Wall Ischemia Research Articles

DIAGNOSE WITH “MIRIZZI SYNDROME”

Mirizzi syndrome is a rare but serious complication of the gallstone disease. In 1948 Pablo Luis Mirizzi for the first time described the so called ‘functional hepatic syndrome in patients ‘, who had obstructing concretion in d. cysticus causing cholestasis in the general bile duct by external compression. The compression, process of inflammation and wall ischemia result in erosion of the tissue engaged and appearance of various complications – abscess of the gallbladder, perivesicalar abscess, cholecystoduodenal fistula, stricture of bile ducts, biliary fistula. Mirizzi syndrome is still a challenge before the surgeon because of the a change in the normal anatomy and the severe process of inflammation. Good knowledge of the problem is essential for the accurate diagnosis and treatment. The operative strategy has two main goals – provision of efficient passage of the gall and reliable restoration of the hepato-choledochus. Choosing the surgical tactics during the operative intervention is of foremost importance – cholecystectomy in type I and restoration of the integrity of the bile ducts by T-tube drainage, plastic surgery of the hepato-choledochus or bilio-digestive anastomoses in type II-IV. The good knowledge of the problem and anatomic variations keeps safe the surgical team form iatrogenic lesions of the bile ducts and contributes for favourable postoperative results.

MR Imaging-based Evaluation of Mesenteric Ischemia Caused by Strangulated Small Bowel Obstruction and Mesenteric Venous Occlusion: An Experimental Study Using Rabbits.

Purpose:This study assessed the MRI findings of strangulated small bowel obstruction (SBO) and mesenteric venous occlusion (MVO) in a rabbit model using 3T MRI.Materials and Methods:Twenty rabbits were included in this study. The strangulated SBO and MVO models were generated via surgical procedures in nine rabbits, and sham surgery was performed in two rabbits. The success of generating the models was confirmed via angiographic, macroscopic, and microscopic findings after the surgical procedure. MRI was performed before and 30 min after inducing mesenteric ischemia. T1-weighted images (T1WIs), T2-weighted images (T2WIs), and fat-suppressed T2WIs (FS-T2WIs) were obtained using the BLADE technique, and fat-suppressed T1WIs (FS-T1WIs) were obtained. The signal intensities of the affected bowel before and after the surgical procedures were visually categorized as high, iso, and low intense compared with the findings for the normal bowel wall on all sequences. Bowel wall thickness was measured, and the signal intensity ratio (SI ratio) was calculated using the signal intensities of the bowel wall and psoas muscle.Results:Angiographic, macroscopic, and microscopic findings confirmed that all surgical procedures were successful. The ischemic bowel wall was thicker than the normal bowel. The bowel wall was thicker in the MVO model (3.17 ± 0.55 mm) than in the strangulated SBO model (2.26 ± 0.46 mm). The signal intensity and SI ratio of the bowel wall were significantly higher after the procedure than before the procedure on all sequences in both models. The mesentery adjacent to the ischemic bowel loop exhibited a high signal intensity in all animals on FS-T2WIs.Conclusion:Non-contrast MRI can be used to evaluate mesenteric ischemia caused by strangulated SBO and MVO. FS-T2WIs represented the best modality for depicting the high signal intensity in the bowel wall and mesentery caused by ischemia.

Thrombotic microangiopathy as a cause of cardiovascular toxicity from the BCR-ABL1 tyrosine kinase inhibitor ponatinib

AbstractThe third-generation tyrosine kinase inhibitor (TKI) ponatinib has been associated with high rates of acute ischemic events. The pathophysiology responsible for these events is unknown. We hypothesized that ponatinib produces an endothelial angiopathy involving excessive endothelial-associated von Willebrand factor (VWF) and secondary platelet adhesion. In wild-type mice and ApoE−/− mice on a Western diet, ultrasound molecular imaging of the thoracic aorta for VWF A1-domain and glycoprotein-Ibα was performed to quantify endothelial-associated VWF and platelet adhesion. After treatment of wild-type mice for 7 days, aortic molecular signal for endothelial-associated VWF and platelet adhesion were five- to sixfold higher in ponatinib vs sham therapy (P < .001), whereas dasatinib had no effect. In ApoE−/− mice, aortic VWF and platelet signals were two- to fourfold higher for ponatinib-treated compared with sham-treated mice (P < .05) and were significantly higher than in treated wild-type mice (P < .05). Platelet and VWF signals in ponatinib-treated mice were significantly reduced by N-acetylcysteine and completely eliminated by recombinant ADAMTS13. Ponatinib produced segmental left ventricular wall motion abnormalities in 33% of wild-type and 45% of ApoE−/− mice and corresponding patchy perfusion defects, yet coronary arteries were normal on angiography. Instead, a global microvascular angiopathy was detected by immunohistochemistry and by intravital microscopy observation of platelet aggregates and nets associated with endothelial cells and leukocytes. Our findings reveal a new form of vascular toxicity for the TKI ponatinib that involves VWF-mediated platelet adhesion and a secondary microvascular angiopathy that produces ischemic wall motion abnormalities. These processes can be mitigated by interventions known to reduce VWF multimer size.

