General Carmen Antonio
Case M. Perez, MD Mart(nez-Noguera,
of the #{149} Jaime
Day1
Llauger, MD
MD
#{149} Lluis
Donoso,
MD
lb.
la.
2.
3.
(la) CT scan shows distended fluid-filled distal bowel loops. A lager center of the abdomen, with air within the wall (arrowheads) . There is a small amount (lb) CT scan obtained after bobus injection of contrast material demonstrates marked bowel walls. (2) CT scan obtained at a lower bevel shows distended proximal bowel orally administered contrast material, to the right of the abdomen. The bowel narrows and no contrast material is seen distally. (3) A more caudal section shows twisting of sign) (arrows). Figures
1-3.
level
HISTORY
U
A 49-year-old dominal pain. tient tomy sults
had undergone for calcifying of laboratory
Indexterms:
Intestines,
RadioGraphics I
From
man presented Twelve years
1991;
the Department
506
U
RSNA,
acute abthe pa-
CT, 741.1211
#{149} Intestines,
ischemia,
of amyhase
The of the
able.
pancreatoduodenoschronic pancreatitis. Retests revealed an increased
underwent
abdomen,
but
plain
findings
Abdominal computed was performed before of contrast
Intestines,
volvulus,
i Sant
Universitat
#{149}
in the
heukocytosis.
patient
(CT) ministration
95.761
and
is seen
of penitoneal fluid. enhancement of the loops, filled with to a point (arrows), the mesenteny (whirl
radiography were
unremark-
tomography and after
the ad-
material.
741.7233
1 1:506-507
of Diagnostic
Claret 167, 08025 Barcelona, 7, 1991, and received February c
with earlier,
loop
Radiology,
Spain. From 8; accepted
Hospital
the 1990 February
de La Santa
RSNA scientific 1 1 . Address
Creu assembly.
reprint
Pau,
Received December requests to C.M.P.
Autonoma, 18,
1990;
Avenida revision
San Antonio
Maria
requested
January
1991
RadioGrapbics
U
Perez
et al
Volume
11
Number
3
FINDINGS
U
ent
CT demonstrated distended, fluid-filled intestinal loops, with some intramural gas (Fig 1) . On scans obtained at lower levels, the bowel was narrowed, with no contrast matenial evident distally (Fig 2), and twisting of the mesentery was observed (Fig 3). DIAGNOSIS: Intestinal to jejunal volvuhus. U
ischemia,
secondary
DISCUSSION
The
diagnosis
of ischemic
intestinal
necrosis
higher in older patients, with a mortality of 80%-90% (1). Clinical presentation, anahytical data, and results from conventional radiographic studies are nonspecific and do not allow a definitive diagnosis to be made (16) . CT allows precise noninvasive diagnosis intramural
and
lar aim (portal or mesentemic) cur late in intestinal ischemia,
.
intravascu-
These signs ochowever, and
.
3
.
4
.
ischemia
secondary
to
occlusive vohvuhus. The reported mortality from this type of intestinal necrosis is 30% and is related to the difficulties in establishing an early diagnosis by means of conventional radiographic techniques and to the rapid
evolution
hoop
(7,8).
to necrosis
of the
diagnosis, markedly
of CT findings, nosis.
Our
which
patient
jejunal
made on the basis improves the prog-
underwent
volvuhus
surgery,
secondary
abrupt
point
of transition
lapsed distal intestinal distended, and twisted contrast material. The entery
which
and
is due
the
ends
5.
to adhe-
with
col-
(2,3,6).
of
Federbe MP, Chun G, Jeffrey RB, Rayon R. Computed tomographic findings in bowel infanction. AJR 1984; 142:9i-95. Clark RA. Computed tomography of bowel infarction. J Comput Assist Tomogr 1987; Alpern MB, Glazer GM, Francis IR. Ischemic or infarcted bowel: CT findings. Radiology 1988; 166:149-152. Balthazar EJ, Hulnick D, Megibow AJ, OpuhenciaJF. Computed tomography of intramural
6.
7.
hemorrhage
ComputAssistlomogr Smerud MJ,Johnson nosis plain
during
course was uneventful. In the experience of other authors, all such patients have survived surgery following correct diagnosis from CT results (6-8). The CT findings of intestinal ischemia 5ccondary to volvuhus are characteristic: distended and fluid-filled proximal bowel
bubbles
11:757-762.
closed
sions and ischemic necrosis of the volvuhated segment were observed. Partial resection with terminal-to-terminal anastomosis was performed, and the patient’s postoperative
sign,
of spherical
intestinal
An accurate
hoops;
line
REFERENCES
2
of intestinal
enable
This
struction. The use of CT should be particularly encouraged in patients with a history previous abdominal surgery who present with acute abdominal pain.
.
not
not is not (6,9).
(9).
of volvuhus
Portal or mesentenic venous gas occurs nelatively infrequently, and it is present in cases of advanced bowel ischemia. In our opinion, CT remains the best radiologic choice for detecting closed-hoop ob-
1
does
is clearly (75%), but be apparent when the mesentenic parallel to the tomographic sec-
sign
only the presence of intramural gas clearly indicates an ischemic complication. Intramural gas may be observed in 50% of patients with intestinal infarction, whether it is of vascular origin on secondary to intestinal obstruction. Intramural gas appears as a small
U
CT demonstration
is characteristic
specific
Although the typical torsion of the mesentenic moot is a characteristic sign of volvuhus,
a bet-
agnosis
1991
tion
ten prognosis when the cause of ischemia is of vascular origin (arterial or venous). On the other hand, CT is helpful in the di-
thus
May
it may
axis
curved
is made in one of 1 ,000 emergency admissions. The prevalence of this condition is
by demonstrating
hoop,
the most
9-
bowel
J
ischemia.
1987; 11:67-72. CD, Stephens DH.
of bowel infarction: films and CT scans
a comparison in 23 cases.
Diagof
AJR
1990; 154:99-103. Perez C, LlaugerJ, PuigJ, PahmerJ. Computed tomographic findings in bowel ischemia. Gastrointest Radio! 1989; 14:24 1-245. Balthazar
EJ, BaumanJS,
agnosis 8.
and
Megibow
AJ.
CT di-
of closed
loop obstruction. J Comput Assistlomogr 1985; 9:953-955. Kessler RM, Lentz JC, Abdenour GE, Poole CA. Mesentenic vascular gas secondary to ischemic bowel in transmesentenic hernia. Radiology FisherJK.
1981; 140:645-646. Computed tomographic
of volvubus in intestinal gy 1981; 140:145-146.
malnotation.
diagnosis
Radiobo-
hoops; and U-shaped, hoop containing oral presence of the whirl
to the
twisting
of the afferent
of the
mes-
and
effem-
Perez
et al
U
RadioGrapbks
U
507