenesis, diagnosis and approach to management. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2007; 21:309-13. [PMID: 17505567 PMCID: PMC2657713 DOI: 10.1155/2007/934908] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hepatic portal venous gas (HPVG) is a rare condition that occurs when intraluminal gas and/or gas produced by intestinal bacteria enters the portal venous circulation. The most common precipitating factors include ischemia, intra-abdominal abscesses and inflammatory bowel disease. However, HPVG has recently been recognized as a rare complication of endoscopic and radiological procedures. Earlier studies advised immediate surgical intervention, but according to current recommendations, in some settings, HPVG can be managed conservatively. The present study reports two cases of HPVG; one that occurred following colonoscopy in a patient with severe Crohn's disease and one in a patient with graft-versus-host disease. METHODS The epidemiology, pathogenesis, diagnosis and management of HPVG are reviewed. Two case reports are presented, followed by the development of a management algorithm. RESULTS Of the two patients that developed HPVG, one was an outpatient undergoing a colonoscopy for assessment of Crohn's disease activity and the other was an inpatient with graft-versus-host disease. Once the diagnosis of HPVG was made, both patients were managed conservatively with antibiotic therapy and management of their underlying disease. CONCLUSIONS HPVG can occur in the setting of severe gastrointestinal disease states and following endoscopic procedures. It is critical that gastroenterologists are aware of the differential diagnosis, pathogenesis, diagnostic approach and management of HPVG.
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Affiliation(s)
- Saleh Alqahtani
- Gastrointestinal Research Group, University of Calgary, Calgary, Alberta
- Liver Unit, University of Calgary, Calgary, Alberta
| | - Carla S Coffin
- Gastrointestinal Research Group, University of Calgary, Calgary, Alberta
- Liver Unit, University of Calgary, Calgary, Alberta
| | - Kelly Burak
- Gastrointestinal Research Group, University of Calgary, Calgary, Alberta
- Liver Unit, University of Calgary, Calgary, Alberta
| | - Fred Chen
- Department of Radiology, University of Calgary, Calgary, Alberta
| | - John MacGregor
- Department of Radiology, University of Calgary, Calgary, Alberta
| | - Paul Beck
- Gastrointestinal Research Group, University of Calgary, Calgary, Alberta
- Correspondence: Dr Paul L Beck, University of Calgary, Health Sciences Centre, Division of Gastroenterology, 3330 Hospital Drive Northwest, Calgary, Alberta T2N 4N1. Telephone 403-220-4500, fax 403-270-0995, e-mail
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Grierson C, Uthappa MC, Uberoi R, Warakaulle D. Multidetector CT appearances of splanchnic arterial pathology. Clin Radiol 2007; 62:717-23. [PMID: 17604758 DOI: 10.1016/j.crad.2007.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Revised: 02/05/2007] [Accepted: 02/14/2007] [Indexed: 10/23/2022]
Abstract
Recent advances in multidetector computed tomography (MDCT) technology have enabled the production of high-resolution diagnostic images of the visceral vessels. The potential of MDCT in relation to splanchnic artery pathology is still being realized, but it already provides a credible quick, non-invasive, low-dose alternative to digital subtraction angiography. A variety of categories of splanchnic artery pathology are demonstrated, including stenosis and occlusion (due to extrinsic compression, mural thrombus, and atherosclerosis), aneurysms, dissection, and haemorrhage.
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Affiliation(s)
- C Grierson
- John Radcliffe Hospital, Headington, Oxford, UK.
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32
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Horton KM, Fishman EK. Multidetector CT angiography in the diagnosis of mesenteric ischemia. Radiol Clin North Am 2007; 45:275-88. [PMID: 17502217 DOI: 10.1016/j.rcl.2007.03.010] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Multidetector CT is an ideal tool for the diagnosis of acute and chronic mesenteric ischemia. Advanced CT scanners and expertise in three-dimensional imaging are becoming increasingly widespread, opening the door to new opportunities and challenges in the evaluation of patients suspected of having mesenteric ischemia. This article reviews contrast administration and image acquisition protocols, the anatomy of the mesenteric vasculature, the etiology of acute and chronic mesenteric ischemia, and CT findings diagnostic for these conditions.
