Manifestations of acute mesenteric ischemia on multidetector computed tomography_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

YANG Fan ¹ , ZENG Yi ² , HU Xiaoyan ¹ , ZHU Fei ³ ,  CHEN Weixia ³ , LIN Wei ¹

1. Department of Radiology, Chengdu First People’s Hospital, Chengdu 610041, P. R. China;
2. Department of Radiology, Sichuan Province Orthopedic Hospital, Chengdu 610041, P. R. China;
3. Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;

Corresponding author：

CHEN Weixia, Email: wxchen25@126.com

Keywords：

acute mesenteric ischemia; transmural intestinal necrosis; computed tomography

DOI：

10.7507/1007-9424.202207072

Video：

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Objective To summarize the manifestations of acute mesenteric ischemia (AMI) on multidetector computed tomography (MDCT) and the diagnostic value of MDCT in the prognosis of AMI. Method Recent studies on pathophysiology, CT features, and prognosis of AMI were retrieved and reviewed. Results Vascular insufficiency of AMI could occur as a result of mesenteric arterial embolism, arterial thrombosis, venous thrombosis, or nonocclusive. Two stages of AMI, early and late, were associated with distinct prognosis. In early ischemia, the lesions were reversible. The late AMI was characterized by the development of irreversible transmural necrosis. A delayed diagnosis leaded to considerable mortality. MDCT findings in AMI could be divided into imaging findings related to vascular insufficiency and ischemic intestinal injury. Pneumoperitoneum could be considered a sign of transmural necrosis in the AMI. While, other imaging features predicting transmural necrosis were controversial because of the heterogeneity of diagnostic tests. Conclusions AMI is a life-threatening abdominal emergency. Early diagnosis can improve the prognosis of patient. It is important for radiologists to identify prognostic features for differentiating early from late forms of AMI.

Citation： YANG Fan, ZENG Yi, HU Xiaoyan, ZHU Fei, CHEN Weixia, LIN Wei. Manifestations of acute mesenteric ischemia on multidetector computed tomography. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2023, 30(2): 224-229. doi: 10.7507/1007-9424.202207072 Copy

