Acute small bowel ischemia: CT imaging findings

Relationship of superior mesenteric artery thrombus density with transmural intestinal necrosis on multidetector computed tomography in acute mesenteric ischemia

Background

Acute arterial occlusive mesenteric ischemia with transmural intestinal necrosis (TIN) is a fatal disease, which is difficult to diagnose on multidetector computed tomography (MDCT). The aim of the present study was to determine the relationship of superior mesenteric artery (SMA) thrombus density with TIN on MDCT in patients with acute mesenteric ischemia (AMI) due to SMA thromboembolism.

Methods

In this retrospective study, 33 patients who underwent abdominal MDCT and angiography for AMI due to SMA thromboembolism were divided into two groups: the AMI with TIN group and the AMI without TIN group. We analyzed the relationships of clinical characteristics, qualitative MDCT signs, and SMA thrombus density with TIN. The SMA thrombus density was measured on non-contrast MDCT. Univariate and multivariate analyses were performed to determine the risk factors for predicting TIN. The diagnostic performances of risk factors were evaluated by receiver-operating characteristic (ROC) curve analysis.

Results

Of the patients with AMI enrolled in this study, 33.3% (11/33) were diagnosed with TIN. Peritonitis (P=0.042), bowel wall thinning (P=0.033), and pneumatosis/portomesenteric gas (P=0.010) were significantly associated with TIN. AMI patients with TIN exhibited a higher SMA thrombus density than AMI patients without TIN [41.2±6.1 vs. 34.2±3.0 Hounsfield unit (HU), P=0.003]. Multivariate analysis showed that SMA thrombus density was an independent predictor of TIN [P=0.044, hazard ratio (HR): 1.82, 95% confidence interval (CI): 1.02-3.25]. For diagnosing AMI with TIN, the area under the ROC curve (AUC) of SMA thrombus density (0.83) was larger than those of peritonitis (0.68), bowel wall thinning (0.66), and pneumatosis/portomesenteric gas (0.71).

Conclusions

In patients with AMI, erythrocyte-rich thrombus blocking the SMA trunk which has a higher density on MDCT is prone to the occurrence of TIN compared with erythrocyte-scarce thrombus with a lower density. SMA thrombus density could be an independent risk factor for TIN in patients with AMI due to SMA thromboembolism.

Vascular assessment in small bowel obstruction: can CT predict requirement for surgical intervention?

PURPOSE

Small bowel obstruction (SBO) is a common cause of emergency presentations for abdominal pain and can be complicated by mesenteric ischemia. Computed tomography is currently central to diagnosis and management planning. Currently accepted signs identify secondary effects of the root physiological insult, which is vascular obstruction. We hypothesized that with advancements in CT technology and reconstruction algorithms, we can now more closely interrogate the mesenteric vasculature for obstruction and more accurately predict the need for surgical intervention.

METHODS

We retrospectively audited the charts of all patients presenting with a clinical diagnosis of SBO at a single institution in a 12-month period. Two blinded consultant radiologists were then asked to analyze 3D MIP reconstruction CT scans for vascular obstruction in addition to any currently accepted signs of ischemia. Comparison between vascular cutoff and accepted current signs in the need for surgical intervention and the presence of any signs of ischemia in theater were recorded.

RESULTS

Vascular cutoff had a comparable, with a trend towards superiority, sensitivity and specificity and inter-observer agreement to currently accepted signs of ischemia. The absence of a cut off sign has an excellent negative predictive value for ischemia with only 2 (3.7%) patients demonstrating ischemia at surgery where the vascular cutoff sign was not seen to be present.

CONCLUSION

Interrogating vascular obstruction using 3D MIP reconstructions in small bowel obstruction may be a more sensitive and specific sign for prediction of surgical intervention, possibly occurring earlier in the obstruction pathway.

Contrast-Enhanced CT for the Diagnosis of Acute Mesenteric Ischemia

OBJECTIVE. The purpose of this article is to provide an overview of the diagnostic and prognostic roles of CT in the management of acute mesenteric ischemia. CONCLUSION. Acute mesenteric ischemia is defined as inadequate blood supply to the gastrointestinal tract resulting in ischemic and inflammatory injury. The prognosis is poor without treatment. Contrast-enhanced CT has become the cornerstone of diagnosis to identify features of vascular disorders and of intestinal ischemic injury and to visualize bowel necrosis.

