Limited utility of MRA for acute bowel ischemia after portal venous phase CT

Shetty, Anup S.; Mellnick, Vincent M.; Raptis, Constantine A.; Loch, Ronald; Owen, Joseph W.; Bhalla, Sanjeev

doi:10.1007/s00261-015-0492-y

Cited by 9 publications

(6 citation statements)

References 17 publications

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“…This case study delineates potential diagnostic limitations, including colonoscopy and colonic mucosal biopsy that help determine the etiology of ischemic colitis [ 15 ]. The other diagnostic methods include barium enema, CT angiography, and contrast-enhanced magnetic resonance angiography (MRA); however, their use is restricted due to potential limitations in the setting of ischemic colitis [ 18 - 19 ]. The underlying comorbidities and recurrent bleeding in severe ischemic colitis challenge its diagnostic management.…”

Section: Discussionmentioning

confidence: 99%

Lactulose-Induced Ischemic Colitis: A Rare Presentation and an Overview of Possible Etiologies of the Disease

Umar¹,

Ilyas²,

Shah³

et al. 2022

Cureus

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Ischemic colitis is one of the most common ischemic pathologies of the gastrointestinal system and can be divided into non-gangrenous and gangrenous forms. The pathophysiology involves restricted blood supply to the colonic mucosa. Several risk factors have been implicated in the development of ischemic colitis. Lactulose, one of the mainstay therapies for the treatment of hepatic encephalopathy in patients with cirrhosis, has been rarely reported as a cause of ischemic colitis. To the best of our knowledge, there has been only one case report associating lactulose use with the development of ischemic colitis. The exact pathophysiology is unknown but might be associated with the fermentation of lactulose by intestinal bacteria, causing gaseous distention and increasing the intraluminal pressure. We present the case of a 77-year-old African American male, a known case of non-alcoholic liver cirrhosis with portal hypertension and esophageal varices, brought in by his family to the emergency department for altered mental status, non-bilious vomiting, abdominal distension, and pain for one day. On physical examination, the patient had upper extremity asterixis and was alert but disoriented to place and person. Diagnostic paracentesis was performed, which revealed leukocytosis, predominantly neutrophils. The patient was admitted for spontaneous bacterial peritonitis and hepatic encephalopathy with decompensated liver cirrhosis. The patient was started lactulose with a goal of three to four bowel movements per day. Despite adequate treatment, the patient continued to develop worsening mental function and abdominal distension. This was later followed by a bloody bowel movement. Laboratory assessment showed an elevated white blood cell count, worsening kidney function, and high anion gap metabolic acidosis. CT scan revealed dilated loops of bowel with air and fluid along with submucosal wall edema, findings suggestive of ischemic colitis. Given the poor prognosis and the patient's condition, colonoscopy was deferred. Lactulose was discontinued, as it was thought to be a contributing cause of the patient's ischemic colitis. His condition continued to deteriorate, and he passed away on Day 18 of admission.

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Section: Discussionmentioning

confidence: 99%

Lactulose-Induced Ischemic Colitis: A Rare Presentation and an Overview of Possible Etiologies of the Disease

Umar¹,

Ilyas²,

Shah³

et al. 2022

Cureus

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“…Finally, only small bowel injury was evaluated in this study and vascular impairment was not analyzed, which may be a problem since the diagnosis of arterial AMI relies strongly on the visualization of arterial insufficiency (occlusion or vasoconstriction in nonocclusive arterial AMI). However, the performance of MR angiography of the mesenteric vascularization has been shown to be good, 38 and Shetty and al found no difference with CT angiography for vascular analysis in AMI patients 39 …”

Section: Discussionmentioning

confidence: 99%

“…However, the performance of MR angiography of the mesenteric vascularization has been shown to be good, 38 and Shetty and al found no difference with CT angiography for vascular analysis in AMI patients. 39…”