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Affiliation(s)
- Karen M Horton
- Johns Hopkins Medical Institutions, 601 N. Caroline Street/JHOC 3253, Baltimore, MD 21287, USA.
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33
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Bilbao Jaureguízar JI, Vivas Pérez I, Cano Rafart D, Martínez de la Cuesta A. Imaging and Intervention in Gastrointestinal Hemorrhage and Ischemia. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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34
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Romano S, Lassandro F, Scaglione M, Romano L, Rotondo A, Grassi R. Ischemia and infarction of the small bowel and colon: spectrum of imaging findings. ACTA ACUST UNITED AC 2006; 31:277-92. [PMID: 16283583 DOI: 10.1007/s00261-005-0376-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- S Romano
- Department of Diagnostic Imaging, "A.Cardarelli" Hospital, Viale Cardarelli 9, Naples 80131, Italy.
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Rosow DE, Sahani D, Strobel O, Kalva S, Mino-Kenudson M, Holalkere NS, Alsfasser G, Saini S, Lee SI, Mueller PR, Fernández-del Castillo C, Warshaw AL, Thayer SP. Imaging of acute mesenteric ischemia using multidetector CT and CT angiography in a porcine model. J Gastrointest Surg 2005; 9:1262-74; discussion 1274-5. [PMID: 16332482 PMCID: PMC3807105 DOI: 10.1016/j.gassur.2005.07.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2005] [Accepted: 07/28/2005] [Indexed: 01/31/2023]
Abstract
Acute mesenteric ischemia, a frequently lethal disease, requires prompt diagnosis and intervention for favorable clinical outcomes. This goal remains elusive due, in part, to lack of a noninvasive and accurate imaging study. Traditional angiography is the diagnostic gold standard but is invasive and costly. Computed tomography (CT) is readily available and noninvasive but has shown variable success in diagnosing this disease. The faster scanning time of multidetector row CT (M.D.CT) greatly facilitates the use of CT angiography (CTA) in the clinical setting. We sought to determine whether M.D.CT-CTA could accurately demonstrate vascular anatomy and capture the earliest stages of mesenteric ischemia in a porcine model. Pigs underwent embolization of branches of the superior mesenteric artery, then imaging by M.D.CT-CTA with three-dimensional reconstruction protocols. After scanning, diseased bowel segments were surgically resected and pathologically examined. Multidetector row CT and CT angiography reliably defined normal and occluded mesenteric vessels in the pig. It detected early changes of ischemia including poor arterial enhancement and venous dilatation, which were seen in all ischemic animals. The radiographic findings--compared with pathologic diagnoses-- predicted ischemia, with a positive predictive value of 92%. These results indicate that M.D.CT-CTA holds great promise for the early detection necessary for successful treatment of acute mesenteric ischemia.
