case abd-02

Person Incharged :

Dr Vimala

Diagnosis :

TRO Ischemic bowel/ TRO Acute appendicitis

Clinical Summary :

60 years old/ Male/ Active smoker , current issue Acute Anteroseptal MI Killip II with LV thrombus complaining of worsening epigastric pain radiating to RIF post PICC insertion

Findings and Discussion :

Atherosclerosis changes with scattered thick mural calcifications of abdominal aorta, bilateral common iliac, and external iliac arteries. Good opacification demonstrated in abdominal aorta. The coeliac artery, main inferior mesentric artery (IMA) and its visualised branches and bilateral renal arteries (single right renal and left double renal arteries) are well opacified. No filling defect.
Proximal superior mesentric artery (SMA) is well opacified. There is filling defect seen within the mid portion of SMA measuring 1.7cm in length. Patchy filling defect also seen within the 3rd and 4th jejunal branches of SMA. Distal SMA and rest of its visualised branches are opacified.The terminal branches of SMA are not clearly visualised.
The iliac and visualised femoral arteries are also normal in calibre.
Presence of air pockets within the SMV, but no filling defects seen within the superior mesenteric vein.
Caecal wall is mildly thickened associated with minimal adjacent pericolonic fat streakiness.
Minimal free fluid seen. Presence of diffuse intramural gases within proximal jejunal until terminal ileum are in keeping with pneumatosis intestinalsis. There are multiple tubular areas of low attenuation seen withn the mesentery , these findings are consistent with gas in the small mesenteric veins.
No bowel dilatation.
No bowel related mass. Appendix is normal. No pneumoperitoneum.

Liver is homogenously enhanced. Presence of branching small air pockets within the liver predominately at periphery of liver in keeping with pneumomatosis portalis.
Portal vein is patent.
No focal liver lesion. The visualised main hepatic artery and immediate branches are patent.
No biliary tree dilatation.
Gallbladder is well distended, and fully occupied by hyperdense material (HU: 369 to472) ? contrast accumulation from previous procedure.
No gallbladder wall thickening or pericholecystic fluid.
Pancreas, spleen, bilateral adrenal glands and kidneys are normal.
No hydroneprosis or hydroureter bilaterally.
Urinary bladder is partially distended. Prostate and seminal vesicles are normal.

Generalised degenerative changes. No suspicious bony lesions.
Patchy consolidation changes with airbronchogram and fibrotic changes seen at visualised bibasal lung fields. No pleural effusion.
Dilated and fluid filled within the visualized distal oesephagus.

Impression:
Features are suggestive of Superior Mesenteric Artery and its jejunal branches thrombosis, with small bowel ischemia and portomesenteric vein gases.

Learning Points :

Treatment decision

Notes:

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