Transient Angioedema of the Small Bowel because of Intravenous Nonionic Iodinated Contrast Media

Abstract

A 14-year-old girl was referred to our hospital for suspected accessory spleen torsion. There was no history of allergy or medication use. Abdominal multiphase contrast-enhanced computed tomography (CT) was performed. The patient had mild abdominal discomfort after intravenous administration of nonionic iodinated contrast media (CM) for CT. CT images in the arterial phase showed normal proximal small bowel (Figure 1); however, CT images in the venous phase revealed that the proximal small bowel had circumferential thickening of the wall including the duodenum (Figure 2). There was no accessory spleen torsion. We believed that the abdominal discomfort was caused by bowel angioedema during CM injection. The symptom resolved conservatively without any treatment.Figure 2Venous phase computed tomography. A, Circumferential thickening of the first to second segment of the duodenum (black arrow). B, Circumferential thickening of the third to fourth segment of the duodenum (white arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) There are several adult case reports on small-bowel anaphylactic angioedema induced by CM administration.1Hu X.H. Gong X.Y. Hu P. Transient small bowel angioedema due to intravenous iodinated contrast media.World J Gastroenterol. 2012; 18: 999-1002Crossref PubMed Scopus (8) Google Scholar, 2Park S.W. Bae I.Y. Eun H.W. Park H.W. Choe J.W. Small-bowel angioedema during screening computed tomography due to intravenous contrast material.J Comput Assist Tomor. 2011; 35: 549-552Crossref PubMed Scopus (6) Google Scholar, 3Kulkarni K.N. Hegde R.G. Balani A. Joshi A.R. Transient angioedema of small bowel secondary to intravenous iodinated contrast media.Indian J Radiol Imaging. 2014; 24: 303-305Crossref PubMed Scopus (2) Google Scholar In an adult study, the incidence of CM-associated bowel angioedema ranged from 1.7% to 3.3%.4Seo N. Chung Y.E. Lim J.S. Song M.K. Kim M.J. Kim K.W. Bowel angioedema associated with iodinated contrast media: incidence and predisposing factors.Invest Radiol. 2017; 52: 514-521Crossref PubMed Scopus (3) Google Scholar CM-associated bowel angioedema rapidly develops in the small intestine, particularly the proximal segment, owing to the richer supply of vessels1Hu X.H. Gong X.Y. Hu P. Transient small bowel angioedema due to intravenous iodinated contrast media.World J Gastroenterol. 2012; 18: 999-1002Crossref PubMed Scopus (8) Google Scholar and, in this case, only the duodenum was affected in the venous phase. Although most patients with CM-associated bowel angioedema tend to complain of mild abdominal discomfort, this symptom usually does not require any specific treatment.3Kulkarni K.N. Hegde R.G. Balani A. Joshi A.R. Transient angioedema of small bowel secondary to intravenous iodinated contrast media.Indian J Radiol Imaging. 2014; 24: 303-305Crossref PubMed Scopus (2) Google Scholar Moreover, no pericentric infiltration, mesenteric edema, free fluid, or vascular abnormality was observed with CM-associated bowel angioedema.4Seo N. Chung Y.E. Lim J.S. Song M.K. Kim M.J. Kim K.W. Bowel angioedema associated with iodinated contrast media: incidence and predisposing factors.Invest Radiol. 2017; 52: 514-521Crossref PubMed Scopus (3) Google Scholar In this case, although the proximal small bowel was normal in the arterial phase, after 45 seconds, there was thickening of the proximal small bowel wall in the venous phase. The patient had abdominal discomfort after CM injection, and the symptom resolved without any particular treatment. There were no associated inflammatory changes or vascular abnormalities. This is the first pediatric case of CM-associated bowel angioedema, indicating that CM-associated bowel angioedema can develop in children.