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Affiliation(s)
- David E Rosow
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
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Huang HH, Chang YC, Yen DHT, Kao WF, Chen JD, Wang LM, Huang CI, Lee CH. Clinical factors and outcomes in patients with acute mesenteric ischemia in the emergency department. J Chin Med Assoc 2005; 68:299-306. [PMID: 16038369 DOI: 10.1016/s1726-4901(09)70165-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The purpose of this study was to determine the initial clinical characteristics of acute mesenteric ischemia and identify variables associated with adverse outcomes in the emergency department (ED). METHODS The charts of 124 consecutive patients with surgically and pathologically identified acute mesenteric ischemia from September 1990 to September 2000 were reviewed retrospectively to obtain data about demographics, initial clinical presentations, predisposing diseases, previous medications, laboratory tests, and common findings on computed tomography scans with contrast. Only patients admitted through the ED and treated on medical or surgical wards were enrolled. RESULTS Mean patient age was 71.1 years (range, 25-100 years). The overall mortality rate was 50%. There were no significant differences in gender, underlying disease, previous medication, initial signs and symptoms, and causes of mesenteric infarction, between survivors and non-survivors. Univariate analysis demonstrated that older age, bandemia, hepatic and renal impairment, hyperamylasemia, metabolic acidosis, hypoxia, intramural pneumatosis, and septic syndrome, were more frequent in patients who died than in those who survived (p < 0.05). Logistic regression identified the following variables as independent predictors of death: old age (odds ratio, OR, 1.077; 95% confidence interval, Cl, 1.013, 1.146; p = 0.02); bandemia (OR, 3.894; 95% Cl, 1.160, 13.074; p = 0.03); elevated serum aspartate aminotransferase (AST; OR, 4.532; 95% Cl, 1.274, 16.122; p = 0.02); increased blood urea nitrogen (BUN; OR, 7.219; 95% Cl, 1.166, 44.696; p = 0.03); and metabolic acidosis (OR, 6.604; 95% Cl, 1.804, 24.171; p < 0.01). CONCLUSION A high index of suspicion and aggressive diagnostic imaging can facilitate early diagnosis and improve outcomes for patients with acute mesenteric ischemia. Risk stratification showed that elderly patients with metabolic acidosis, bandemia, or elevated AST and BUN had a poor prognosis. Greater therapeutic intervention is advocated to reduce mortality in high-risk patients with acute mesenteric ischemia.
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Affiliation(s)
- Hsien-Hao Huang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, R.O.C
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Ripollés T, Simó L, Martínez-Pérez MJ, Pastor MR, Igual A, López A. Sonographic findings in ischemic colitis in 58 patients. AJR Am J Roentgenol 2005; 184:777-85. [PMID: 15728597 DOI: 10.2214/ajr.184.3.01840777] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to describe the sonographic findings of 58 patients with proven ischemic colitis and to evaluate whether any of the findings are related to the presence or development of transmural necrosis. MATERIALS AND METHODS We reviewed the histories of patients diagnosed with ischemic colitis over a period of 5.5 years. Sixty-two patients had undergone sonographic examinations. The spectrum of sonographic findings in ischemic colitis was based on the original imaging report, with an analysis of the presence of colonic abnormalities and their associated alterations. In the second part of the study, we divided the patients into two groups according to the presence or absence of transmural necrosis, and the sonographic findings of each group were compared. Ten patients had sonographic follow-up studies during their hospital stay. RESULTS The prospective sensitivity of sonography for the characterization of colonic abnormalities was 93.5% (58/62 patients). Segmental involvement was detected in 57 of the 58 patients, with left-sided colitis in 47 (81%). The mean length of bowel involved was 19 cm, with a mean wall thickness of 7.6 mm. Colon wall stratification was preserved in 38 patients (66%). Altered pericolic fat was observed in 16 patients (28%). Absence of or barely visible color Doppler flow in the thickened bowel wall was recorded in 80% of patients. Altered pericolic fat was the only sonographic variable significantly associated with the presence of transmural necrosis (p = 0.004). Improvement as assessed on sonography was observed in all patients with a good clinical course. In patients with transmural necrosis, sonography did not show improvement. CONCLUSION Sonography is a valuable technique for the detection of colonic abnormalities resulting from ischemic colitis. In this study, altered pericolic fat or the absence of improvement in sonographic follow-up studies were factors associated with transmural necrosis.
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Affiliation(s)
- Tomás Ripollés
- Department of Radiology, Hospital Universitario Dr. Peset, 90 Gaspar Aguilar Ave., Valencia 46017, Spain.
