Presentation
Vague abdominal pain and shortness of breath for 2 days.
Patient Data
Long segment of filling defects noted within the superior mesenteric vein extending into the main portal vein and right portal vein. Small bowel mesenteric congestion and stranding. Superior mesenteric artery appears to be well opacified.
Long segment of small bowel wall thickening with "target sign" involving the proximal jejunum. This segment of thickened jejunal bowel wall appears to be hypoenhancement compared to the rest of bowel wall.
No pneumatosis intestinalis , portal venous gas or pneumoperitoneum.
Long segment of filling defects are also noted within the left common iliac vein and external iliac vein.
Marked degree of ascites at upper abdomen, bilateral paracolic gutters, mesentery and pelvis.
Mild hepatomegaly. Bilateral renal cortical hypodense leisons (too small to characterize).
Uterus is bulky and anteverted with thickened endometrium. Left adnexal cystic lesions.
Wedge shaped lung consolidation at the posterobasal segment of left lower lobe with minimal left pleural effusion. Centrally located filling defects seen within subsegmental branches of left lower lobe posterobasal segment artery, suspicious of pulmonary embolism.
Annotated images showed the thickened proximal jejunal bowel wall, thrombus within the superior mesenteric vein and portal vein as well as the left lower lobe pulmonary embolism.
Case Discussion
Veno-occlusive mesenteric ischemia confirmed with emergency laparotomy. Long segment of proximal jejunum bowel resection with stoma formation. Patient was investigated for possible etiology of her hypercoagulable state.
Incidental finding of wedged shape lung consolidation raises the suspicion of pulmonary infarction. Prudent search of possible filling defects in the adjacent pulmonary arteries (although not the dedicated CT pulmonary angiogram) would be helpful to look for acute pulmonary embolism. This can account for patient's respiratory symptoms.
Veno-occlusive causes of acute mesenteric ischemia are not common, accounting for only 5-15% of all cases of acute mesenteric ischemia.
It is crucial to have review other sites of possible organ ischemia, including kidneys and lung in the case of widespread thrombosis.
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