Mesenteric ischemia CT: Difference between revisions

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{{Mesenteric ischemia}}
{{Mesenteric ischemia}}
{{CMG}} {{AE}} {{FT}}
{{CMG}} {{AE}} {{FT}}
==Overview==


==Overview==
Computerised axial tomographic [[Angiogram|angiography]] should be performed as soon as possible in order to diagnose [[Mesenteric ischemia|mesenteric]] ischemia becasue of its ability to define the [[Artery|arterial]] [[anatomy]] and demonstrate the site of [[occlusion]].


==CT==
==CT==
* [[Computed tomography|Computerised]] axial tomographic [[Angiogram|angiography]] (CTA) without intravenous contrast should be the first investigation done for the diagnosis of [[Mesenteric ischemia|mesenteric]] ischemia regardless of the etiology.<ref name="pmid15833694">{{cite journal| author=Sreenarasimhaiah J| title=Chronic mesenteric ischemia. | journal=Best Pract Res Clin Gastroenterol | year= 2005 | volume= 19 | issue= 2 | pages= 283-95 | pmid=15833694 | doi=10.1016/j.bpg.2004.11.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15833694  }} </ref><ref name="YikilmazKarahan2011">{{cite journal|last1=Yikilmaz|first1=Ali|last2=Karahan|first2=Okkes Ibrahim|last3=Senol|first3=Serkan|last4=Tuna|first4=Ibrahim Sacit|last5=Akyildiz|first5=Hizir Yakup|title=Value of multislice computed tomography in the diagnosis of acute mesenteric ischemia|journal=European Journal of Radiology|volume=80|issue=2|year=2011|pages=297–302|issn=0720048X|doi=10.1016/j.ejrad.2010.07.016}}</ref>
* Intravenous contrast is avoided for the following reasons:<ref name="pmid9342567">{{cite journal| author=Li KC| title=Magnetic resonance angiography of the visceral arteries: techniques and current applications. | journal=Endoscopy | year= 1997 | volume= 29 | issue= 6 | pages= 496-503 | pmid=9342567 | doi=10.1055/s-2007-1004254 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9342567  }} </ref><ref name="pmid12172987">{{cite journal| author=Laissy JP, Trillaud H, Douek P| title=MR angiography: noninvasive vascular imaging of the abdomen. | journal=Abdom Imaging | year= 2002 | volume= 27 | issue= 5 | pages= 488-506 | pmid=12172987 | doi=10.1007/s00261-001-0063-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12172987  }} </ref><ref name="pmid12598031">{{cite journal| author=Fleischmann D| title=Multiple detector-row CT angiography of the renal and mesenteric vessels. | journal=Eur J Radiol | year= 2003 | volume= 45 Suppl 1 | issue=  | pages= S79-87 | pmid=12598031 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12598031  }} </ref><ref name="pmid12016369">{{cite journal| author=Bradbury MS, Kavanagh PV, Chen MY, Weber TM, Bechtold RE| title=Noninvasive assessment of portomesenteric venous thrombosis: current concepts and imaging strategies. | journal=J Comput Assist Tomogr | year= 2002 | volume= 26 | issue= 3 | pages= 392-404 | pmid=12016369 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12016369  }} </ref><ref name="pmid12659334">{{cite journal| author=Horton KM, Fishman EK| title=The current status of multidetector row CT and three-dimensional imaging of the small bowel. | journal=Radiol Clin North Am | year= 2003 | volume= 41 | issue= 2 | pages= 199-212 | pmid=12659334 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12659334  }} </ref><ref name="pmid12659341">{{cite journal| author=Kim AY, Ha HK| title=Evaluation of suspected mesenteric ischemia: efficacy of radiologic studies. | journal=Radiol Clin North Am | year= 2003 | volume= 41 | issue= 2 | pages= 327-42 | pmid=12659341 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12659341  }} </ref><ref name="pmid17667501">{{cite journal| author=Mitsuyoshi A, Obama K, Shinkura N, Ito T, Zaima M| title=Survival in nonocclusive mesenteric ischemia: early diagnosis by multidetector row computed tomography and early treatment with continuous intravenous high-dose prostaglandin E(1). | journal=Ann Surg | year= 2007 | volume= 246 | issue= 2 | pages= 229-35 | pmid=17667501 | doi=10.1097/01.sla.0000263157.59422.76 | pmc=1933563 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17667501  }} </ref>
** It can obscure the vessels
** Delays the diagnosis
** Hides the [[Intestine|bowel]] wall enhancement
* CTA shows the following findings consistent with mesenteric ischemia, which are as follows:<ref name="pmid18690454">{{cite journal| author=Ofer A, Abadi S, Nitecki S, Karram T, Kogan I, Leiderman M et al.| title=Multidetector CT angiography in the evaluation of acute mesenteric ischemia. | journal=Eur Radiol | year= 2009 | volume= 19 | issue= 1 | pages= 24-30 | pmid=18690454 | doi=10.1007/s00330-008-1124-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18690454  }} </ref><ref name="pmid18425546">{{cite journal| author=Aschoff AJ, Stuber G, Becker BW, Hoffmann MH, Schmitz BL, Schelzig H et al.| title=Evaluation of acute mesenteric ischemia: accuracy of biphasic mesenteric multi-detector CT angiography. | journal=Abdom Imaging | year= 2009 | volume= 34 | issue= 3 | pages= 345-57 | pmid=18425546 | doi=10.1007/s00261-008-9392-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18425546  }} </ref><ref name="pmid20186630">{{cite journal| author=Qiang JW, Li RK, Feng XY, Liao ZH, He C, Feng Q et al.| title=[Multidetector-row CT evaluation of acute bowel ischemia induced by embolization of superior mesenteric artery in experimental porcine models]. | journal=Zhonghua Wei Chang Wai Ke Za Zhi | year= 2010 | volume= 13 | issue= 2 | pages= 151-5 | pmid=20186630 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20186630  }} </ref><ref name="pmid21993179">{{cite journal| author=Barmase M, Kang M, Wig J, Kochhar R, Gupta R, Khandelwal N| title=Role of multidetector CT angiography in the evaluation of suspected mesenteric ischemia. | journal=Eur J Radiol | year= 2011 | volume= 80 | issue= 3 | pages= e582-7 | pmid=21993179 | doi=10.1016/j.ejrad.2011.09.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21993179  }} </ref><ref name="pmid16332482">{{cite journal| author=Rosow DE, Sahani D, Strobel O, Kalva S, Mino-Kenudson M, Holalkere NS et al.| title=Imaging of acute mesenteric ischemia using multidetector CT and CT angiography in a porcine model. | journal=J Gastrointest Surg | year= 2005 | volume= 9 | issue= 9 | pages= 1262-74; discussion 1274-5 | pmid=16332482 | doi=10.1016/j.gassur.2005.07.034 | pmc=3807105 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16332482  }} </ref>
'''Early radiological features:'''
** [[Intestine|Bowel]] dilation
** Focal or segmental [[Intestine|bowel]] wall thickening
** [[Mesentery|Mesenteric]] stranding
'''Late radiological features:'''
** [[Intestine|Intestinal]] [[Pneumatosis intestinalis|pneumatosis]] (presence of air within the bowel wall)
** [[Portal venous gas]]
* Following radiological features are seen on [[CT angiography|CTA]] in mesenteric ischemia of different etiologies:<ref name="JangMin2010">{{cite journal|last1=Jang|first1=Kyung Mi|last2=Min|first2=Kwangseon|last3=Kim|first3=Min Jeong|last4=Koh|first4=Sung Hye|last5=Jeon|first5=Eui Yong|last6=Kim|first6=In-Gyu|last7=Choi|first7=Dongil|title=Diagnostic Performance of CT in the Detection of Intestinal Ischemia Associated With Small-Bowel Obstruction Using Maximal Attenuation of Region of Interest|journal=American Journal of Roentgenology|volume=194|issue=4|year=2010|pages=957–963|issn=0361-803X|doi=10.2214/AJR.09.2702}}</ref><ref name="pmid12659341">{{cite journal| author=Kim AY, Ha HK| title=Evaluation of suspected mesenteric ischemia: efficacy of radiologic studies. | journal=Radiol Clin North Am | year= 2003 | volume= 41 | issue= 2 | pages= 327-42 | pmid=12659341 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12659341  }} </ref>