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Cademartiri F, Raaijmakers RHJM, Kuiper JW, van Dijk LC, Pattynama PMT, Krestin GP. Multi-detector row CT angiography in patients with abdominal angina. Radiographics 2005; 24:969-84. [PMID: 15256621 DOI: 10.1148/rg.244035166] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Abdominal angina (AA) is an infrequently occurring syndrome characterized by postprandial abdominal pain due to reduced blood flow to organs in the territory of the celiac trunk, superior mesenteric artery (SMA), and inferior mesenteric artery. Multi-detector row computed tomographic (CT) angiography with four- or 16-row scanners has become a primary tool for the evaluation of patients with suspected steno-occlusive diseases of the abdominal vessels. In patients with suspected AA, multi-detector row CT angiography can help evaluate the presence and degree of stenosis in the celiac trunk and SMA, demonstrate the collateral circulation, and help exclude other causes of vascular obstruction. It also allows visualization of small vessels and of vessel wall abnormalities in the absence of significant stenosis. Vessels with a complex anatomic configuration can easily be visualized with proper postprocessing techniques. This modality can also be used to follow up patients who have undergone percutaneous interventional treatment. Limitations include the lack of dynamic representation of flow abnormalities and difficulty in evaluating heavily calcified vessels. Nevertheless, multi-detector row CT angiography with appropriate postprocessing techniques is highly effective for the diagnosis, evaluation, and treatment of suspected AA. Additional studies will help further evaluate the performance and applications of this modality.
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Affiliation(s)
- Filippo Cademartiri
- Department of Radiology, Erasmus Medical Center-Rotterdam, Dr Molenwaterplein 40, 3015 GD-Rotterdam, The Netherlands.
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Wiesner W, Hauser A, Steinbrich W. Accuracy of multidetector row computed tomography for the diagnosis of acute bowel ischemia in a non-selected study population. Eur Radiol 2004; 14:2347-56. [PMID: 15378337 DOI: 10.1007/s00330-004-2462-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2004] [Revised: 07/09/2004] [Accepted: 07/16/2004] [Indexed: 02/06/2023]
Abstract
The diagnostic accuracy of multidetector row computed tomography for the prospective diagnosis of acute bowel ischemia in the daily clinical routine was analyzed. Two hundred ninety-one consecutive patients with an acute or subacute abdomen, examined by MDCT over a time period of 5 months, were included in the study. All original CT diagnoses made during the daily routine by radiological generalists were compared to the final diagnoses made by using all available medical information from endoscopies, surgical interventions, autopsies and follow-up. Finally, all CT examinations of patients with an initial CT diagnosis or a final diagnosis of bowel ischemia were reread by a radiologist specialized in abdominal imaging in order to analyze the CT findings and the reasons for initially false negative or false positive CT readings. Twenty-four patients out of 291 (8.2%) had acute bowel ischemia. The age of affected patients ranged from 50 to 94 years (mean age: 75.7 years). Eleven patients were male, and 13 female. Reasons for acute bowel ischemia were: arterio-occlusive (n=11), non-occlusive (n=5), strangulation (n=2), over-distension (n=3) and radiation (n=3). The prospective sensitivity, specificity, PPV and NPV of MDCT for the diagnosis of acute bowel ischemia in the daily routine were 79.17, 98.51, 90.48 and 98.15%. MDCT reaches a similarly high sensitivity in diagnosing acute bowel as angiography. Furthermore, it has the advantage of being helpful in most of its clinical differential diagnoses and of being less invasive with the consecutive possibility of being used earlier in the diagnostic process with all the resulting positive effects on the patients prognosis. Therefore, nowadays MDCT should probably be used as the first step imaging modality of choice in patients with suspected acute bowel ischemia.
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Affiliation(s)
- Walter Wiesner
- Institute of Diagnostic Radiology, University Hospital Basel, Basel, Switzerland.
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Angelelli G, Scardapane A, Memeo M, Stabile Ianora AA, Rotondo A. Acute bowel ischemia: CT findings. Eur J Radiol 2004; 50:37-47. [PMID: 15093234 DOI: 10.1016/j.ejrad.2003.11.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2003] [Revised: 11/19/2003] [Accepted: 11/27/2003] [Indexed: 02/06/2023]
Abstract
Acute bowel ischemia represents one of the most dramatic abdominal emergencies and, despite the fact it is more and more frequently observed in clinical practice, its mortality rate remains very high. In recent years Computed Tomography (CT) has proved to be a valid diagnostic tool in the evaluation of patients with acute abdominal syndrome and in the visualization of early signs of bowel ischemia. This paper reviews the aetiological and pathophysiological aspects as well as a broad spectrum of CT findings of this clinical condition.