1.	Sinha D, Kale S, Kundaragi NG, et al. Mesenteric ischemia: a radiologic perspective. Abdom Radiol (NY), 2022, 47(5): 1514-1528.
2.	Wadman M, Syk I, Elmståhl S. Survival after operations for ischaemic bowel disease. Eur J Surg, 2000, 166(11): 872-877.
3.	Tsai MS, Lin CL, Chen HP, et al. Long-term risk of mesenteric ischemia in patients with inflammatory bowel disease: a 13-year nationwide cohort study in an Asian population. Am J Surg, 2015, 210(1): 80-86.
4.	Henes FO, Pickhardt PJ, Herzyk A, et al. CT angiography in the setting of suspected acute mesenteric ischemia: prevalence of ischemic and alternative diagnoses. Abdom Radiol (NY), 2017, 42(4): 1152-1161.
5.	Hagspiel KD, Flors L, Hanley M, et al. Computed tomography angiography and magnetic resonance angiography imaging of the mesenteric vasculature. Tech Vasc Interv Radiol, 2015, 18(1): 2-13.
6.	Menke J. Diagnostic accuracy of multidetector CT in acute mesenteric ischemia: systematic review and meta-analysis. Radiology, 2010, 256(1): 93-101.
7.	Clair DG, Beach JM. Mesenteric ischemia. N Engl J Med, 2016, 374(10): 959-968.
8.	Garzelli L, Nuzzo A, Copin P, et al. Contrast-enhanced CT for the diagnosis of acute mesenteric ischemia. AJR Am J Roentgenol, 2020, 215(1): 29-38.
9.	Costa AF, Chidambaram V, Lee JJ, et al. Multidetector computed tomography of mesenteric ischaemia. Insights Imaging, 2014, 5(6): 657-666.
10.	Florim S, Almeida A, Rocha D, et al. Acute mesenteric ischaemia: a pictorial review. Insights Imaging, 2018, 9(5): 673-682.
11.	Levine JS, Jacobson ED. Intestinal ischemic disorders. Dig Dis, 1995, 13(1): 3-24.
12.	Pedersoli F, Schönau K, Schulze-Hagen M, et al. Endovascular revascularization with stent implantation in patients with acute mesenteric ischemia due to acute arterial thrombosis: clinical outcome and predictive factors. Cardiovasc Intervent Radiol, 2021, 44(7): 1030-1038.
13.	Ha C, Magowan S, Accortt NA, et al. Risk of arterial thrombotic events in inflammatory bowel disease. Am J Gastroenterol, 2009, 104(6): 1445-1451.
14.	Matsumoto S, Sekine K, Funaoka H, et al. Diagnostic performance of plasma biomarkers in patients with acute intestinal ischaemia. Br J Surg, 2014, 101(3): 232-238.
15.	Klar E, Rahmanian PB, Bücker A, et al. Acute mesenteric ischemia: a vascular emergency. Dtsch Arztebl Int, 2012, 109(14): 249-256.
16.	Andraska E, Haga L, Reitz K, et al. Acute superior mesenteric venous thrombosis results in high rates of readmission and morbidity. J Vasc Surg Venous Lymphat Disord, 2020, 8(5): 748-755.
17.	Watson DW, Sodeman WA. The small intestine//Sodeman, Thomas M. Sodeman’s pathologic physiology. Philadelphia: WB Saunders, 1985: 813-851.
18.	Bagnacci G, Guerrini S, Gentili F, et al. Non-occlusive mesenteric ischemia (NOMI) and prognostic signs at CT: reperfusion or not reperfusion that is the question! Abdom Radiol (NY), 2022, 47(5): 1603-1613.
19.	Nakamura F, Yui R, Muratsu A, et al. A strategy for improving the prognosis of non-occlusive mesenteric ischemia (NOMI): a single-center observational study. Acute Med Surg, 2019, 6(4): 365-370.
20.	Expert Panels on Vascular Imaging and Gastrointestinal Imaging, Ginsburg M, Obara P, et al. ACR Appropriateness Criteria® imaging of mesenteric ischemia. J Am Coll Radiol, 2018, 15(11S): S332-S340. doi: 10.1016/j.jacr.2018.09.018.
21.	Chuong AM, Corno L, Beaussier H, et al. Assessment of bowel wall enhancement for the diagnosis of intestinal ischemia in patients with small bowel obstruction: value of adding unenhanced CT to contrast-enhanced CT. Radiology, 2016, 280(1): 98-107.
22.	Obmann MM, Punjabi G, Obmann VC, et al. Dual-energy CT of acute bowel ischemia. Abdom Radiol (NY), 2022, 47(5): 1660-1683.
23.	Daniel F, Alsheikh M, Ghieh D, et al. Bowel wall thickening on computed tomography scan: inter-observer agreement and correlation with endoscopic findings. Arab J Gastroenterol, 2020, 21(4): 219-223.
24.	Schieda N, Fasih N, Shabana W. Triphasic CT in the diagnosis of acute mesenteric ischaemia. Eur Radiol, 2013, 23(7): 1891-1900.
