Radiological Diagnosis

Mesenteric Ischaemia Causing Jejunal Infarction

Topogram of abdomen revealed Intramural air in small bowel wall on left side of abdomen with mildly dilated loops [Figure - 1]

Axial CT scan revealed dilated jejunal loops with intramural air . Note haziness of adjacent mesentry suggestive of inflammation and edema .The medial jejunal wall is thinned out suggestive of impending perforation. [Figure - 2] and [Figure - 3]

On basis of these findings diagnosis of mesenteric ischaemia causing Jejunal infarction was made and patient was operated upon .At surgery a 5 feet long segment of jejunum was found to be infarcted and was resected

Discussion

Mesenteric Ischaemia causing bowel infarction is divided into two categories :-

I)Occlusive disease( Large vessel) and II)Non occlusive (Microcirculatory ) [1] Mucosa is sensitive area to anoxia from arterial and venous occlusion with early ulceration leading to formation of stricture. Principle cause of arterial occlusion leading to mesenteric ischaemia are thrombosis, embolism or dissecting aneurysm, surgical trauma, intussusception, strangulated hernia, complication of angiography or complication of neoplasms[2]. Venous occlusion as result of volvulus or blood dyscrasia may also cause occlusive ischaemia Nonocclusive ischaemia may result from heart failure, shock, drugs, systemic diseases and abdominal trauma. If the trauma is less severe it can cause a mesenteric tear or directly traumatize the wall of the small intestine causing ischaemia and stricture formation [3]

Severe acute abdominal pain , no abdominal signs and rapid hypovolemia form a classical Clinical triad . .Degree of illness is often out of proportion to the clinical signs. Laboratory findings are increased Hemoglobin ( due to plasma loss),Leukocytosis, moderately raised serum amylase and a persistent metabolic acidosis. CT plays an important role in early diagnosis of intestinal infarction. CT demonstrates characteristic features of intramural gas, portal or mesenteric venous gas ,the focal thickening of intestinal wall, focal or diffuse fluid-filled dilated intestines .Clot in the superior mesenteric artery is demonstrated by dynamic scanning with IV contrast which reveals a filling defect in the superior mesenteric artery [4]

Plain radiograph initially shows gasless abdomen and later shows thickened edematous wall of the diseased intestine. Barium examination shows separation of the loops of intestine with edema and marked thickening of valvulae conniventes [5]

Radiological techniques that may help in the management of acute mesenteric ischaemia center around a prompt and accurate diagnosis, the infusion of vasodilators and in some situations low dose fibrinolytic infusions [6]