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Affiliation(s)
- Giuseppe Angelelli
- Department of Radiology--University Hospital "Policlinico" of Bari--Piazza G. Cesare, 11-70124 Bari, Italy.
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Kim JH, Ha HK, Kim JK, Eun HW, Park KB, Kim BS, Kim TK, Kim JC, Auh YH. Usefulness of known computed tomography and clinical criteria for diagnosing strangulation in small-bowel obstruction: analysis of true and false interpretation groups in computed tomography. World J Surg 2003; 28:63-8. [PMID: 14648046 DOI: 10.1007/s00268-003-6899-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Computed tomography (CT) criteria have proven useful, but not sufficient, for diagnosis of bowel strangulation. The purpose of the present study was to evaluate the use of clinical criteria in the interpretation of CT scans as a means of improving the diagnostic accuracy of CT, especially in patients whose CT scans are equivocal for distinguishing simple obstruction from strangulated obstruction. We analyzed the CT scans of 136 patients with simple (n=70) or strangulated (n=66) small-bowel obstruction. Three radiologists interpreted the CT scans independently for the presence of intestinal strangulation. According to their interpretation, 136 patients were divided into two groups, i.e., a false and a true interpretation group. The diagnostic value of known CT and four clinical criteria (tenderness, tachycardia, fever, and leukocytosis) were compared in the two groups. The diagnostic accuracy of CT criteria for distinguishing simple obstructions from strangulated small-bowel obstructions ranged between 73% and 80%. Of the 136 patients, 31 belonged to the false group and 105 to the true group. The CT criteria that were highly specific in both groups included severe mesenteric haziness, serrated beak, and poor bowel wall enhancement. Among the clinical criteria, both tachycardia and leukocytosis were highly specific in both groups. The number of positive clinical criteria was helpful in making a diagnosis; none or one clinical criterion indicated a simple obstruction, whereas three or four criteria indicated a strangulated obstruction; when this result was applied retrospectively to the false group, the CT diagnostic accuracy improved in 19 of the 31 patients. The use of clinical criteria when CT findings are equivocal, may overcome the inherent limitations of CT for diagnosing strangulated small-bowel obstruction.
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Affiliation(s)
- Jung Hoon Kim
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Poongnap-Dong, Songpa-Ku, 138-040 Seoul, Korea
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Abstract
Ischemic injury to the gastrointestinal tract can threaten bowel viability with potential catastrophic consequences, including intestinal necrosis and gangrene. The presenting symptoms and signs are relatively nonspecific and diagnosis requires a high index of clinical suspicion. AMI often results from an embolus or thrombus within the SMA, although a low-flow state through an area of profound atherosclerosis may also induce severe ischemia. Because most laboratory and radiologic studies are nonspecific in early ischemia an aggressive approach to diagnosis with imaging of the splanchnic vasculature by mesenteric angiography is advocated. Various therapeutic approaches, including the infusion of vasodilators and thrombolytics, may then be used. Proper diagnosis and management of patients with AMI requires vigilance and a readiness to pursue an aggressive course of action.