The Pathogenesis of Nonocclusive Mesenteric Ischemia: Implications for Research and Clinical Practice

Nonocclusive mesenteric ischemia (NOMI) is a condition that can encompass ischemia, inflammation, and infarction of the intestinal wall. In contrast to most patients with acute mesenteric ischemia, NOMI is distinguished by patent arteries and veins. The clinical presentation of NOMI is often insidious and nonspecific, resulting in a delayed diagnosis. Patients most at risk are those with severe acute and critical disease, including major surgery and trauma. Nonocclusive mesenteric ischemia is part of a spectrum, from mild, asymptomatic, and an unexpected finding on CT scanning, through to those exhibiting abdominal distension and peritonitis. Severe NOMI is associated with a significant mortality rate. This review of NOMI pathophysiology was conducted to document current concepts and evidence, to examine the implications for diagnosis and treatment, and to identify gaps in knowledge that might direct future research. The key pathologic mechanisms involved in the genesis of NOMI represent an exaggerated normal physiological response to maintain perfusion of vital organs at the expense of mesenteric perfusion. A supply-demand mismatch develops in the intestine due to the development of persistent mesenteric vasoconstriction resulting in reduced blood flow and oxygen delivery to the intestine, particularly to the vulnerable superficial mucosa. This mismatch can be exacerbated by raised intra-abdominal pressure, enteral nutrition, and the use of certain vasoactive drugs, ultimately resulting in the development of intestinal ischemia. Strategies for prevention, early detection, and treatment are urgently needed.

Acute Bowel Computed Tomography

Acute abdominal pain is a common presenting complaint in the emergency department. Increasingly, computed tomography is utilized for evaluating these patients. Radiologists are therefore expected to be familiar with the pertinent clinical and radiologic information related to acute bowel pathology. This primer will review the need-to-know and latest updates related to computed tomography evaluation of acute bowel pathology.

Unenhanced Computed Tomography to Visualize Hollow Viscera and/or Mesenteric Injury After Blunt Abdominal Trauma: A Single-Institution Experience

To identify and describe the major features of unenhanced computed tomography (CT) images of blunt hollow viscera and/or mesenteric injury (BHVI/MI) and to determine the value of unenhanced CT in the diagnosis of BHVI/MI. This retrospective study included 151 patients who underwent unenhanced CT before laparotomy for blunt abdominal trauma between January 2011 and December 2013. According to surgical observations, patients were classified as having BHVI/MI (n = 73) or not (n = 78). Sensitivity, specificity, P values, and likelihood ratios were calculated by comparing CT findings between the 2 groups. Six significant CT findings (P < 0.05) for BHVI/MI were identified and their sensitivity and specificity values determined, as follows: bowel wall thickening (39.7%, 96.2%), mesentery thickening (46.6%, 88.5%), mesenteric fat infiltration (12.3%, 98.7%), peritoneal fat infiltration (31.5%, 87.1%), parietal peritoneum thickening (30.1%, 85.9%), and intra- or retro-peritoneal air (34.2%, 96.2%). Unenhanced CT scan was useful as an initial assessment tool for BHVI/MI after blunt abdominal trauma. Six key features on CT were correlated with BHVI/MI.

Comparison of Ischemic and Nonischemic Bowel Segments in Patients With Mesenteric Ischemia: Multidetector Row Computed Tomography Findings and Measurement of Bowel Wall Attenuation Changes

OBJECTIVE

To describe multidetector row computed tomography (MDCT) findings and to compare the enhancing ratio of ischemic and nonischemic bowel wall segments in patients with mesenteric ischemia.

