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Case 238

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A 88-year-old male patient was admitted to the Emergency Department with reports of massive intestinal bleeding within the last 24 hours. It was stabilized in CTI and diagnostic investigation began. Upper endoscopy showed gastric ulcers without signs of recent bleeding. During the preparation for colonoscopy, the patient presented abdominal distension, vomiting, hemodynamic instability and metabolic acidosis. History of diverticular disease and megacolon of unknown etiology. Due the latter symptoms were requested radiography and computed tomography (CT) of the abdomen / pelvis to proceed the investigation.

According to the clinical history and imaging tests in this case, choose the incorrect answer.

a) The tests presented were unable to establish the cause of gastrointestinal bleeding

25%

b) Computed tomography demonstrated changes consistent with intestinal ischemia.

25%

c) Imaging studies show dilation of colonic handles and small intestine.

25%

d) Computed tomography evidence cholelithiasis and aerobilia, indicating the diagnosis of biliary ileus.

25%
   

Image analysis

 

Image 5: Abdominal radiography in the supine position (bed), incidence posterior anterior, showing diffuse bowel distension.

 

 

Image 6: Axial CT scan of the abdomen without contrast, showing important distension of the intestinal wall (in red) and aeroportograma in left hepatic lobe (blue circle). Presence of gastric tube.

 

 

Image 7: Axial CT scan of the abdomen without contrast, showing bowel distension (in red) with air-fluid levels (yellow contour) and radiopaque concretion in gallbladder topography suggesting cholelithiasis (blue circle).

 

 

Image 8: Axial CT scan of the abdomen without contrast, showing bowel distension (in red) with air-fluid levels (yellow contour) and the presence of air in the intestinal wall in the cecum topography – intestinal pneumatosis (green arrows).

Highlights

- Intestinal ischemia results from occlusion of mesenteric vessels or hypovolemic states (dehydration, sepsis);

- Acute intestinal ischemia is characterized by abdominal pain disproportionate to the laboratory and clinical findings. Already chronic form presents as periumbilical pain or intermittent epigastric after feeding;

- The diagnosis is based on clinical suspicion and laboratory tests, but diagnostic confirmation is given by mesenteric angiography;

- Intestinal pneumatosis associated with the presence of air in the portal system (aeroportograma) is suggestive of intestinal ischemia or necrosis;

- The prognosis is limited when the diagnosis is delayed.

References

- Tendler, DA, Lamont JT. Overview of intestinal ischemia in adults. UpToDate 2016 [internet]. Acess on july 26, 2016. Available in:  http://www.uptodate.com/contents/overview-of-intestinal-ischemia-in-adults

- Townsend, CM, Beauchamp RD, Evers, BM, Mattox KL. Sabiston – Tratado de Cirurgia, 18th edition. Rio de Janeiro: Elsevier 2010.

- Sociedade Brasileira de Endoscopia Digestiva. Consenso Brasileiro em Endoscopia Digestiva. GED – vol 21, jan/fev 2002.

- Goel A et al. Intestinal ischaemia. Available in:  http://radiopaedia.org/articles/intestinal-ischaemia

- Monteiro AMV, Lima CMAO, Ribeiro EB. Diagnóstico por imagem no abdome agudo não traumático. Jan/Jun 2009. Revista HUPE UERJ.

- Silva CI, D’Ippolito G, Rocha AJ. Gastrointestinal, série Colégio Brasileiro de Radiologia e Diagnóstico por Imagem. Elsevier, 2011.

Authors

Pétala Silva Ribeiro, 5th year medical student at UFMG.

E-mail: petalasilva_3[arroba]hotmail.com

Supervisors

Eduardo Ribeiro Neto, General Surgeon at the Evangelical Hospital, Belo Horizonte, MG

E-mail: eduardodiso[arroba]yahoo.com.br

Reviewers

Fabio Satake, Cairo Mendes, Laio Bastos, Giovanna Vieira, Fellype Borges, Carla Faraco, Profa. Viviane Parisotto, Prof. José Nelson Mendes Vieira.

Translated by

Daniele Araújo Pires, 6th year medical student at UFMG.

E-mail: daniarpires[at]gmail.com

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