{| class="wikitable"
!Radiological feature
!Mesenteric arterial occlusion
!Mesenteric venous thrombosis
!Non occlusive mesenteric ischemia
|-
|'''[[Intestine|Bowel]] wall'''
|Thinning ("paper thin wall")
|Thickening
|No change in the bowel wall
|-
|'''Attenuation of bowel wall on unenhanced CT'''
|Not characteristic
|Low with [[edema]], high with [[Bleeding|hemorrhage]]
|Not characteristic
|-
|'''Bowel dilation'''
|Not apparent
|Moderate to prominent
|Not apparent
|-
|'''[[Mesentery|Mesenteric]] vessels'''
|Filling defect in the artery or absence of flow
|[[Vein|Venous]] filling defect
|Areas of focal narrowing in major branches with a string-of-beads appearance, reduced or absent flow in the smaller vessels, and an absent [[Submucosa|submucosal]] "blush."
|-
|'''[[Mesentery]]'''
|Normal until bowel infarction has occurred
|Hazy with [[ascites]]
|Normal until [[Intestine|bowel]] [[infarction]] has occurred
|}
[[File:Miscgif.gif|500px|center|thumb|Mesenteric ischemia <br> Source: Wikimedia commons <ref name="urlFile:Ischemicbowel.PNG - Wikimedia Commons">{{cite web |url=https://commons.wikimedia.org/wiki/File:Ischemicbowel.PNG |title=File:Ischemicbowel.PNG - Wikimedia Commons |format= |work= |accessdate=}}</ref>]]