MP17-01 DOES URETERAL ACCESS SHEATH CAUSE URETERAL STRICTURE IN RETROGRADE INTRARENAL SURGERY?

INTRODUCTION AND OBJECTIVES:Placement of the ureteral access sheath (UAS) carries an increased risk of ureteral wall ischaemia and injury to the mucosal or muscular layers of the ureter, and it the...

Попытка эндоскопического лечения высокой обтурационной кишечной непроходимости, обусловленной билиарными конкрементами

The interest of the above clinical case is that cholecysto-duodenal fistula, which arose against the background of cholelithiasis and caused high obstructive small intestinal obstruction by biliary calculi migrated from it, is a very rare complication of gallstones and was diagnosed at the preoperative stage. Patient B, 75 years old, was admitted to GBUZ “KKB No. 2” in Krasnodar on July 21, 2016 with a diagnosis of Cholelithiasis. Chronic calculous cholecystitis. Choledocholithiasis. High small bowel obstruction? The first step was performed diagnostic esophagogastroduodenoscopy. When endoscopy at the output level of the LDPC, along the back wall, a wall defect in the form of a cholecysto-duodenal fistula with visualization of the gallbladder cavity is determined. At the level of the lower horizontal branch of the duodenum, there are mobile multiple biliary concrements that completely overlap the lumen of the duodenum. It was decided to perform endoscopic mechanical litoextraction of these stones. With the Dormia basket probe, movable duodenal calculi were captured and removed. After deleting the mobile calculus data, we found a large calculus that completely covered the duodenal lumen. An attempt was made to electrohydraulic lithotripsy of this large calculus of duodenum. The calculus was fragmented. But when trying to hold an endoscope for calculus fragments, in order to capture them with a basket of Dormia, the ischemic wall of the duodenum perforated. The patient was transferred to the operating room, where laparotomy, duodenotomy, removal of the wedged calculus of the lower horizontal branch of the duodenum, suturing of the duodenum defect were performed. On day 12 after surgery, the patient was discharged from the hospital in a satisfactory condition.

A case report: unmasking a singular culprit for cardiogenic shock: looking beyond the coronary tree.

BackgroundCardiogenic shock remains challenging in its therapy and aetiology.Case summaryA 74-year-old woman admitted for cardiogenic shock requiring mechanical ventilation and high-dose inotropics and vasopressors with an electrocardiogram showing left ventricular (LV) lateral wall ischaemia had diffuse coronary artery disease but TIMI III flow in the coronary tree. An echocardiogram showed a suspicious mass invading the left ventricle and computed tomography scan revealed an advanced lung cancer with LV wall and pulmonary artery invasion as the cardiogenic shock cause.DiscussionWhen managing cardiogenic shock, it is important to consider different and not obvious diagnosis. A high level of clinical suspicion and multimodality imaging assessment was very important in the present case to attain the diagnosis.

