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Case 12

Ischaemic colitis

An elderly man with right lower quadrant pain

This 63 year old man presented with a day's history of right lower quadrant pain. His only past medical history was of an appendicectomy.

On examination he was found to be pyrexial, 38.8 °ree;C, with tenderness and guarding in the right iliac fossa. His white cell count was 19.9.

A CT scan was ordered as a diverticular abcess was suspected. What is the diagnosis?

Findings

The CT was obtained during iv contrast infusion, and following oral contrast. It demonstrates distension of the caecum. The bowel wall is thickened, and contains multiple small intramural gas bubbles. The surrounding fat is increased in attenuation, with thickening of the adjacent fascial planes due to inflammation.

Compare with the normal descending colon seen on the left. The lumen is smaller, and the wall is barely perceptible. The surrounding fat is darker with no streaking.

Note also calcification in the iliac arteries.

Diagnosis

Ischaemic colitis

Discussion

At emergency laparotomy the caecum was necrotic and the remainder of the right colon was also dusky. A right hemicolectomy was performed.

Ischaemic colitis typically presents with acute lower abdominal pain, diarrhoea and rectal bleeding. It is confined to those over 50 years, and usually affects the watershed between SMA and IMA territories (ie. splenic flexure and left colon).

The classic plain film finding is thumbprinting due to mucosal oedema. The presence of intramural gas is a sign of irreversible ischaemia and imminent perforation requiring emergency surgery. It may be associated with portal venous gas on the plain film or CT.

There are three possible outcomes:

• Transient ischaemia with recovery
• Ischaemic stricture - smooth long stricture at splenic flexure
• Necrosis and perforation

The cause was not identified, but the vascular calcification, and the mural thrombus seen in the aorta (not shown) suggest atherosclerosis. An embolic cause should be excluded.

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