25.	Kim JY, Ha HK, Byun JY, et al. Intestinal infarction secondary to mesenteric venous thrombosis: CT-pathologic correlation. J Comput Assist Tomogr, 1993, 17(3): 382-385.
26.	Giambelluca D, Cutaia G, Midiri M, et al. The “paper-thin wall”appearance in acute mesenteric ischemia. Abdom Radiol (NY), 2019, 44(8): 2953-2954.
27.	Calame P, Winiszewski H, Doussot A, et al. Evaluating the risk of irreversible intestinal necrosis among critically ill patients with nonocclusive mesenteric ischemia. Am J Gastroenterol, 2021, 116(7): 1506-1513.
28.	Yikilmaz A, Karahan OI, Senol S, et al. Value of multislice computed tomography in the diagnosis of acute mesenteric ischemia. Eur J Radiol, 2011, 80(2): 297-302.
29.	Wiesner W, Khurana B, Ji H, et al. CT of acute bowel ischemia. Radiology, 2003, 226(3): 635-650.
30.	Moschetta M, Telegrafo M, Rella L, et al. Multi-detector CT features of acute intestinal ischemia and their prognostic correlations. World J Radiol, 2014, 6(5): 130-138.
31.	Fuchsjäger MH. The small-bowel feces sign. Radiology, 2002, 225(2): 378-379.
32.	Berl S, Dawkins A, DiSantis D. The small bowel feces sign. Abdom Radiol (NY), 2016, 41(4): 794-795.
33.	Tang W, Zhang J, Kuang LQ, et al. Relationship of superior mesenteric artery thrombus density with transmural intestinal necrosis on multidetector computed tomography in acute mesenteric ischemia. Quant Imaging Med Surg, 2021, 11(7): 3120-3132.
34.	Kanasaki S, Furukawa A, Fumoto K, et al. Acute mesenteric ischemia: multidetector ct findings and endovascular management. Radiographics, 2018, 38(3): 945-961.
35.	Wasnik A, Kaza RK, Al-Hawary MM, et al. Multidetector CT imaging in mesenteric ischemia—pearls and pitfalls. Emerg Radiol, 2011, 18(2): 145-156.
36.	Woodhams R, Nishimaki H, Fujii K, et al. Usefulness of multidetector-row CT (MDCT) for the diagnosis of non-occlusive mesenteric ischemia (NOMI): assessment of morphology and diameter of the superior mesenteric artery (SMA) on multi-planar reconstructed (MPR) images. Eur J Radiol, 2010, 76(1): 96-102.
37.	Siegelman SS, Sprayregen S, Boley SJ. Angiographic diagnosis of mesenteric arterial vasoconstriction. Radiology, 1974, 112(3): 533-542.
38.	Bala M, Kashuk J, Moore EE, et al. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World J Emerg Surg, 2017, 12: 38. doi: 10.1186/s13017-017-0150-5.
39.	Nuzzo A, Maggiori L, Ronot M, et al. Predictive factors of intestinal necrosis in acute mesenteric ischemia: prospective study from an Intestinal Stroke Center. Am J Gastroenterol, 2017, 112(4): 597-605.
40.	Atre ID, Eurboonyanun K, O’Shea A, et al. Predictors of transmural intestinal necrosis in patients presenting with acute mesenteric ischemia on computed tomography. Abdom Radiol (NY), 2022, 47(5): 1636-1643.
41.	Wang Y, Zhao R, Xia L, et al. Predictive risk factors of intestinal necrosis in patients with mesenteric venous thrombosis: retrospective study from a single center. Can J Gastroenterol Hepatol, 2019, 2019: 8906803. doi: 10.1155/2019/8906803.
42.	Lee SS, Ha HK, Park SH, et al. Usefulness of computed tomography in differentiating transmural infarction from nontransmural ischemia of the small intestine in patients with acute mesenteric venous thrombosis. J Comput Assist Tomogr, 2008, 32(5): 730-737.
43.	Wang X, Chu C, Sun S, et al. Outcomes and clinical characteristics of transmural intestinal necrosis in acute mesenteric ischemia. Scand J Gastroenterol, 2019, 54(8): 953-959.
44.	Zhao H, Meng Y, Zhang P, et al. Predictors and risk factors for intestinal necrosis in patients with mesenteric ischemia. Ann Transl Med, 2021, 9(4): 337. doi: 10.21037/atm-20-8154.
45.	Emile SH. Predictive factors for intestinal transmural necrosis in patients with acute mesenteric ischemia. World J Surg, 2018, 42(8): 2364-2372.
46.	Duron VP, Rutigliano S, Machan JT, et al. Computed tomographic diagnosis of pneumatosis intestinalis: clinical measures predictive of the need for surgical intervention. Arch Surg, 2011, 146(5): 506-510.