PATIENTS AND METHODS

We performed a retrospective review of 69 patients with pathologically proven mesenteric ischemia who underwent a preoperative MDCT evaluation from January 1, 2010, through December 31, 2014. Two reviewers performed quantitative MDCT measurements of the bowel wall attenuation of the ischemic and nonischemic bowel segments on the unenhanced phase, arterial phase, and portal venous phase. Receiver operating characteristic curves for the enhancing ratios on the arterial phase and portal venous phase (ERv) were calculated to discriminate the 2 segments. A concordance correlation coefficient was used to assess interobserver variability.

RESULTS

The most common origin of ischemia was the mesenteric artery (45 of the 69 patients [65.2%]), but only 5 patients (7.2%) had evidence of arterial thrombus on MDCT. The quantitative MDCT measurements indicated that the ischemic bowel segments had significantly less bowel wall attenuation than the nonischemic bowel segments on the arterial phase (28.58±9.28 vs 58.97±12.50; P<.001) and the portal venous phase (33.93±11.16 vs 76.25±13.56; P<.001). The enhancing ratio on the arterial phase (cutoff, 0.32 or less; sensitivity, 89.9%; specificity, 98.6%) and the ERv (cutoff, 0.81 or less; sensitivity, 95.7%; specificity, 98.6%) predicted bowel ischemia. The most common MDCT findings in ischemic bowel were thickened bowel wall in 59 patients (85.5%), mesenteric fatty stranding in 57 (82.6%), and decreased bowel wall enhancement in 56 (81.2%). All quantitative measurements reached moderate to substantial agreement (0.399-0.601).

CONCLUSION

Without oral contrast administration and at a constant 120-peak kilovolt setting, MDCT findings of decreased enhancement of the thickened bowel wall together with a low ERv value predicted the presence of an ischemic bowel segment.

Radiological Evaluation of Bowel Ischemia

Intestinal ischemia, which refers to insufficient blood flow to the bowel, is a potentially catastrophic entity that may require emergent intervention or surgery in the acute setting. Although the clinical signs and symptoms of intestinal ischemia are nonspecific, computed tomography (CT) findings can be highly suggestive in the correct clinical setting. In our article, we review the CT diagnosis of arterial, venous, and nonocclusive intestinal ischemia. We discuss the vascular anatomy, pathophysiology of intestinal ischemia, CT techniques for optimal imaging, key and ancillary radiological findings, and differential diagnosis.

Multimodality approach for imaging of non-traumatic acute abdominal emergencies

"Acute abdomen" includes spectrum of medical and surgical conditions ranging from a less severe to life-threatening conditions in a patient presenting with severe abdominal pain that develops over a period of hours. Accurate and rapid diagnosis of these conditions helps in reducing related complications. Clinical assessment is often difficult due to availability of over-the-counter analgesics, leading to less specific physical findings. The key clinical decision is to determine whether surgical intervention is required. Laboratory and conventional radiographic findings are often non-specific. Thus, cross-sectional imaging plays a pivotal role for helping direct management of acute abdomen. Computed tomography is the primary imaging modality used for these cases due to fast image acquisition, although US is more specific for conditions such as acute cholecystitis. Magnetic resonance imaging or ultrasound is very helpful in patients who are particularly sensitive to radiation exposure, such as pregnant women and pediatric patients. In addition, MRI is an excellent problem-solving modality in certain conditions such as assessment for choledocholithiasis in patients with right upper quadrant pain. In this review, we discuss a multimodality approach for the usual causes of non-traumatic acute abdomen including acute appendicitis, diverticulitis, cholecystitis, and small bowel obstruction. A brief review of other relatively less frequent but important causes of acute abdomen, such as perforated viscus and bowel ischemia, is also included.

Acute Mesenteric Ischaemia

Acute mesenteric ischaemia (AMI) is a surgical emergency, and has a high mortality. The term AMI covers arterial embolism, arterial thrombosis, non-occlusive mesenteric ischaemia and venous thrombosis which all lead to ischaemia/reperfusion syndrome of the bowel. Multi-detector row helical CT (MDCT) technology has dramatically improved the performance of CT by allowing rapid volumetric data acquisition to provide increased resolution, leading to better identification of the site, level and cause of ischaemia. CT angiography for diagnosing mesenteric ischaemia is now highly sensitive and specific, and should be used as first line when AMI is suspected. The aim of management is to restore intestinal blood flow in a timely manner. Therapeutic decisions are based on the presence of peritonitis, the presence of irreversible ischaemia or infarcted segments of the bowel, the general condition of the patient and the pathophysiological process underlying the ischaemia. AMI remains a challenging condition with high mortality. There is a need for good general surgical cover on the intensive care unit, with continuing care and clinical review by experienced senior surgeons with an interest in this condition.