Кишечная стенка при острой ишемии: данные прижизненной оптической когерентной томографии и гистологического анализа

The objective is to study the morphometric signs of small bowel ischemic damage basing on intravital optical coherence tomography data and further histological analysis Materials and methods. The study was carried out on male Wistar rats with the use of two models of acute intestinal ischemia: acute occlusive mesenteric ischemia by а. jejunales ligation (group “I”) and acute arteriovenous ischemia by a small bowel loop and frill strangulation together with а. et v. jejunales (group “II”). The state of intramural vessels in vivo was evaluated with the use of optical coherence angiography (OCA). After the macroscopic signs of non-viability appeared the bowel was resected and its stepwise histological analysis was carried out. Results. Ischemic damage development in group “I” was accompanied by decrease of bowel wall thickness by 34,8-42,4% (p=0,032) due to submucous layer destruction - based on histological analysis data and also by decrease of total length of functioning intramural vessels by 4,6% (p=0,004) - based on OCA data. According to the OCA data in group “II” the length of functioning vessels decreased by 89,6%in the strangulated bowel loop and by 6,1% in adducent and abducent sections (p=0,001). In the strangulated loop histological specimens sharply dilated thrombosed veins were seen in all layers of bowel wall, seromuscular layer oedema and diapedesis hemorrhages of mucous coat also took place as well as bowel wall thickening by 25,2% in comparison with the intact one. Conclusions. Сomplex analysis of in vivo optical coherence tomography results and further histological analysis of ischemic small bowel wall made it possible to determine the morphological manifestations which are specific for arterial and arteriovenous mesenteric blood flow disorder. In cases of mesenteric artery occlusion hypoperfusion and mucous coat ischemia are predominant among pathogenetic mechanisms of bowel wall alteration. In the strangulated bowel the main factor of destruction and necrosis is acute insufficiency of venous outflow.

59 - Effects of chronic antioxidant supplementation in diabetic mellitus patients

Background Diabetes mellitus is a chronic metabolic disorder induces ROS/advance glycation end (AGE) products leading to oxidative stress and other diabetic-associated complications. While short term antioxidant supplementation appears to be beneficial in diabetic patients, their chronic effects seem to be inefficient. Here we clinically assessed the long-term effects of multivitamin/antioxidant consumption in diabetic patients. Methods Diabetic patients (n=45; 26 male & 19 female) receiving either insulin or anti-hyperglycemic drugs (i.e. Gliclazide-80mg or Metformin-500mg/day) were included in this study. These patients were allowed to consume antioxidant/vitamin supplements (500mg/day) regularly for about 5 years. Body mass index, fasting/postprandial blood glucose, blood pressure, glycated hemoglobin (HbA1c), and electrocardiogram were assessed during their first visit and after 5 years. Results Based on the blood glucose/HbA1c levels, the patients were classified into 3 groups; GpI – pre (n=29), GpII – moderately (n=8) and GpIII – severely diabetic (n-8). At the end of year 5, the total antioxidant capacity was significantly higher (>2.5 fold) in diabetic patients consuming antioxidant combo vs. healthy controls. While there was a significant improvement in controlling diabetes in one-half of the patients, the remaining half exhibited severe diabetes (n=22). Interestingly, a subset of (n=7) these patients developed signs of heart failure after 5 years of antioxidant consumption. In particular, impaired electrocardiographic patterns for heart failure such as decreased T-wave, antero-spetal MI with left anterior hemi block (T-wave inversion), right bundle branch block, left ventricular hypertrophy with tall QRS, disrupted V4-V6 leads, and anterior wall ischemia with compromised V1-V6 leads were noticed. These results reveal that a chronic consumption of antioxidant combo failed to protect the patients from diabetic complications. Conclusion Our results conclude that while antioxidant consumptions did not suppress diabetes, a subset of diabetic patients developed signs for CVD risk. Our future investigations will include a larger patient cohort to confirm these claims.