1. Sinha D, Kale S, Kundaragi NG, et al. Mesenteric ischemia: a radiologic perspective. Abdom Radiol (NY), 2022, 47(5): 1514-1528.
2. Wadman M, Syk I, Elmståhl S. Survival after operations for ischaemic bowel disease. Eur J Surg, 2000, 166(11): 872-877.
3. Tsai MS, Lin CL, Chen HP, et al. Long-term risk of mesenteric ischemia in patients with inflammatory bowel disease: a 13-year nationwide cohort study in an Asian population. Am J Surg, 2015, 210(1): 80-86.
4. Henes FO, Pickhardt PJ, Herzyk A, et al. CT angiography in the setting of suspected acute mesenteric ischemia: prevalence of ischemic and alternative diagnoses. Abdom Radiol (NY), 2017, 42(4): 1152-1161.
5. Hagspiel KD, Flors L, Hanley M, et al. Computed tomography angiography and magnetic resonance angiography imaging of the mesenteric vasculature. Tech Vasc Interv Radiol, 2015, 18(1): 2-13.
6. Menke J. Diagnostic accuracy of multidetector CT in acute mesenteric ischemia: systematic review and meta-analysis. Radiology, 2010, 256(1): 93-101.
7. Clair DG, Beach JM. Mesenteric ischemia. N Engl J Med, 2016, 374(10): 959-968.
8. Garzelli L, Nuzzo A, Copin P, et al. Contrast-enhanced CT for the diagnosis of acute mesenteric ischemia. AJR Am J Roentgenol, 2020, 215(1): 29-38.
9. Costa AF, Chidambaram V, Lee JJ, et al. Multidetector computed tomography of mesenteric ischaemia. Insights Imaging, 2014, 5(6): 657-666.
10. Florim S, Almeida A, Rocha D, et al. Acute mesenteric ischaemia: a pictorial review. Insights Imaging, 2018, 9(5): 673-682.
11. Levine JS, Jacobson ED. Intestinal ischemic disorders. Dig Dis, 1995, 13(1): 3-24.
12. Pedersoli F, Schönau K, Schulze-Hagen M, et al. Endovascular revascularization with stent implantation in patients with acute mesenteric ischemia due to acute arterial thrombosis: clinical outcome and predictive factors. Cardiovasc Intervent Radiol, 2021, 44(7): 1030-1038.
13. Ha C, Magowan S, Accortt NA, et al. Risk of arterial thrombotic events in inflammatory bowel disease. Am J Gastroenterol, 2009, 104(6): 1445-1451.
14. Matsumoto S, Sekine K, Funaoka H, et al. Diagnostic performance of plasma biomarkers in patients with acute intestinal ischaemia. Br J Surg, 2014, 101(3): 232-238.
15. Klar E, Rahmanian PB, Bücker A, et al. Acute mesenteric ischemia: a vascular emergency. Dtsch Arztebl Int, 2012, 109(14): 249-256.
16. Andraska E, Haga L, Reitz K, et al. Acute superior mesenteric venous thrombosis results in high rates of readmission and morbidity. J Vasc Surg Venous Lymphat Disord, 2020, 8(5): 748-755.
17. Watson DW, Sodeman WA. The small intestine//Sodeman, Thomas M. Sodeman’s pathologic physiology. Philadelphia: WB Saunders, 1985: 813-851.
18. Bagnacci G, Guerrini S, Gentili F, et al. Non-occlusive mesenteric ischemia (NOMI) and prognostic signs at CT: reperfusion or not reperfusion that is the question! Abdom Radiol (NY), 2022, 47(5): 1603-1613.
19. Nakamura F, Yui R, Muratsu A, et al. A strategy for improving the prognosis of non-occlusive mesenteric ischemia (NOMI): a single-center observational study. Acute Med Surg, 2019, 6(4): 365-370.
20. Expert Panels on Vascular Imaging and Gastrointestinal Imaging, Ginsburg M, Obara P, et al. ACR Appropriateness Criteria® imaging of mesenteric ischemia. J Am Coll Radiol, 2018, 15(11S): S332-S340. doi: 10.1016/j.jacr.2018.09.018.
21. Chuong AM, Corno L, Beaussier H, et al. Assessment of bowel wall enhancement for the diagnosis of intestinal ischemia in patients with small bowel obstruction: value of adding unenhanced CT to contrast-enhanced CT. Radiology, 2016, 280(1): 98-107.
22. Obmann MM, Punjabi G, Obmann VC, et al. Dual-energy CT of acute bowel ischemia. Abdom Radiol (NY), 2022, 47(5): 1660-1683.
23. Daniel F, Alsheikh M, Ghieh D, et al. Bowel wall thickening on computed tomography scan: inter-observer agreement and correlation with endoscopic findings. Arab J Gastroenterol, 2020, 21(4): 219-223.
24. Schieda N, Fasih N, Shabana W. Triphasic CT in the diagnosis of acute mesenteric ischaemia. Eur Radiol, 2013, 23(7): 1891-1900.
