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Unusual computed tomography findings in a patient presenting with acute abdominal pain

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3192 (Published 19 August 2009) Cite this as: BMJ 2009;339:b3192
  1. James K K Chan, senior house officer in surgery,
  2. Richard Lovegrove, specialist registrar in surgery,
  3. Matt Dunckley, senior house officer in surgery,
  4. Eric K Woo, consultant radiologist,
  5. Marwan Farouk, consultant surgeon
  1. 1Stoke Mandeville Hospital, Buckinghamshire NHS Trust, Aylesbury, Bucks HP21 8AL
  1. Correspondence to: J K K Chan jackichan17{at}hotmail.com

    An 84 year old woman presented with acute, diffuse, colicky abdominal pain associated with intermittent vomiting, and had a six week background of general malaise and weight loss. Her medical history included atrial fibrillation, peripheral vascular disease, transitional cell carcinoma of the bladder, pulmonary embolism, and chronic obstructive pulmonary disease.

    At initial assessment, the patient’s temperature was 36.7 °C, pulse 112 beats/min irregular, and blood pressure 91/71 mm Hg. Her respiratory rate was 20 breaths/min and her blood oxygen saturation was 98% on 15 litres oxygen.

    On examination, the patient was dehydrated but alert and oriented. Her abdomen was rigid with absent bowel sounds. Digital rectal examination was tender for the patient and there were firm stools in the rectum. Both feet were pale, cold, and cyanosed with a capillary refill time of more than 5 seconds.

    The patient’s arterial blood gas results on 10 litres oxygen were as follows: pH 7.33; pCO2 5.1 mm Hg; pO2 24.7 mm Hg; lactic acid 2.7 mmol/l; base excess 5.9 mmol/l; and HCO3 20.8 mmol/l. Her blood results were: haemoglobin 13.1 g/dl; white cell count 57.9 × 109/l; neutrophils 54.6 × 109/l; Na+ 138 mmol/l; K+ 4.2 mmol/l; urea 25.8 mmol/l; creatinine 363 μmol/l; and C reactive protein 307 mg/l. Her liver function tests were normal.

    Electrocardiography confirmed atrial fibrillation. Urgent computed tomography of the abdomen and pelvis was performed the same day.

    Questions

    • 1 What is the diagnosis?

    • 2 What signs on the computed tomogram point to the diagnosis?

    • 3 What are the causes of this condition?

    • 4 How should this patient be managed?

    Answers

    Short answers

    • 1 This patient has mesenteric ischaemia.

    • 2 The computed tomogram shows portal venous gas and pneumatosis intestinalis—that is, air within the liver and bowel wall, respectively—and some intra-abdominal …

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