Pneumatosis Intestinalis: Cost Paid for Rheumatoid Arthritis Treatment

Background: Pneumatosis intestinalis (PI) is the presence of air in the bowel wall. It is a rare complication of chemotherapy; herein we describe a case resulting from treatment with Rituximab. Case description: A 75-year-old woman with rheumatoid arthritis who began Rituximab therapy 8 weeks prior to admission came with 1 week history of abdominal distension and constipation. She was seen in the emergency department 2 days prior to this and X-ray of her abdomen at that time showed bowels filled with stools and was discharged home after enema. She presented again with worsening symptoms and with new radiographic evidence of air in the bowel wall. She had stable vitals and no signs of sepsis. Examination revealed diffuse abdominal discomfort. CT showed pneumatosis in the descending colon without obstruction. Ceftriaxone and metronidazole were started for presumed colitis. Two days after admission, her symptoms improved but she developed leukocytosis of 18*103/uL with 18% bands and Bacteroides bacteremia. Repeat CT abdomen showed pneumatosis extending to the cecum and terminal ileum. On day 5 an exploratory laparotomy was performed, which showed necrotic ascending colon and terminal ileum, and walled off perforation with multiple abscesses. Hemicolectomy with diversion loop ileostomy was performed. Pathological examination of the resected bowel revealed hemorrhagic ischemic bowel wall with ulcerations. Patient recovered well after 35 days of hospital stay. Discussion: Rituximab is a CD20 monoclonal antibody works by inducing antibody and complement mediated cellular cytotoxicity. Rituximab mediated adverse effects including bowel obstruction and perforation, typically occur between 1-77 days after the first dose, as was seen in our patient. Our case is an example of how chemotherapy can mask signs of inflammation. Despite having abdominal perforation and abscess our patient had only mild abdominal discomfort and no other signs of peritonitis. The pathogenesis of PI is unclear. While PI from Rituximab is thought to be secondary to increased mucosal permeability, the ischemic bowel wall in our patient may be due to a direct cytotoxic effect. Conclusion: Since symptoms of perforation may be less evident in patients receiving chemotherapy, clinicians should consider that select patients may need operative intervention, as opposed to conservative management, if they fail to improve.1517 Figure 1 No Caption available.

The possibility of assessing the viability of the intestinal wall of rabbits in experimental mesenterial thrombosis with the help of the device «Minimax-Doppler-K»

Experimental thrombosis of mesenteric vessels was caused by the upper mesenteric artery compression by 30 minutes at different levels in 7 rabbits. With the help of microcirculation prarameters registered by the device «Minimax-Doppler-K» and ad oculus evaluation the zones of intestinal wall ischemia caused by thrombosis were determined. It is revealed that the ad oculus ischemia zones are significantly less common in area than the ischemia zones registered with the help of the device. Subsequent studies can reduce the % of insolvency of the seams after operations.

The Case for Takotsubo Cardiomyopathy (Syndrome) as a Variant of Acute Myocardial Infarction

The Case for Takotsubo Cardiomyopathy (Syndrome) as a Variant of Acute Myocardial Infarction

Abstract 422: Recognition of Pharyngeal Pain as an Angina Equivalent

A 64-year-old man presented to his physician with a 5-day history of throat pain and hoarseness. An initial diagnosis of pharyngitis was made, and the patient was sent home with a 7-day course of antibiotic therapy. He returned 6 days after his initial visit with persistent symptoms, which he now described as worsening on exertion such as when lifting weights. He was sent for a neck computed tomography to evaluate cervical soft tissues: No masses, enhancing lesions, lymphadenopathies, or imaging findings suggesting vocal cord paresis were noted. An ECG was ordered by the patient’s primary care physician and demonstrated new lateral T-wave inversions. The patient was also referred to ENT, and via direct laryngoscopy normal true vocal cords and questionable evidence of laryngopharyngeal reflux were visualized. He was then recommended to begin lifestyle modifications and start empiric treatment with omeprazole twice daily. Due to the ECG findings, an exercise stress test was ordered. During the exercise stress test, He developed throat tightness and the study was converted to a Lexiscan nuclear stress test. The stress test revealed inferior wall ischemia of moderate severity. Consequently, a coronary cath demonstrated quadruple vessel disease with 75% occlusion of left main, 70% stenosis of proximal LAD, 60% stenosis of the first diagonal, and total occlusion of the mid RCA. After undergoing quadruple coronary bypass surgery, the patient experienced a total resolution of his throat pain. Discussion: When approaching craniofacial pain elicited with exertion, it is essential for the clinician to consider ischemic heart disease as an etiology. Furthermore, the link of pain with physical activity and, additionally, pain relief with rest should drive the physician to consider cardiac ischemia. Isolated craniofacial pain or sole pharyngeal pain of cardiac origin are infrequent indicators of significant coronary artery disease. In a prospective multicenter study, only 6% of patients with confirmed ischemic cardiomyopathy presented with craniofacial pain as the only complaint. This case illustrates the importance of a thorough history and physical examination as well as a broad differential diagnosis when evaluating patients with throat pain and hoarseness.