Automated CT detection of intestinal abnormalities and ischemia for decision making in emergency medicine

Background

Evaluation of computed tomography (CT) for the diagnosis of intestinal wall abnormalities and ischemia is important for clinical decision making in patients with acute abdominal pain to which if surgery should be performed in the emergency department. Interpretation of such information on CT is usually based on visual assessment by medical professionals and still remains a challenge in a variety of settings of the medical emergency care. This paper reports a pilot study in the implementation of image processing methods for automated detection of intestinal wall abnormalities and bowel ischemia, which can be of a potential application for CT-based detection of the intestinal disease.

Methods

CT scans of 3 patients of ischemia, one benign and one control subjects were used in this study. Statistical and geometrical features of the CT scans were extracted for pattern classification using two distance measures and the k-nearest neighbor algorithm. The automated detection of intestinal abnormalities and ischemia was carried out using labeled data from the training process with various proportions of training and testing samples to validate the results.

Results

Detection rates of intestinal ischemia and abnormalities are promising in terms of sensitivity and specificity, where the sensitivity is higher than the specificity in all test cases. The overall classification accuracy between the diseased and control subjects can be as high as 100% when all CT scans were included for measuring the difference between a cohort of three patients of ischemia and a single control subject.

Conclusion

The proposed approach can be utilized as a computer-aided tool for decision making in the emergency department, where the availability of expert knowledge of the radiologist and surgeon about this complex bowel disease is limited.

Increased unenhanced bowel-wall attenuation at multidetector CT is highly specific of ischemia complicating small-bowel obstruction

PURPOSE

To evaluate performance of increased bowel-wall attenuation on unenhanced 64-section multidetector computed tomographic (CT) images for diagnosing bowel-wall ischemia in patients with mechanical small-bowel obstruction (SBO) and to evaluate the diagnostic accuracy of multidetector CT in detecting small-bowel ischemia complicating SBO, with surgical and histopathologic findings as reference standard.

MATERIALS AND METHODS

The local institutional review board approved this retrospective study; informed consent requirement was waived. In 44 patients (10 men, 34 women; age range, 30-100 years) who were admitted because they were suspected of having SBO and treated surgically within the next 7 days, 45 multidetector CT scans were retrospectively reviewed. Two gastrointestinal radiologists performed independent blinded reviews of images to identify specific signs of ischemia; disagreements were resolved in consensus with a third gastrointestinal radiologist. Results were compared with both findings in prospective radiology reports and surgical and histopathologic findings. Fisher exact and χ(2) tests were used to assess associations between CT signs and ischemia, and the κ statistic was used to assess interobserver agreement.

RESULTS

In 19 of 45 (42%) multidetector CT scans, ischemia was confirmed at surgery and/or histopathologic examination. Increased bowel-wall attenuation on unenhanced images was significantly associated with ischemia (P < .0001); in this highly selected population, this sign had a 100% (24 of 24) specificity and a 56% (10 of 18) sensitivity. Sensitivity and specificity of multidetector CT for ischemia were 63% (12 of 19) and 92% (24 of 26), respectively, for the prospective reports and 84% (16 of 19) and 96% (25 of 26), respectively, for the consensus review. Decreased segmental bowel-wall enhancement was the most accurate 64-section multidetector CT sign for diagnosing ischemia (sensitivity, 78% [14 of 18]; specificity, 96% [24 of 25]; P < .0001). The small-bowel feces sign was significantly associated with ischemia (P = .0308).

CONCLUSION

Increased bowel-wall attenuation on unenhanced 64-section multidetector CT images is a specific sign for ischemia complicating SBO. Diagnostic accuracy of 64-section multidetector CT for ischemia associated with SBO was excellent.

