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Case 66: Abdominal pain in the elderly

A 76 year old woman presents with abdominal pain. She is tachycardic, pale and has lower abdominal tenderness.

1. What does the CT show?

There is a loop of bowel which is thick walled. The luminal contents contain locules of gas however some locules appear to extend into the wall of the bowel. Intramural gas is suggestive of ischaemic bowel. Importantly the gas locules are not only in the anti-dependent parts of the bowel wall.

2. What is the likely underlying cause?

Ischaemic bowel may be due to arterial pathology, either embolic occlusion or thrombosis of the superior mesenteric artery or its branches. Mesenteric venous occlusion can also lead to ischaemia which typically takes longer to develop and is usually diagnosed late. Extrinsic factors such as stranulation ina an internal hernia, bands and volvulus may also lead to segmental ischaemia.

3. How would you manage this woman?

After resuscitation she requires urgent exploratory laparotomy. She and her family should be aware of the potential poor prognosis and the unsalvagable situation of whole gut infarction.