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Affiliation(s)
- Bryan J Burns
- Division of Gastroenterology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
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Kirkpatrick IDC, Kroeker MA, Greenberg HM. Biphasic CT with mesenteric CT angiography in the evaluation of acute mesenteric ischemia: initial experience. Radiology 2003; 229:91-8. [PMID: 12944600 DOI: 10.1148/radiol.2291020991] [Citation(s) in RCA: 271] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE To evaluate the sensitivity and specificity of biphasic computed tomography (CT) with mesenteric CT angiography in the diagnosis of acute mesenteric ischemia (AMI). MATERIALS AND METHODS Sixty-two patients with clinically suspected AMI underwent prospective imaging with biphasic multi-detector row CT. Mesenteric CT angiography was performed with 1.25-mm collimation starting 25 seconds after 140 mL of intravenous contrast agent was administered at a rate of 4 mL/sec, followed by portal venous phase imaging with 5-mm collimation and a 60-70-second delay. CT angiograms were reconstructed with multiplanar (including transverse), maximum intensity projection, and volume-rendered techniques. All scans were evaluated prospectively by two independent radiologists for CT evidence of ischemia. AMI was confirmed with surgical or pathologic proof in 25 of 26 patients. In one patient, AMI was confirmed with clinical findings and serial CT examinations. In patients with AMI, sensitivity and specificity of each CT sign were calculated retrospectively by using patients who did not have intestinal ischemia as a control group. CT criteria that optimized sensitivity and specificity for the diagnosis of AMI were then developed. RESULTS AMI was diagnosed in 26 patients. The CT angiogram depicted arterial disease in eight patients and altered care in five. A finding of any one of pneumatosis intestinalis, venous gas, superior mesenteric artery occlusion, celiac and inferior mesenteric artery occlusion with distal SMA disease, or arterial embolism was 100% specific but only 73% sensitive. Alternatively, a finding of bowel wall thickening in addition to focal lack of bowel wall enhancement, solid organ infarction, or venous thrombosis was 50% sensitive and 94% specific. By using either of these criteria for the diagnosis, a sensitivity of 96% and a specificity of 94% can be achieved. CONCLUSION Biphasic CT with mesenteric CT angiography is effective in the diagnosis of AMI.
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Affiliation(s)
- Iain D C Kirkpatrick
- Department of Radiology, University of Manitoba Health Sciences Centre, 820 Sherbrook Street, Winnipeg, Manitoba, Canada R3A 1R9.
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Segatto E, Mortelé KJ, Ji H, Wiesner W, Ros PR. Acute small bowel ischemia: CT imaging findings. Semin Ultrasound CT MR 2003; 24:364-76. [PMID: 14620718 DOI: 10.1016/s0887-2171(03)00074-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Small bowel ischemia is a disorder related to a variety of conditions resulting in interruption or reduction of the blood supply of the small intestine. It may present with various clinical and radiologic manifestations, and ranges pathologically from localized transient ischemia to catastrophic necrosis of the intestinal tract. The primary causes of insufficient blood flow to the small intestine are various and include thromboembolism (50% of cases), nonocclusive causes, bowel obstruction, neoplasms, vasculitis, abdominal inflammatory conditions, trauma, chemotherapy, radiation, and corrosive injury. Computed tomography (CT) can demonstrate changes because of ischemic bowel accurately, may be helpful in determining the primary cause of ischemia, and can demonstrate important coexistent findings or complications. However, common CT findings in acute small bowel ischemia are not specific and, therefore, it is often a combination of clinical, laboratory and radiologic signs that may lead to a correct diagnosis. Understanding the pathogenesis of various conditions leading to mesenteric ischemia and being familiar with the spectrum of diagnostic CT signs may help the radiologist recognize ischemic small bowel disease and avoid delayed diagnosis. The aim of this article is to provide a review of the pathogenesis and various causes of acute small bowel ischemia and to demonstrate the contribution of CT in the diagnosis of this complex disease.
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Affiliation(s)
- Enrica Segatto
- Department of Radiology, Division of Abdominal Imaging and Intervention, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Furukawa A, Yamasaki M, Takahashi M, Nitta N, Tanaka T, Kanasaki S, Yokoyama K, Murata K, Sakamoto T. CT diagnosis of small bowel obstruction: scanning technique, interpretation and role in the diagnosis. Semin Ultrasound CT MR 2003; 24:336-52. [PMID: 14620716 DOI: 10.1016/j.sult.2003.08.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Intestinal obstruction is a relatively common condition with diagnosis based on the clinical signs, patient history, and radiographical findings. Once suspected, its presence should be determined and if present, the site and cause of obstruction, and presence of strangulation should be assessed for the appropriate patient management. With the recent technological developments, the role of computed tomography (CT) in the diagnosis of bowel obstruction has expanded. The examination should be performed with intravenous contrast administration and thinner sections and multi-planner image reformation are recommended to evaluate a site of particular interest. CT is reported to have a sensitivity refer to detection of a small bowel obstruction at over 90% for complete or high-grade obstruction and to disclose causes of obstruction in 70% to 95% of cases. CT also provides characteristic findings indicating the presence of closed-loop obstruction and intestinal ischemia, which leads to appropriate and timely management for these emergent cases.