Mesenteric vascular occlusion: comparison of ancillary CT findings between arterial and venous occlusions and independent CT findings suggesting life-threatening events

OBJECTIVE

To compare the ancillary CT findings between superior mesenteric artery thromboembolism (SMAT) and superior mesenteric vein thrombosis (SMVT), and to determine the independent CT findings of life-threatening mesenteric occlusion.

MATERIALS AND METHODS

Our study was approved by the institution review board. We included 43 patients (21 SMAT and 22 SMVT between 1999 and 2008) of their median age of 60.0 years, and retrospectively analyzed their CT scans. Medical records were reviewed for demographics, management, surgical pathology diagnosis, and outcome. We compared CT findings between SMAT and SMVT groups. Multivariate analysis was conducted to determine the independent CT findings of life-threatening mesenteric occlusion.

RESULTS

Of 43 patients, 24 had life-threatening mesenteric occlusion. Death related to mesenteric occlusion was 32.6%. A thick bowel wall (p < 0.001), mesenteric edema (p < 0.001), and ascites (p = 0.009) were more frequently associated with SMVT, whereas diminished bowel enhancement (p = 0.003) and paralytic ileus (p = 0.039) were more frequent in SMAT. Diminished bowel enhancement (OR = 20; p = 0.007) and paralytic ileus (OR = 16; p = 0.033) were independent findings suggesting life-threatening mesenteric occlusion.

CONCLUSION

The ancillary CT findings occur with different frequencies in SMAT and SMVT. However, the independent findings indicating life-threatening mesenteric occlusion are diminished bowel wall enhancement and paralytic ileus.

Errors in the radiological evaluation of the alimentary tract: part II

Plain abdominal radiography and computed tomographic (CT) enteroclysis are 2 essential radiological investigations in the study of gastrointestinal tract. Errors in patient preparation, execution, and interpretation may lead to severe consequences in the diagnosis and thus in patient outcome. Abdominal radiography is one of the most frequently requested radiographic examinations, and has an established role in the assessment of the acute abdomen. CT enteroclysis has revolutionized the assessment of small-bowel pathology, especially in patients with inflammatory bowel. The purpose of this article is to describe the pitfalls in the execution and interpretation of plain abdominal film and CT enteroclysis.

Radiologists' performance in the diagnosis of acute intestinal ischemia, using MDCT and specific CT findings, using a variety of CT protocols

The aim of this study was to evaluate the performance of radiologists in the diagnosis of acute intestinal ischemia using specific multi-detector CT findings. The abdominal CT scans of 90 patients were retrospectively reviewed by three radiologists: an abdominal imaging specialist, an experienced general radiologist, and a senior resident. Forty-seven patients had surgically proven intestinal ischemia and comprised the case group, while 43 patients had no evidence of intestinal ischemia at surgery and comprised the control group. Images were reviewed in a random and blinded fashion. Radiologists' performance in diagnosing bowel ischemia from other bowel pathologies was evaluated. The sensitivity, specificity, and accuracy for diagnosing bowel ischemia were 89%, 67%, and 79% for the abdominal imager; 83%, 67%, and 76% for the general radiologist; and 66%, 83%, and 74% for the senior resident, respectively. The calculated kappa value for inter-observer agreement regarding the presence of bowel ischemia was 0.79. CT findings that significantly distinguished bowel ischemia from other bowel pathologies were decreased or absent bowel wall enhancement, filling defect in the superior mesenteric artery, small bowel pneumatosis, and gas in the portal veins or superior mesenteric vein. For most of these signs, there was good inter-observer agreement. Radiologists' performance in diagnosing bowel ischemia is good, but lower than previously reported since a significant amount of cases are evaluated using a suboptimal CT technique. Radiologists' experience and expertise have an important impact on their performance.

Multidetector CT imaging in mesenteric ischemia--pearls and pitfalls

Mesenteric ischemia is a complex and devastating disease which still remains a diagnostic challenge to the clinicians due to non-specific clinical and laboratory findings. Several imaging features have been described with multidetector computed tomography which allows the diagnosis of mesenteric ischemia with high sensitivity and specificity. However, there are imaging features which overlap with other pathologies including benign inflammation and infection. Knowledge of imaging findings in mesenteric ischemia and its potential mimics is important in early and definitive diagnosis.

