0:00

Here we have another case of abdominal pain

0:03

in a patient with a contrast enhanced CT scan.

0:05

Here we can see that the liver is fairly homogeneous,

0:08

and the spleen is a little heterogeneous,

0:10

but that might be the phase of enhancement.

0:12

I'm not sure, or it could be embolic disease.

0:14

I'll have to look at that a little

0:15

bit further on future images.

0:18

And here we have the pancreas, which looks good.

0:21

And as we come down to the lower abdomen, we

0:24

start to see some dilated loops of small bowel

0:26

at the very terminal ileum that demonstrate

0:29

a lot of fecal internal material, and a

0:32

bit of stranding within the mesentery.

0:34

Now I'm going to take you to the coronal images

0:37

because I always like the coronal images

0:39

in order to show you that abnormal bowel.

0:41

Again, uh, could this be a bowel obstruction?

0:43

Let's think it out.

0:44

So here we have the fecalized small bowel.

0:47

We see that in bowel obstruction, correct?

0:49

But as we follow this, we don't

0:51

really see an abrupt transition point.

0:54

We just see the small bowel become slowly but surely

0:57

decreased in caliber, so it's unlikely to be

1:00

a small bowel obstruction because obstruction

1:03

usually has a single point of decompression.

1:05

So I have to start thinking, what

1:07

is this outside of obstruction?

1:09

Notice also that the wall of the bowel here

1:12

is nicely enhancing, and then it goes to a

1:14

region where there's not a lot of enhancement.

1:16

All right, so that is concerning.

1:19

Concerning for ischemia and/or

1:21

necrosis of the bowel here.

1:23

So I said, oh, that spleen looked a little bit funny.

1:25

Hmm, maybe I'll rethink that.

1:27

I thought maybe it was just the phase of

1:28

contrast, but, you know, I've been wrong before.

1:31

So now I'm thinking, oh, those do look like

1:32

small wedges of peripheral decreased enhancement.

1:36

So that is concerning to me for splenic infarcts.

1:39

Now I have

1:40

distal small bowel, which is looking

1:42

ischemic and splenic infarcts.

1:44

This is concerning to me for some

1:47

kind of ischemic embolic phenomenon.

1:50

So I'm going to look closer at my vessels.

1:53

So let's go down in the abdomen, and we'll see that

1:56

the celiac axis has pretty good enhancement here.

1:59

Uh, bifurcating as it does.

2:01

We'll see an intraluminal thrombus

2:03

within the osteum of the SMA.

2:05

So this is a large SMA thrombus.

2:07

Let's see if we can find this on

2:09

an arterial segment of this exam.

2:12

Boy, we've imaged this patient in every single

2:15

phase of contrast, but here on these MIP images,

2:17

you can see that they take off of the celiac

2:19

axis as well enhancing as opposed to this

2:22

very large embolism within the proximal SMA.

2:26

So this would be a typical appearance of

2:28

ischemic bowel resulting from a lack of.

2:31

Blood flow from an embolus within a feeding vessel.

2:35

Sometimes people think that all dilated loops of small

2:38

bowel are obstructed, but that's just not the case.

2:40

Ischemic bowel will dilate as well.

2:43

It'll become very atonic and result

2:45

in a very similar appearance.

2:47

So you really wanna look at those loops closely.