25. Kim JY, Ha HK, Byun JY, et al. Intestinal infarction secondary to mesenteric venous thrombosis: CT-pathologic correlation. J Comput Assist Tomogr, 1993, 17(3): 382-385.
26. Giambelluca D, Cutaia G, Midiri M, et al. The “paper-thin wall”appearance in acute mesenteric ischemia. Abdom Radiol (NY), 2019, 44(8): 2953-2954.
27. Calame P, Winiszewski H, Doussot A, et al. Evaluating the risk of irreversible intestinal necrosis among critically ill patients with nonocclusive mesenteric ischemia. Am J Gastroenterol, 2021, 116(7): 1506-1513.
28. Yikilmaz A, Karahan OI, Senol S, et al. Value of multislice computed tomography in the diagnosis of acute mesenteric ischemia. Eur J Radiol, 2011, 80(2): 297-302.
29. Wiesner W, Khurana B, Ji H, et al. CT of acute bowel ischemia. Radiology, 2003, 226(3): 635-650.
30. Moschetta M, Telegrafo M, Rella L, et al. Multi-detector CT features of acute intestinal ischemia and their prognostic correlations. World J Radiol, 2014, 6(5): 130-138.
31. Fuchsjäger MH. The small-bowel feces sign. Radiology, 2002, 225(2): 378-379.
32. Berl S, Dawkins A, DiSantis D. The small bowel feces sign. Abdom Radiol (NY), 2016, 41(4): 794-795.
33. Tang W, Zhang J, Kuang LQ, et al. Relationship of superior mesenteric artery thrombus density with transmural intestinal necrosis on multidetector computed tomography in acute mesenteric ischemia. Quant Imaging Med Surg, 2021, 11(7): 3120-3132.
34. Kanasaki S, Furukawa A, Fumoto K, et al. Acute mesenteric ischemia: multidetector ct findings and endovascular management. Radiographics, 2018, 38(3): 945-961.
35. Wasnik A, Kaza RK, Al-Hawary MM, et al. Multidetector CT imaging in mesenteric ischemia—pearls and pitfalls. Emerg Radiol, 2011, 18(2): 145-156.
36. Woodhams R, Nishimaki H, Fujii K, et al. Usefulness of multidetector-row CT (MDCT) for the diagnosis of non-occlusive mesenteric ischemia (NOMI): assessment of morphology and diameter of the superior mesenteric artery (SMA) on multi-planar reconstructed (MPR) images. Eur J Radiol, 2010, 76(1): 96-102.
37. Siegelman SS, Sprayregen S, Boley SJ. Angiographic diagnosis of mesenteric arterial vasoconstriction. Radiology, 1974, 112(3): 533-542.
38. Bala M, Kashuk J, Moore EE, et al. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World J Emerg Surg, 2017, 12: 38. doi: 10.1186/s13017-017-0150-5.
39. Nuzzo A, Maggiori L, Ronot M, et al. Predictive factors of intestinal necrosis in acute mesenteric ischemia: prospective study from an Intestinal Stroke Center. Am J Gastroenterol, 2017, 112(4): 597-605.
40. Atre ID, Eurboonyanun K, O’Shea A, et al. Predictors of transmural intestinal necrosis in patients presenting with acute mesenteric ischemia on computed tomography. Abdom Radiol (NY), 2022, 47(5): 1636-1643.
41. Wang Y, Zhao R, Xia L, et al. Predictive risk factors of intestinal necrosis in patients with mesenteric venous thrombosis: retrospective study from a single center. Can J Gastroenterol Hepatol, 2019, 2019: 8906803. doi: 10.1155/2019/8906803.
42. Lee SS, Ha HK, Park SH, et al. Usefulness of computed tomography in differentiating transmural infarction from nontransmural ischemia of the small intestine in patients with acute mesenteric venous thrombosis. J Comput Assist Tomogr, 2008, 32(5): 730-737.
43. Wang X, Chu C, Sun S, et al. Outcomes and clinical characteristics of transmural intestinal necrosis in acute mesenteric ischemia. Scand J Gastroenterol, 2019, 54(8): 953-959.
44. Zhao H, Meng Y, Zhang P, et al. Predictors and risk factors for intestinal necrosis in patients with mesenteric ischemia. Ann Transl Med, 2021, 9(4): 337. doi: 10.21037/atm-20-8154.
45. Emile SH. Predictive factors for intestinal transmural necrosis in patients with acute mesenteric ischemia. World J Surg, 2018, 42(8): 2364-2372.
46. Duron VP, Rutigliano S, Machan JT, et al. Computed tomographic diagnosis of pneumatosis intestinalis: clinical measures predictive of the need for surgical intervention. Arch Surg, 2011, 146(5): 506-510.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Manifestations of acute mesenteric ischemia on multidetector computed tomography

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