Section: Limitationsmentioning

confidence: 99%

MRI for the Detection of Small Bowel Ischemic Injury in Arterial Acute Mesenteric Ischemia: Preclinical Study in a Porcine Model

Garzelli

Felli

Barberio

et al. 2022

Magnetic Resonance Imaging

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Background: MRI is the reference for the diagnosis of arterial cerebral ischemia, but its role in acute mesenteric ischemia (AMI) is poorly known. Purpose: To assess MRI detection of early ischemic bowel lesions in a porcine model of arterial AMI. Study Type: Prospective/cohort. Animal Model: Porcine model of arterial AMI obtained by embolization of the superior mesenteric artery (seven pigs). Field Strength/Sequence: A 5-T. T1 gradient-echo-weighted-imaging (WI), half-Fourier-acquisition-single-shot-turbo-spinecho, T2 turbo-spin-echo, true-fast-imaging-with-steady-precession (True-FISP), diffusion-weighted-echo-planar (DWI). Assessment: T1-WI, T2-WI, and DWI were performed before and continuously after embolization for 6 hours. The signal intensity (SI) of the ischemic bowel was assessed visually and quantitatively on all sequences. The apparent diffusion coefficient (ADC) was assessed. Statistical Tests: Paired Student's t-test or Mann-Whitney U-test, significance at P < 0.05. Results: One pig died from non-AMI-related causes. The remaining pigs underwent a median 5 h53 (range 1 h24-6 h01) of ischemia. Visually, the ischemic bowel showed signal hyperintensity on DWI-b800 after a median 85 (57-276) minutes compared to the nonischemic bowel. DWI-b800 SI significantly increased after 2 hours (+19%) and the ADC significant decrease within the first hour (À31%). The ischemic bowel was hyperintense on precontrast T1-WI after a median 87 (70-171) minutes with no significant quantitative changes over time (P = 0.46-0.93). The ischemic bowel was hyperintense on T2-WI in three pigs with a significant SI increase on True-FISP after 1 and 2 hours. Data Conclusion: Changes in SI and ADC can be seen early after the onset of arterial AMI with DWI. The value of T2-WI appears to be limited.

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“…MRA is tailored to depict mesenteric vasculature and less likely to show ischemic findings within the bowel itself compared to CT, such as pneumatosis and portovenous gas; it is also unlikely to provide additional information in the acute setting if portal venous phase CT has already been performed [48]. MRA without contrast can be attempted in some cases; however, evaluation of smaller vessels may be suboptimal [46].…”

Section: Discussion Of Procedures By Variantmentioning

confidence: 99%

ACR Appropriateness Criteria® Imaging of Mesenteric Ischemia

Ginsburg

Obara

Lambert

et al. 2018

Journal of the American College of Radiology

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Mesenteric ischemia is an uncommon condition resulting from decreased blood flow to the small or large bowel in an acute or chronic setting. Acute ischemia is associated with high rates of morbidity and mortality; however, it is difficult to diagnose clinically. Therefore, a high degree of suspicion and prompt imaging evaluation are necessary. Chronic mesenteric ischemia is less common and typically caused by atherosclerotic occlusion or severe stenosis of at least two of the main mesenteric vessels. While several imaging examination options are available for the initial evaluation of both acute and chronic mesenteric ischemia, CTA of the abdomen and pelvis is overall the most appropriate choice for both conditions.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

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Limited utility of MRA for acute bowel ischemia after portal venous phase CT

Cited by 9 publications

References 17 publications

Lactulose-Induced Ischemic Colitis: A Rare Presentation and an Overview of Possible Etiologies of the Disease

Lactulose-Induced Ischemic Colitis: A Rare Presentation and an Overview of Possible Etiologies of the Disease

MRI for the Detection of Small Bowel Ischemic Injury in Arterial Acute Mesenteric Ischemia: Preclinical Study in a Porcine Model

ACR Appropriateness Criteria® Imaging of Mesenteric Ischemia

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