Prepared by Nina D. Raoof, MD, and
Stephen M. Pastores, MD, Critical Care Medicine Service, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, NYC
An 84-year-old man with Crohn's disease presented to the emergency department with a rigid, distended abdomen associated with obtundation and respiratory failure requiring mechanical ventilation. A computed tomography (CT) scout film (Figure 1) and a CT scan of the abdomen (Figure 2) are shown.
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Diagnosis: Colonic volvulus with mesenteric ischemia.
This diagnosis
must be considered in the differential
diagnosis of the elderly patient presenting
with abdominal pain and distention.
This patient?s CT reveals classic
findings associated with mesenteric
ischemia: marked distention of the
small and large bowels, with pneumatosis
intestinalis and with extensive
portal venous gas (Figure 2).
The radiologic findings of pneumatosis
intestinalis may be associated with
a spectrum of diagnoses, including
asthma, Clostridium difficile infection,
and intestinal ischemia. Similarly,
when portal venous gas is seen on an
imaging study, a distinction must be
made between the isolated finding and
the association of portal venous gas
with pneumatosis intestinalis. Although
unusual, the former may signal
nonlethal conditions; the latter,
however, is almost always secondary
to mesenteric ischemia.
Acute mesenteric ischemia with
multiorgan failure was diagnosed in
this patient based on the clinical and
radiologic findings. Not deemed to be
a candidate for surgery, he was admitted
to the intensive care unit and died
20 hours later. Such rapid clinical deterioration
as well as the radiographic
findings are characteristic of acute
mesenteric ischemia.
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- Figure 2—Pneumatosis intestinalis (red arrow) and diffuse portal venous gas (blue arrow).
