Case 8_ Mesenteric Ischemia choosing the imaging modality .pptx

mesenteric ischemia general overview and pathophysiology, imaging modality of choice according to ACR, writing radiological request.

1. Mesenteric Ischemia Cas#8: Homme de 89 ans. Suspicion ischémie mésentérique . Echographie Doppler des vaisseaux mésentériques Scanner sans injection Scanner avec injection Angioscanner Angiographie Presented to: Dr. Charbel Mourad By: Rym Santbay and Zahra Awaly

2. In this case the best exam to choose is angioscan. Before getting into details… here’s a small review about this condition. Mesenteric ischemia is a rare disease associated with a high mortality rate, especially in the acute setting. It is more prevalent in the elderly population (the case of our patient aged 89 y.o) Mortality rate influenced by associated comorbidities and the low index of suspicion being clinically non specific with relatively benign physical exam. Can be acute or more rarely chronic. acute mesenteric ischemia present with abdominal pain out of proportion to the physical examination c hronic mesenteric ischemia, patients classically present with the clinical triad of postprandial abdominal pain, weight loss, and food avoidance. Early in the course of disease, laboratory findings are of little value.

3. Pathophysiology Acute form causes: Acute SMA embolism (most common) Acute mesenteric artery thrombosis (second most common) Non occlusive mesenteric ischemia Mesenteric and portal venous thrombosis (least common) Chronic form causes: It is due to occlusive or stenotic atherosclerotic disease and is more prevalent among elderly or those having severe atherosclerosis.

4. ACR guidelines

5. ACR guidelines

6. Justification Timing of the diagnosis is very critical, excluding other diagnoses and detecting the location of occlusion or the area of non-occlusive ischemia is crucial, as well as mapping of the arteries for revascularization . Echo Doppler des vaisseaux mésentériques: high specificity but low sensitivity for identifying vascular occlusions. Its accuracy is limited by extensive gas within the loops of bowel. It plays a limited role in detecting distal arterial emboli, (the IMA hardly visible). It is not recommended for the initial evaluation of patients with suspected acute mesenteric ischemia due to the critical timing of diagnosis. Nevertheless, it may prove useful as an initial screening tool for chronic mesenteric ischemia. Scanner sans injection: In the context of this diagnosis, Non-contrast CT scans are good at only detecting calcifications in blood vessels (can be indicative of atherosclerosis). It can still offer information about the surrounding soft tissues and exclude differential diagnoses. Scanner avec injection: angioscan is a variation of it that allows better appreciation of vessels and blood flow. Angioscanner: fast and noninvasive evaluating bowel signs AND assessing intestinal vasculature. Allows 3D volume reformatting, accurate evaluation of the entire GI and GU tract, helping to exclude most other causes. Can be helpful in stratifying patients to identify those who would benefit from angiography as opposed to emergent surgery. has been the reference standard test, as it allows diagnosis and treatment with a single procedure. However , with advances in CT, it has become an alternative. Traditional angio is invasive and linked to procedural complications. It is not recommended for patients with significant hypovolemia and hypotension, where immediate surgery is preferred. Additionally, its role in the acute setting with developed peritoneal signs is controversial. Replaced as 1st line, but remains gold standard in chronic especially.

7. Here we have a sagittal view with normal proximal SMA but the occlusion locates more distally (left picture) And we see on the right picture the bowel wall thickness which is a sign of bowel ischemia This is another sagittal (left picture) and coronal (right picture) view of SMA occlusion showing a far down occlusion with normal proximal segment

8. Radiology request Patient X, 89 y.o., is suspected to have mesenteric ischemia. I would like to request an angioscanner focusing on the gastrointestinal and genitourinary tract to also eliminate any another potential cause, knowing that this technique is very useful in his case showing precisely vasculature and anatomic structures. Please let me know of the type of occlusion if present and any other associated signs.

9. Second Step: If Diagnosis is confirmed/increased suspicion Is the patient hemodynamically stable and no peritonitis? Yes → Angiography as Tx No → open surgery