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Affiliation(s)
- Akira Furukawa
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga 520-2192, Japan.
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Abstract
Enhanced computed tomography (CT) is frequently performed for possible bowel ischaemia. It has the distinct advantage of possible detection of the causes of ischaemia. Radiologists therefore need to be familiar with the spectrum of diagnostic CT signs. We present the CT imaging findings in surgically proven cases of small bowel ischaemia. In addition to signs pertaining to the underlying aetiological pathology, bowel dilatation, bowel wall thickening, mural gas, occlusion of mesenteric vessels, ascites and infarct of other abdominal organs were observed.
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Affiliation(s)
- R Lee
- Department of Radiology, The University of Hong Kong, Queen Mary Hospital, SAR, Hong Kong, People's Republic of China.
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47
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Horton KM, Fishman EK. The current status of multidetector row CT and three-dimensional imaging of the small bowel. Radiol Clin North Am 2003; 41:199-212. [PMID: 12659334 DOI: 10.1016/s0033-8389(02)00121-5] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Radiologists have played an important role in evaluation of patients with small bowel pathology. The small bowel series and, later, enteroclysis were the mainstays in radiologic diagnosis of many small bowel diseases, because the resolution and speed of CT was limited. Continued improvements in CT technology over the last 2 decades have resulted in a expanding role of CT for evaluation of the gastrointestinal tract, including the small intestine. Many conditions, such as small bowel obstruction and ischemia, that would traditionally be imaged with other modalities (small bowel series or angiography) are now routinely imaged with CT. The development of MDCT and improvements in 3D imaging systems have greatly improved the ability to examine the small bowel and mesenteric vasculature. With the introduction of new CT oral contrast agents and faster 32-detector row CT scanners, the diagnosis and evaluation of patients with small bowel disease will continue to improve.
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Affiliation(s)
- Karen M Horton
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 601 North Caroline Street, Room 3253, Baltimore, MD 21287, USA.
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Abstract
Bowel ischemia may be caused by many conditions and manifest with typical or atypical and specific or nonspecific clinical, laboratory, and radiologic findings. It may mimic various intestinal diseases and be confused with certain nonischemic conditions clinically and at computed tomography (CT). Bowel ischemia severity ranges from mild (generally transient superficial changes of intestinal mucosa) to more dangerous and potentially life-threatening transmural bowel wall necrosis. Causes of critically reduced blood flow to the bowel are diverse, ranging from occlusions of mesenteric arteries or veins to complicated bowel obstruction and overdistention. CT can demonstrate changes in ischemic bowel segments accurately, is often helpful in determining the primary cause of ischemia, and can demonstrate important coexistent findings or complications. Unfortunately, common CT findings in bowel ischemia are not specific, and specific findings are rather uncommon. Therefore, it often is a combination of nonspecific clinical, laboratory, and radiologic findings-especially detailed knowledge about the pathogenesis of acute bowel ischemia in different conditions-that helps most in correct interpretation of CT findings. To improve understanding of this complex heterogeneous entity, this article provides an overview of the anatomy and physiology of mesenteric perfusion and discussions of causes and pathogenesis of acute bowel ischemia, CT findings in various types of acute bowel ischemia, and potential pitfalls of CT.
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Affiliation(s)
- Walter Wiesner
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
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49
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Affiliation(s)
- Karen M Horton
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
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50
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Ruíz-Guanter A, Ripollés T, Simó L, Martínez-Pérez MJ, Agramunt M. Colitis isquémica: hallazgos en TC. RADIOLOGIA 2002. [DOI: 10.1016/s0033-8338(02)77766-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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