Presentation
Severe abdominal pain.
Patient Data
Both arterial and portal venous phase images have been included, however note that there is relatively little difference in enhancement/erfusion between the two series related to poor cardiac function. The heart is dilated and there is thinning of the left ventricle.
On arterial phase images, there is a clear abrupt cut off at the origin of the superior mesenteric artery where there is absent filling distally and only minimal reconstitution of a few distal branches. On portal venous phase imaging, there are areas of hypoperfusion and peripheral ischemia of the posterior right hepatic lobe, infarcts of much of the spleen, and smaller infarcts within the kidneys.
Several abnormal loops of small bowel are mildly dilated with some fecalized contents and thin wall.
Case Discussion
This case is a challenging reminder that sometimes what you do not see" is the most important finding. This is particularly true of acute vascular events which could include both arterial and venous ischemia. However, this takes or much higher with arterial ischemia, and indeed the entire superior mesenteric artery is thrombosed in this case, likely due to cardiogenic embolus given the patient's heart disease. Additionally, there are multiple other areas of ischemia/infarct involving the right hepatic lobe, spleen, and small areas of the kidneys. The small bowel shows typical findings of acute ischemia, which were supported by the patient's earlier presentation of about 4 hours of abdominal pain, with cavitation/dilation and relatively thin hypoenhancing walls. Unfortunately, the patient was a poor operative candidate due to cardiac function and low ejection fraction, and passed shortly after this examination.
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