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Small bowel (SB) ischemia resulting from mesenteric arterial or venous narrowing or occlusion, leading to inadequate supply of nutrients and oxygen
Best imaging tool
CT angiography; multiplanar reformations; water for oral contrast
Catheter angiography for confirmation & treatment
Imaging findings vary, based on etiology and acuity of ischemic injury
Acute arterial thrombosis or embolus
Little SB wall thickening, mesenteric edema, or ascites
Lack of bowel mucosal enhancement due to compromised arterial flow
CT signs of embolic ischemic injury to other organs
Chronic arterial occlusive disease
Narrowing or occlusion of SMA with collateral vessels
Mesenteric venous thrombosis
Fluid-distended SB with thick walls
Infiltrated mesentery and ascites
Occurs in prothrombotic (hypercoagulable) disorders
Pneumatosis intestinalis and portal venous gas
Not sensitive nor specific for bowel ischemia
Branching gas extending to periphery of liver
Nonocclusive bowel ischemia
Common etiologies: Closed-loop SB obstruction; cocaine or methamphetamine use; hypotensive episode; vasculitis
Multiplanar, multiphasic CECT is best imaging tool
Can generate CT angiogram; makes arterial or venous occlusion more apparent and quantifiable
Shows etiology of nonocclusive ischemia (e.g., closed-loop SB obstruction)
Catheter angiography
Diagnostic confirmation and treatment of arterial occlusive disease
Diagnosis of bowel ischemia demands correlation of clinical, laboratory, and imaging findings
Acute mesenteric ischemia
Small bowel (SB) ischemia resulting from mesenteric arterial or venous narrowing or occlusion, leading to inadequate supply of nutrients and oxygen
Best diagnostic clue
Pneumatosis (SB wall gas) ± portal vein gas
This is late sign; neither sensitive nor specific for bowel infarction
Imaging findings vary, based on etiology and acuity of ischemic injury
Radiography
Dilated bowel with air-fluid levels; ileus pattern
Thickening of valvulae conniventes
Linear distribution of gas (pneumatosis intestinalis)
Barium studies
Thickening of valvulae conniventes (transverse SB folds)
Thumbprinting pattern: Intramural accumulation of blood distending submucosa → focally rounded SB folds, especially along mesenteric border
Stack of coins pattern: Enlarged, smooth, straight, parallel folds perpendicular to longitudinal axis of SB (submucosal edema)
Strictures often seen with proximal bowel dilation (subacute or chronic finding)
Mottled, frothy, bubbly, or linear collections of gas in bowel wall (pneumatosis intestinalis)
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