Analysis of ischaemic crisis using the informational causal entropy-complexity plane

In the present work, an ischaemic process, mainly focused on the reperfusion stage, is studied using the informational causal entropy-complexity plane. Ischaemic wall behavior under this condition was analyzed through wall thickness and ventricular pressure variations, acquired during an obstructive flow maneuver performed on left coronary arteries of surgically instrumented animals. Basically, the induction of ischaemia depends on the temporary occlusion of left circumflex coronary artery (which supplies blood to the posterior left ventricular wall) that lasts for a few seconds. Normal perfusion of the wall was then reestablished while the anterior ventricular wall remained adequately perfused during the entire maneuver. The obtained results showed that system dynamics could be effectively described by entropy-complexity loops, in both abnormally and well perfused walls. These results could contribute to making an objective indicator of the recovery heart tissues after an ischaemic process, in a way to quantify the restoration of myocardial behavior after the supply of oxygen to the ventricular wall was suppressed for a brief period.

Chest Pain and Palpitations - Lacrosse

HISTORY: A 15-year-old female HS lacrosse player presented for episodes of chest pain and palpitations, initially at rest for minutes and then became exertional with SOB. She denied nausea, HA, and syncope. Family history was negative for congenital heart disease and sudden cardiac death, but her mother had atrial fibrillation and MGF died before age 60 from an MI. PHYSICAL EXAMINATION: T 97.7°F, HR 56, BP 116/68, RR 20, SpO2 98% RA, BMI 20.7 Well appearing with clear breath sounds. Cardiac exam: regular rhythm, normal S1 and S2, no S3 or S4, and a 2/6 low frequency systolic murmur best heard at the left upper sternal border. 2+ pulses. No peripheral edema, cyanosis, or hepatomegaly. DIFFERENTIAL DIAGNOSIS: 1. arrhythmia - SVT, WPW, aflutter, afib, PACs 2. pulmonary valve stenosis, tricuspid valve regurgitation 3. cardiomyopathy—hypertrophic cardiomyopathy, ARVD 4. ASD 5. anemia 6. hyperthyroidism TEST AND RESULTS: -ECG- sinus bradycardia, no chamber enlargements or pre-excitation, normal QTc -28 day event monitor- two episodes of chest pain and rapid heart beat correlate with nsr and sinus tachycardia -Transthoracic echocardiogram- normal cardiac segmentation, valvular function, biventricular size, and systolic function. No effusion. There is a small coronary cameral fistula entering the main pulmonary artery. -Exercise stress with 2D echocardiogram performed showed normal EF with no wall motion abnormalities, ischemia, or arrhythmias FINAL WORKING DIAGNOSIS: Coronary-cameral fistula TREATMENT AND OUTCOMES: 1. The patient was cleared to play after symptoms spontaneously resolved and serial echocardiograms over a 5 year period demonstrated a stable coronary-cameral fistula. 2. Cardiology consultants recommended a rest/stress MRI to further determine the anatomical nature of the fistula given the symptom history. However, they believe that the fistula was an incidental finding and likely not the cause of her symptomatology. 3. Coronary-cameral fistula is a rare cause of congenital cardiac anomalies. Although most are small and asymptomatic, larger ones may cause MI or CHF, thus requiring intervention. 4. There are no published reports of this condition in athletes, highlighting provocative issues surrounding risks of incidental findings of unknown significance and return to play considerations.

Bouveret's Syndrome: Literature Review.

It was in 1896 that Bouveret’s syndrome acquired its name after the French physician Leon Bouveret, who published two case reports in Revue de Medecin. Bouveret’s syndrome describes gastric outlet obstruction secondary to an impacted gallstone. The gallstone reaches the small bowel through a bilioenteric fistula as a consequence of chronic inflammation and adherence between the biliary system and the bowels which increase the intraluminal pressure and leads to secondary wall ischemia and wall perforation with gallstone passage into the bowel. Bouveret’s syndrome’s prevalence is highest among elderly women. Despite the rarity of Bouveret’s syndrome, it can cause notable morbidity and mortality rates. We underwent a review of literature about Bouveret syndrome to increase awareness of its occurrence and potentially life-threatening complications.