CT diagnosis of acute mesenteric ischemia from various causes

OBJECTIVE

Acute mesenteric ischemia can be caused by various conditions such as arterial occlusion, venous occlusion, strangulating obstruction, and hypoperfusion associated with nonocclusive vascular disease, and the CT findings vary widely depending on the cause and underlying pathophysiology. The aim of this article is to review the CT appearances of acute mesenteric ischemia in various conditions.

CONCLUSION

Recognition of characteristic CT appearances and the variations associated with each cause may help in the accurate interpretation of CT in the diagnosis of mesenteric ischemia.

Imaging in intestinal ischemic disorders

Intestinal ischemia and infarction are a heterogeneous group of diseases that have as their unifying theme hypoxia of the small bowel or colon. The incidence of bowel ischemia and infarction is on the rise for several reasons: the aging of the population, the ability of intensive care units to salvage critically ill patients, and heightened clinical awareness of these disorders. Improvements in diagnostic imaging techniques have greatly contributed to the earlier diagnosis of intestinal ischemia, which can have a positive influence on patient outcomes. In this article, role of radiology in the detection, differential diagnosis, and management of patients who have intestinal ischemia and infarction is discussed.

Computed tomographic imaging findings of bowel ischemia

LEARNING OBJECTIVES

Learning objectives of this paper are to review and to summarize the pathogenesis of bowel ischemia and to describe its clinical, pathological, and radiological manifestations.

BACKGROUND

Bowel ischemia is a common disorder produced by several causes, and it shows various clinical presentations connected with an high mortality. With the increase in average life expectancy, bowel ischemia represents one of the most threatening abdominal conditions in elderly patients. In the last decade, computed tomography has tremendously altered the diagnostic approach to bowel ischemia also influencing the therapeutic approach in the current practice.

IMAGING FINDINGS

Computed tomographic imaging findings include bowel wall thickening, portal venous gas, intramural pneumatosis, engorgement of mesenteric veins, loss or increase of bowel wall enhancement, and infarction of other abdominal organs.

CONCLUSIONS

Bowel ischemia shows a broad spectrum of radiological manifestations, and regardless of the primary causes, it produces similar radiological features. Bowel ischemia may simulate cancer or inflammatory conditions; so it is a mandatory tight integration between radiological and clinical signs.

Mesenteric Ischemia

Mesenteric ischemia is a difficult clinical diagnosis that requires a high index of clinical suspicion because the clinical and imaging features of intestinal ischemia and infarction overlap with many other intestinal disorders, and patients who have mesenteric ischemia often have coexisting diseases. Multidetector CT (MDCT) evaluation of the abdomen is the examination of choice when mesenteric ischemia is suspected because of its ability to provide two-dimensional multiplanar and three-dimensional display of the mesenteric vasculature and small intestine. This article reviews the clinical features, pathophysiology, and MDCT features of mesenteric ischemia.

Noncancer Causes of Death in Survivors of Testicular Cancer

BACKGROUND

Although modern treatments for testicular cancer are associated with increased survival, the long-term health effects of these treatments are unclear. We conducted a population-based study to quantify the long-term risks of mortality from noncancer causes among men with testicular cancer.

METHODS

We identified 38,907 one-year survivors of testicular cancer within 14 population-based cancer registries in North America and Europe (from 1943 through 2002). We used data from these registries to calculate standardized mortality ratios (SMRs) for noncancer deaths and to evaluate associations between histology, age at testicular cancer diagnosis, calendar year of diagnosis, and initial treatment and the risk of noncancer mortality. All statistical tests were two-sided.

