肠系膜缺血影像学表现

Radiographic Findings of Mesenteric Ischemia Joyce Liu, Harvard Medical School, Year IV Gillian Lieberman, MD Joyce Liu Gillian Lieberman, MD August 2001 2 Agenda • Patient presentation • Initial presentation • Radiographic findings • Differential diagnosis • Clinical course • Imaging of mesenteric ischemia • Modalities • Findings Joyce Liu Gillian Lieberman, MD 3 Our Patient Initial Presentation • 68 yo woman admitted with severe congestive heart failure and atrial fibrillation • Transthoracic echocardiogram revealed two large 1.5 cm thrombi in left atrial appendage • Gradual onset of abdominal pain after admission Joyce Liu Gillian Lieberman, MD 4 KUB: Upright & Supine Joyce Liu Gillian Lieberman, MD PACS PACS Splenic Artery Calcification 5 CT: Significant findings • Calcified splenic artery Joyce Liu Gillian Lieberman, MD • Splenic infarct • Free fluid in abdomen • Several thickened loops of bowel PACS 6 CT: Significant findings • Calcified splenic artery Joyce Liu Gillian Lieberman, MD • Splenic infarct • Free fluid in abdomen • Several thickened loops of bowel PACS 7 CT: Significant findings • Calcified splenic artery Joyce Liu Gillian Lieberman, MD • Splenic infarct • Free fluid in abdomen • Several thickened loops of bowel PACS 8 CT: Significant findings • Calcified splenic artery Joyce Liu Gillian Lieberman, MD • Splenic infarct • Free fluid in abdomen • Several thickened loops of bowel PACS 9 Differential Diagnosis: Bowel Wall Thickening • Regular • Coagulation defects • Trauma • Ischemia/Infarction • Hypoproteinemia • Ascites • Mesenteric lymphatic or venous obstruction • Giardiasis Joyce Liu Gillian Lieberman, MD • Irregular • Infection – Giardia, Histoplasmosis, TB, Yersinia, Strongyloides • Lymphoma • Metastases • Crohn’s disease • Whipple’s disease • Amyloidosis 10 CT: Vascular Imaging • Patent superior mesenteric artery (SMA) and celiac trunk • Calcified splenic artery • Free fluid • Splenic infarct PACS 11 Clinical Course #1 • Patient received IV antibiotics and appeared to improve clinically. • Approximately one week later, patient again developed abdominal pain, worsening greatly over 24-36 hours, with accompanying rise in WBC to 23,000. Joyce Liu Gillian Lieberman, MD 12 CT: Scout Film • Dependent air Joyce Liu Gillian Lieberman, MD • Bubbly appearance of air ? in lumen ? Bowel wall PACS 13 CT: Significant Finding • Dilated bowel loops • Free fluid • Heavily calcified aorta • No portal venous air • No free air • Bubbly dependent air ? In bowel wall Joyce Liu Gillian Lieberman, MD PACS Air in bowel wall = Pneumatosis Intestinalis 14 CT: Significant Findings • Dilated bowel loops Joyce Liu Gillian Lieberman, MD • Bubbly gas appearance noted on lung windows ? In bowel wall PACS 15 CT: Significant Findings • Air in dependent portions of small bowel Joyce Liu Gillian Lieberman, MD PACS 16 Differential Diagnosis: Pneumatosis Intestinalis • Adults – Mesenteric vascular disease (~30%) • Infants – Necrotizing enterocolitis Joyce Liu Gillian Lieberman, MD • Pneumatosis cystoides intestinalis (4-15%) • Bowel obstruction (~30%) • Crohn’s disease • Autoimmune diseases – lupus, scleroderma • Chronic obstructive pulmonary disease • Transplants – renal, liver • AIDS 17 Clinical Course #2 • Given patient’s history, exploratory laparotomy was performed. • At surgery, the following were found: • Murky, bloody ascites with foul smell • 2.5 foot section of necrotic small bowel in mid-jejunum, with ~1 foot that was gangrenous and perforated • Small bowel resection was performed. Joyce Liu Gillian Lieberman, MD 18 Mesenteric Ischemia • Acute or chronic • Three pathophysiologic mechanisms: • Arterial occlusion • Venous occlusion • Low-flow state • Commonly used imaging modalities: • Plain film (KUB) • CT • Angiography • MR angiography (MRA) – in development Joyce Liu Gillian Lieberman, MD 19 Imaging Mesenteric Ischemia: KUB • Dilated bowel loops • Bowel wall thickening • Paucity of gas in abdomen • Pneumatosis • Portal vein gas • Fixation of infarcted loops on serial examinations Joyce Liu Gillian Lieberman, MD 20 Pneumatosis Coli = Air in bowel wall • Dilated bowel loops • Bowel wall thickening • Paucity of gas in abdomen • Pneumatosis • Portal vein gas • Fixation of infarcted loops on serial examinations Joyce Liu Gillian Lieberman, MD 21 Air in portal venous system on KUB • Dilated bowel loops • Bowel wall thickening • Paucity of gas in abdomen • Pneumatosis • Portal vein gas • Fixation of infarcted loops on serial examinations Joyce Liu Gillian Lieberman, MD 22 Imaging Mesenteric Ischemia: CT • Dilated bowel loops • Bowel wall thickening • Large mesenteric vessels • Pneumatosis • Free fluid • Portal vein gas • Mesenteric venous gas • Infarction of other viscera • Thrombus • Pneumoperitoneum Joyce Liu Gillian Lieberman, MD • Mesenteric venous gas • Thrombus • Portal vein gas 23 Imaging Mesenteric Ischemia: CT • Dilated bowel loops • Bowel wall thickening • Large mesenteric vessels • Pneumatosis • Free fluid • Portal vein gas • Mesenteric venous gas • Infarction of other viscera • Thrombus • Pneumoperitoneum Joyce Liu Gillian Lieberman, MD • Mesenteric venous gas • Thrombus • Portal vein gas 24 Imaging Mesenteric Ischemia: CT • Dilated bowel loops • Bowel wall thickening • Large mesenteric vessels • Pneumatosis • Free fluid • Portal vein gas • Mesenteric venous gas • Infarction of other viscera • Thrombus • Pneumoperitoneum Joyce Liu Gillian Lieberman, MD • Mesenteric venous gas • Thrombus • Portal vein gas 25 Imaging Mesenteric Ischemia: Angiography Joyce Liu Gillian Lieberman, MD PACS PACS Aortogram Stenosis Selective Celiac Arteriogram 26 Imaging Mesenteric Ischemia: Angiography • Tortuous Arc of Riolan Joyce Liu Gillian Lieberman, MD PACS 27 Imaging Mesenteric Ischemia: Angiography • Tortuous Arc of Riolan Joyce Liu Gillian Lieberman, MD PACS 28 Imaging Mesenteric Ischemia: Angiography • Tortuous Arc of Riolan Joyce Liu Gillian Lieberman, MD PACS 29 Imaging Mesenteric Ischemia: Angiography • Tortuous Arc of Riolan Joyce Liu Gillian Lieberman, MD PACS 30 Imaging Mesenteric Ischemia: MRA Joyce Liu Gillian Lieberman, MD celiac SMA 31 Summary • Modalities for imaging mesenteric ischemia: • KUB • CT • Radiologic findings with mesenteric ischemia: Joyce Liu Gillian Lieberman, MD • KUB • Dilated bowel loops • Bowel wall thickening (Thumbprinting) • Pneumatosis (air in bowel wall) • Portal vein gas • CT • Large mesenteric vessels • Free fluid • Mesenteric venous gas • Thrombus in vessels • Bowel wall thickening • Air in bowel wall • Air in portal venous system• Angiography • Filling defects • Stenoses/blockage • Tortuous Arc of Riolan • Angiography • MRA (in development) 32 References • Baden JG, Racy DJ, Grist TM. Contrast-Enhanced Three-Dimensional Magnetic Resonance Angiography of the Meseteric Vasculature. Journal of Magnetic Resonance Imaging, 1999. 10: 369-375. • Brancatelli G, Rosello M. Images in Hepatology: Gas in the Portal Vein. Journal of Hepatology, 1999. 30: 1151. • Friedman S, DeMuro JP, Brebbia J, Ortega D, Barraco R, Brathwaite C, Perez JM, Smith T. Pneumatosis Cystoides Intestinalis in a Patient with Celiac Sprue. Contemporary Surgery, Jan 2001. 57(1): 11-13. • Hofmann LV, Beall DP, Jones B, Fishman EK, Heitmiller R. Hepatic-portal venous gas and pneumatosis intestinalis: Two cases with open jejunostomy tubes. Applied Radiology, Nov 1997. • Lund EC, Han SY, Holley HC, Berland LL. Intestinal ischemia: Comparison of plain radiographic and computed tomographic findings. RadioGraphics, Nov 1988. 8(6): 1083- 1108. • Scholz, FJ. Ischemic Bowel Disease. Radiologic Clinics of North America. Nov 1993. 31(6): 1197-1218. • Sebastia C, Quiroga S, Espin E, Boye R, Alvarez-Castelis A, Armengol M. Portomesenteric Vein Gas: Pathologic Mechanisms, CT Findings, and Prognosis. RadioGraphics, Sep 2000. 20(5): 1213-1226. Joyce Liu Gillian Lieberman, MD 33 Acknowledgments Many thanks to the following individuals for their invaluable assistance: Dr. Gillian Lieberman Dr. Scott Lin Pamela Lepkowski Larry Barbaras and Cara Lyn D’amour Joyce Liu Gillian Lieberman, MD Radiographic Findings of Mesenteric Ischemia Agenda Our Patient �Initial Presentation KUB: Upright & Supine CT: Significant findings Slide Number 6 Slide Number 7 Slide Number 8 Differential Diagnosis:�Bowel Wall Thickening CT: Vascular Imaging Clinical Course #1 CT: Scout Film CT: Significant Finding CT: Significant Findings CT: Significant Findings Differential Diagnosis:�Pneumatosis Intestinalis Clinical Course #2 Mesenteric Ischemia Imaging Mesenteric Ischemia: KUB Slide Number 20 Slide Number 21 Imaging Mesenteric Ischemia: CT Slide Number 23 Slide Number 24 Imaging Mesenteric Ischemia: Angiography Imaging Mesenteric Ischemia: Angiography Slide Number 27 Slide Number 28 Slide Number 29 Imaging Mesenteric Ischemia: MRA Summary References Acknowledgments