Case discussion
01Clinical context
An elderly patient presented with abdominal pain and elevated serum lactate, raising suspicion for acute mesenteric ischaemia. Urgent CT angiography was performed to evaluate mesenteric vascular patency and bowel viability.
02Key imaging findings
CT angiography demonstrated extensive acute occlusion of the superior mesenteric artery starting about 4 cm distal to its origin, with preserved proximal flow. There was severe atherosclerosis involving the abdominal aorta and major branches, including marked stenosis at the coeliac axis origin. The inferior mesenteric artery remained patent. Multiple proximal small-bowel loops were dilated with distal collapse and a transition point in the left lower quadrant. Subtle mesenteric venous gas, minimal mesenteric inflammatory stranding, and a small amount of free fluid were present. No definitive bowel-wall thickening or pneumoperitoneum was seen. These findings indicate critical interruption of intestinal blood supply with evolving ischaemic injury, despite relatively subtle bowel-wall changes.
03Diagnostic reasoning
The diagnosis was established by CT angiography, which provided detailed visualization of the mesenteric arterial tree. The key finding was the extensive occlusion of the superior mesenteric artery distal to its origin, with preserved proximal flow. Multiplanar reformations allowed identification of subtle mesenteric venous gas and inflammatory stranding, which raised concern for evolving ischaemic injury despite the absence of definitive bowel-wall thickening. The combination of vascular and bowel findings, correlated with clinical presentation and elevated lactate, supported the diagnosis of acute mesenteric ischaemia with threatened bowel viability. Bowel necrosis and subsequent clinical outcome were not confirmed in the supplied material.
04Questions for clinical practice
What is the urgency of this condition?
Acute mesenteric ischaemia is a surgical emergency requiring immediate multidisciplinary evaluation to preserve bowel viability.
Does absence of bowel-wall thickening exclude infarction?
No, severe arterial occlusion may occur before definitive bowel-wall signs appear.
What is the significance of mesenteric venous gas?
It is a concerning sign indicating possible transmural ischaemia or necrosis.
How does CT angiography guide management?
It identifies the site and extent of arterial occlusion, associated vascular disease, and bowel complications, aiding surgical and vascular planning.
05Teaching point
This case highlights that severe arterial occlusion in acute mesenteric ischaemia may precede definitive bowel-wall signs of infarction. Mesenteric venous gas and subtle inflammatory changes increase suspicion for significant ischaemic injury. CT angiography is essential for rapid diagnosis and treatment planning, as vascular findings can identify life-threatening ischaemia even when bowel-wall abnormalities are inconclusive. Early recognition and multidisciplinary management are critical to preserving bowel viability.
Shown for education. De-identified — no identifiable patient data. A radiology report is a specialist opinion and must be read with the full clinical context by the treating physician.