Safety and Efficacy of Prostatic Artery Chemoembolization for Prostate Cancer—Initial Experience

PurposeTo evaluate outcome of prostatic artery chemoembolization for patients with prostate cancer (PCa). Materials and MethodsThis single-center prospective cohort study was conducted between August 2013 and July 2016 in 20 patients with PCa who underwent chemoembolization. Mean patient age was 67.5 years ± 6.4. Gleason score was 6–10, and staging was T2N0M0. Fifteen patients refused prostatectomy and 5 wanted to stop hormonal therapy because of side effects. For chemoembolization, Chelidonium majus mother tincture 1 mL was slowly injected into the prostatic arteries. Docetaxel 1 mL and 150–300 μm Embosphere (Merit Medical Systems, Inc, South Jordan, Utah) microspheres 0.5 mL were thoroughly mixed, and the mixture was slowly injected by the same route. Embolization of prostatic arteries was finished with 150–300 μm Embosphere microspheres. Technical success was defined as bilateral prostatic artery embolization. Biochemical failure was defined as prostate specific antigen (PSA) decrease to < 2 ng/mL followed by recurrence when PSA increased to > 2 ng/mL within 1 month after success. ResultsTechnical success was 80.0% (16/20 patients). Biochemical failure was 18.7% (3/16 patients). There was 1 short-term biochemical recurrence at 4 months and 2 midterm recurrences (12–18 months). Biochemical success at 12–18 months was 62.5% (10/16 patients). Adverse events (31.3%) included a small area (2 cm2) of bladder wall ischemia, which was removed by surgery (n = 1); transient acute urinary retention (n = 1) and urinary urgency (n = 1) for 1 week; sexual dysfunction (n = 2), which completely recovered after 10 and 12 months, respectively. ConclusionsProstatic artery chemoembolization allowed a biochemical response in patients with localized PCa and is a promising treatment.

Which strategy should be chosen for ischemic free wall rupture on-pump or off-pump?

In 2017, I reported sutureless repair as a treatment for ischemic heart rupture, and found that an offpump technique using fibrin glue sheets or other materials might contribute to excellent clinical results. In a similar case, Ishii and colleagues reported a patient who underwent sutureless repair with hemostat materials on the bleeding site without cardiopulmonary bypass. Even today, conventional repair under cardiopulmonary bypass leads to unsatisfactory results. A case of a huge pseudoaneurysm after such a repair of left ventricular wall rupture was reported. Although this kind of repair is a simple procedure for ischemic rupture of the left ventricle, clinicians should consider that it carries a potential risk of aneurysmal formation after surgery.

Midterm outcomes of transmyocardial laser revascularization with intramyocardial injection of adipose derived stromal cells for severe refractory angina.

IntroductionRefractory angina has limited effective therapeutic options and often contributes to frequent hospitalizations, morbidity and impaired quality of life.AimWe sought to examine midterm results of a bio-interventional therapy combining transmyocardial laser revascularization (TMLR) and intramyocardial injection of adipose derived stem cells (ADSC) in patients with refractory angina not amenable to percutaneous or surgical revascularization.Material and methodsWe included 15 patients with severe refractory angina and anterior wall ischemia who were ineligible for revascularization strategies. Adipose tissue was harvested and purified, giving the stem cell concentrate. All patients underwent left anterior thoracotomy and TMLR using a low-powered holmium : yttrium–aluminum–garnet laser and intramyocardial injection of ADSC using a combined delivery system.ResultsNo deaths or major adverse cardiovascular or cerebrovascular events were observed in the 6-month follow-up. Mean ejection fraction increased from 35% to 38%, and mean Canadian Cardiovascular Society Angina Score decreased from 3.2 to 1.4, with decreased necessity of nitrate usage. Seventy-three percent of patients reported health improvement particularly regarding general health and bodily pain. Improvement in endocardial movement, myocardial thickening and stroke volume index (35.26 to 46.23 ml/m2) on cardiac magnetic resonance imaging (MRI) was observed in 3 patients who had repeat CMR imaging after 6 months.ConclusionsOur study suggested that interventional therapy combining TMLR with intramyocardial implantation of ADSC may reduce symptoms and improve quality of life in patients with refractory angina. These early findings need further validation in large scale randomized controlled trials.

