Korean J Radiol.  2017 Dec;18(6):936-945. 10.3348/kjr.2017.18.6.936.

Post-Ischemic Bowel Stricture: CT Features in Eight Cases

• Kim JS
• Kim HJ
• Hong SM
• Park SH
• Lee JS
• Kim AY
• Ha HK

• KMID: 2427203
• DOI: http://doi.org/10.3348/kjr.2017.18.6.936

Abstract

OBJECTIVE
To investigate the characteristic radiologic features of post-ischemic stricture, which can then be implemented to differentiate that specific disease from other similar bowel diseases, with an emphasis on computed tomography (CT) features.
MATERIALS AND METHODS
Eight patients with a diagnosis of ischemic bowel disease, who were also diagnosed with post-ischemic stricture on the basis of clinical or pathologic findings, were included. Detailed clinical data was collected from the available electronic medical records. Two radiologists retrospectively reviewed all CT images. Pathologic findings were also analyzed.
RESULTS
The mean interval between the diagnosis of ischemic bowel disease and stricture formation was 57 days. The severity of ischemic bowel disease was variable. Most post-ischemic strictures developed in the ileum (n = 5), followed by the colon (n = 2) and then the jejunum (n = 1). All colonic strictures developed in the "watershed zone." The pathologic features of post-ischemic stricture were deep ulceration, submucosal/subserosal fibrosis and chronic transmural inflammation. The mean length of the post-ischemic stricture was 7.4 cm. All patients in this study possessed one single stricture. On contrast-enhanced CT, most strictures possessed concentric wall thickening (87.5%), with moderate enhancement (87.5%), mucosal enhancement (50%), or higher enhancement in portal phase than arterial phase (66.7%).
CONCLUSION
Post-ischemic strictures develop in the ileum, jejunum and colon after an interval of several weeks. In the colonic segment, strictures mainly occur in the "watershed zone." Typical CT findings include a single area of concentric wall thickening of medium length (mean, 7.4 cm), with moderate and higher enhancement in portal phase and vasa recta prominence.

Keyword

Bowel stricture; Stenosis; Ischemic stricture; Bowel ischemia; CT

MeSH Terms

Adult
Aged
Aged, 80 and over
Colon/diagnostic imaging/pathology
Constriction, Pathologic
Female
Humans
Ileum/diagnostic imaging/pathology
Inflammatory Bowel Diseases/*diagnosis/diagnostic imaging/pathology
Jejunum/diagnostic imaging/pathology
Male
Middle Aged
Retrospective Studies
Time Factors
*Tomography, X-Ray Computed

Figure

• 

  Fig. 1 67-year-old man with multiple pre-existing and underlying pathologies (including diabetes mellitus, hypertension, chronic renal failure, and complete AV block) (patient #1) who suffered loss of consciousness during defecation. A. CT scan performed (at time of diagnosis of ischemic bowel disease) shows some areas of decreased enhancement (arrows) in splenic flexure of colon, which is consistent with ischemic colitis. Patient had diarrhea at that time, and vital parameters were stable. Patient was managed conservatively, with antibiotics. B. Coronal arterial and portal phase images obtained 98 days after ischemic event show better bowel wall enhancement in portal phase than arterial phase (mild homogeneous enhancement in arterial phase and moderate mucosal enhancement in portal phase) (arrows) as well as vasa recta prominence around site of stricture. C. Colon study shows thickened folds (“thumb printing”), which is typical finding in cases of ischemic colitis. Patient underwent subtotal colectomy. D. Gross specimen of resected large bowel reveals approximately ten centimeters long segmental stricture (arrows) with dilatation of proximal bowel segment. This corresponds with CT image findings (arrows in B) and colon study (arrows in C). AV = atrioventricular

• 

  Fig. 2 55-year-old man without underlying disease (patient #6). A, B. Coronal and axial images from reformatted CT scan performed at time of diagnosis (with ischemic bowel disease) show thickening of wall of ileum with decreased enhancement, which is consistent with venous ischemia (arrow in A); inferior mesenteric vein thrombosis is also noted (arrowheads in B). Patient had abdominal pain at that time, and vital parameters were stable. Patient underwent anticoagulation therapy with Heparin. C. Coronal images from contrast-enhanced CT obtained when patient had abdominal pain, fourteen days after ischemic event. Post-ischemic stricture with concentric wall thickening and higher enhancement in portal phase than arterial phase (moderate mucosal enhancement in arterial phase and moderate layered enhancement in portal phase) (arrows) was identified. D. Small bowel series reveals fold effacement at site of stricture (arrows). Patient underwent small bowel resection and anastomosis. E. Gross specimen of resected large bowel reveals approximately four centimeters long segmental stricture (arrows) with dilatation of proximal bowel segment, which corresponds with CT image findings (arrow in C). F. Low power magnification shows ulceration (arrows) and dilatation of submucosal venules and capillaries (arrowheads) (original magnification, × 12.5) G. Mucosa shows ulceration (arrows) and crypt distortion of residual epithelial cells (arrowheads) (× 40).

• 

  Fig. 3 29-year-old man without underlying disease (patient #8). A, B. Coronal and axial images obtained from reformatted CT scan performed at time of diagnosis with ischemic bowel disease reveal superior mesenteric vein thrombosis (arrowheads) and layered enhancement of thickened jejunal wall indicating venous ischemia (arrows). Patient had abdominal pain at that time and vital parameters were stable. Patient underwent anticoagulation therapy with Heparin. C. Axial and coronal images of contrast-enhanced CT scan obtained when patient had abdominal pain, which was 54 days after ischemic event, reveal segmental post-ischemic stricture with concentric wall thickening and better enhancement in portal phase than arterial phase (moderate mucosal enhancement during arterial phase and moderate homogeneous enhancement during portal phase). Proximal bowel dilatation is also seen, indicating high-grade obstruction. Patient underwent small bowel resection and anastomosis. D. Gross specimen of resected large bowel reveals approximately twp centimeter long segmental stricture with dilatation of proximal bowel segment, which corresponds with CT image findings (arrows in C and D).

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