RESULTS

A total of 2942 deaths from all noncancer causes were reported after a median follow-up of 10 years, exceeding the expected number of deaths from all noncancer causes in the general population by 6% (SMR = 1.06, 95% confidence interval [CI] = 1.02 to 1.10); the noncancer standardized mortality ratios did not differ statistically significantly between patients diagnosed before and after 1975, when cisplatin-based chemotherapy came into widespread use. Compared with the general population, testicular cancer survivors had higher mortality from infections (SMR = 1.28, 95% CI = 1.12 to 1.47) and from digestive diseases (SMR = 1.44, 95% CI = 1.26 to 1.64). Mortality from all circulatory diseases was statistically significantly elevated in men diagnosed with testicular cancer before age 35 years (1.23, 95% CI = 1.09 to 1.39) but not in men diagnosed at older ages (SMR = 0.94; 95% CI = 0.89 to 1.00). Men treated with chemotherapy (with or without radiotherapy) in 1975 or later had higher mortality from all noncancer causes (SMR = 1.34, 95% CI = 1.15 to 1.55), all circulatory diseases (SMR = 1.58, 95% CI = 1.25 to 2.01), all infections (SMR = 2.48, 95% CI = 1.70 to 3.50), and all respiratory diseases (SMR = 2.53, 95% CI = 1.26 to 4.53). Testicular cancer patients who were younger than 35 years at diagnosis and were treated with radiotherapy alone in 1975 or later had higher mortality from all circulatory diseases (SMR = 1.70, 95% CI = 1.21 to 2.31) compared with the general population.

CONCLUSION

Men who have survived for at least 1 year after being diagnosed with testicular cancer have a slightly higher risk of dying from noncancer causes, including infections, digestive diseases, and circulatory diseases, than the general population. Men treated with chemotherapy in 1975 or later may be at particularly high risk.

Giant cell arteritis presenting as small bowel infarction

Giant cell arteritis predominantly affects cranial arteries and rarely involves other sites. We report a patient who presented with small bowel obstruction because of infarction from mesenteric giant cell arteritis. She had an unusual cause of her obstruction and a rare manifestation of giant cell arteritis. In spite of aggressive therapy with steroids, she died a month later because of multiple complications. We discuss the diagnosis and management of small bowel obstruction and differential diagnosis of vasculitis of the gastrointestinal tract. We were able to find 11 cases of bowel involvement with giant cell arteritis in the English literature. This case report illustrates that giant cell arteritis can be a cause of small bowel obstruction and bowel infarction. In the proper clinical setting, vasculitides need to be considered early in the differential diagnosis when therapy may be most effective.

Multidetector row CT of the small bowel

Multidetector row CT (MDCT) has become an imaging technique of choice to study routinely the small bowel. Thin collimation and fast scanning allow coverage of the entire abdomen within a single suspended respiration phase allowing the use of multiple enhancement phases after intravenous contrast administration. MDCT of the small bowel can identify and stage most of the common diseases of the small bowel. MDCT is changing the paradigm for diagnosing small bowel disease by becoming the first diagnostic line for almost all small bowel diseases. MDCT has the needed sensitivity and specificity, the availability, and the safety for a front-line diagnostic method.

Prospective study on the role of the CT scan in patients with an acute abdomen

OBJECTIVES

Recent reports indicate that early CT scan (within 24 h) increases diagnostic accuracy, reduces hospital stay and mortality in patients with an acute abdomen. The aim of this study was to assess the surgeons' use of CT in patients with an acute abdomen and the impact of this on diagnostic accuracy and mortality.

PATIENTS AND METHODS

Patients older than 25 years admitted as an emergency with acute abdominal pain were prospectively evaluated.

RESULTS

Two hundred and eleven patients fulfilled the inclusion criteria including 129 women and 82 men with a mean age of 62.4 years (range 27-92 years). The correct diagnosis on admission was made in 99 (47%) patients. CT was performed in 81 (38%), including 24 who had the scan performed within 24 h of admission. The sensitivity, specificity and accuracy of CT were 86%, 79% and 84%. CT was considered to have changed clinical management in 40 patients. Fifteen patients died, and one death may have been prevented by an early CT. Five had a delay in diagnosis of a serious condition; all could have been prevented by early CT.

CONCLUSION

Selective use of CT increases diagnostic accuracy and improves the management of patients with an acute abdomen. Clinical trials are necessary to assess outcome following selective vs routine use of CT in this group of patients.