Mesenteric Volvulus With Superior Mesenteric Vein Obstruction Presenting as Hemorrhagic Ascites and Bowel Ischemia

Introduction: A spontaneous mesenteric volvulus in case of non-reduction, can cause venous obstruction resulting from the entaglement of superior mesenteric vein (SMV) around the superior mesenteric artery (SMA) thereby ultimately causing fluid accumulation in abdomen and eventual bowel necrosis. More commonly seen in neonates, this process is extremely uncommon in adulthood. We here present a case of a 54-year old woman who presented with mesenteric volvulus resulting in SMV obstruction and bowel necrosis. Case Presentation: A 54-year old woman with medical history of hypertension presented with complaints of mild diffuse abdominal pain and worsening distention for about 3 weeks. Patient denied any nausea, vomiting or blood in the stool. Patient was hemodynamically stable and examination was significant for abdominal distention with ascitic fluid thrill. A diagnostic paracentesis revealed hemorrhagic ascites but no malignant cells. Patient was found to have anemia (Hemoglobin of 10gm/dL) and severe leucocytosis (25 × 103/μL). Computerized tomography scan of abdomen revealed mesenteric volvulus (Figure 1) with small bowel wall edema/ischemia (Figure 2) and SMV obstruction. Patient underwent an emergent laparotomy that showed ischemic bowel which was resected (FIgure 3).Figure: Sagittal CT image showing swirling mesentery consistent with volvulus (red arrow).Figure: CT showing loop of small bowel extending through mesenteric defect. Bowel loops at the right abdomen demonstrate wall thickening and decreased enhancement consistent with volvulus and ischemia (red arrow).Figure: Perioperative description A) Mesenteric defect B) Hypermic small bowel C) Necrotic small bowel D) Resected necrotic small bowelDiscussion: Unlike SMA obstruction, SMV obstruction rarely causes small bowel ischemia because of collateral venous circulation. SMV obstruction commonly happens due to hypercaogulable states, prior abdominal surgeries, mechanical obstruction from an adjacent mass. To the best of our knowledge, a case of SMV obstruction secondary to mesenteric volvulus presenting as chronic abdominal pain with hemorrhagic ascites eventually leading to small bowel necrosis- in a middle aged adult, was never reported. SMV obstruction usually presents with severe abdominal pain with distention and rectal bleeding. In our case, patient presented with ascites which was found to be hemorrhagic on paracentesis. The likely pathophysiology behind the hemorrhagic ascites could be the venous congestion in the SMV leading to bowel wall edema and hyperemia. The gold standard to diagnose SMV obstruction is CTA. Patient with SMV obstruction with mesenteric volvulus should be managed surgically to relieve the mechanical obstruction of the SMV in a prompt manner to prevent bowel wall ischemia. If surgical intervention is deferred, outcomes can be devastating.

Improved CT-detection of acute bowel ischemia using frequency selective non-linear image blending.

BackgroundComputed tomography (CT) as a fast and reliable diagnostic technique is the imaging modality of choice for acute bowel ischemia. However, diagnostic is often difficult mainly due to low attenuation differences between ischemic and perfused segments.PurposeTo compare the diagnostic efficacy of a new post-processing tool based on frequency selective non-linear blending with that of conventional linear contrast-enhanced CT (CECT) image blending for the detection of bowel ischemia.Material and MethodsTwenty-seven consecutive patients (19 women; mean age = 73.7 years, age range = 50–94 years) with acute bowel ischemia were scanned using multidetector CT (120 kV; 100–200 mAs). Pre-contrast and portal venous scans (65–70 s delay) were acquired. All patients underwent surgery for acute bowel ischemia and intraoperative diagnosis as well as histologic evaluation of explanted bowel segments was considered “gold standard.” First, two radiologists read the conventional CECT images in which linear blending was adapted for optimal contrast, and second (three weeks later) the frequency selective non-linear blending (F-NLB) image. Attenuation values were compared, both in the involved and non-involved bowel segments creating ratios between unenhanced and CECT.ResultsThe mean attenuation difference between ischemic and non-ischemic wall in the portal venous scan was 69.54 HU (reader 2 = 69.01 HU) higher for F-NLB compared with conventional CECT. Also, the attenuation ratio between contrast-enhanced and pre-contrast CT data for the non-ischemic walls showed significantly higher values for the F-NLB image (CECT: reader 1 = 2.11 (reader 2 = 3.36), F-NLB: reader 1 = 4.46 (reader 2 = 4.98)]. Sensitivity in detecting ischemic areas increased significantly for both readers using F-NLB (CECT: reader 1/2 = 53%/65% versus F-NLB: reader 1/2 = 62%/75%).ConclusionFrequency selective non-linear blending improves detection of bowel ischemia compared with conventional CECT by increasing attenuation differences between ischemic and perfused segments.