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

General case of the day. Intestinal ischemia, secondary to jejunal volvulus.

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...
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