 
[[File:Portal-venous-gas-2.jpg|thumb|center|☃☃adiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/19680">rID: 19680</a>]]
 
 
 
 
 
 
[[Computed tomography]] (CT scan) is often used.<ref name="pmid3336673">{{cite journal | author = Alpern M, Glazer G, Francis I | title = Ischemic or infarcted bowel: CT findings. | journal = Radiology | volume = 166 | issue = 1 Pt 1 | pages = 149-52 | year = 1988 | id = PMID 3336673}}</ref><ref>{{cite journal | author = Taourel P, Deneuville M, Pradel J, Régent D, Bruel J | title = Acute mesenteric ischemia: diagnosis with contrast-enhanced CT. | journal = Radiology | volume = 199 | issue = 3 | pages = 632-6 | year = 1996 | id = PMID 8637978|doi=10.1148/rg.243035084|url=http://radiology.rsnajnls.org/cgi/reprint/199/3/632.pdf}}</ref> The accuracy of the [[Computed tomography|CT scan]] depends on whether a small bowel obstruction (SBO) is present <ref name="pmid15835585">{{cite journal |author=Staunton M, Malone DE |title=Can acute mesenteric ischemia be ruled out using computed tomography? Critically appraised topic |journal=Canadian Association of Radiologists journal = Journal l'Association canadienne des radiologistes |volume=56 |issue=1 |pages=9-12 |year=2005 |pmid=15835585 | url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=16596241&site=ehost-live}}</ref>.
 
'''SBO absent'''
* prevalence of mesenteric ischemia 23%
* [[sensitivity (tests)|sensitivity]] 64%
* [[specificity (tests)|specificity]] 92%
* [[positive predictive value]] (at prevalence of 23%) 79%
* [[negative predictive value]] (at prevalence of 23%) 95%
'''SBO present'''
* prevalence of mesenteric ischemia 62%
* [[sensitivity (tests)|sensitivity]] 83%
* [[specificity (tests)|specificity]] 93%
* [[positive predictive value]] (at prevalence of 62%) 93%
* [[negative predictive value]] (at prevalence of 62%) 61%
 
Findings on [[Computed tomography|CT scan]] include:
* Mesenteric edema<ref name="pmid3336673" />
* Bowel dilatation<ref name="pmid3336673" />
* Bowel wall thickening<ref name="pmid3336673" />
* Intramural gas<ref name="pmid3336673" />
* Mesenteric stranding<ref name="pmid15143223">{{cite journal |author=Pereira JM, Sirlin CB, Pinto PS, Jeffrey RB, Stella DL, Casola G |title=Disproportionate fat stranding: a helpful CT sign in patients with acute abdominal pain |journal=Radiographics : a review publication of the Radiological Society of North America, Inc |volume=24 |issue=3 |pages=703–15 |year=2004 |pmid=15143223 |doi=10.1148/rg.243035084}}</ref>
 
* The CT and MR imaging findings represent a combination of those seen at plain radiography, barium studies, and angiography (vascular occlusion).
* CT and/or MR imaging may be helpful in determining the primary cause of bowel ischemia as well as allowing direct evaluation of the bowel wall, adjacent mesentery, and vascular structures.
 
* The '''most common CT finding in bowel ischemia is bowel wall thickening''' (nonspecific finding). The thickened bowel wall is sometimes associated with the [[target sign]], alternating layers of high and low attenuation within the thickened bowel wall, which results from submucosal edema or hemorrhage.
* '''Absent or poor enhancement of the bowel wall is the most specific finding for bowel ischemia.'''
* Other CT findings of bowel ischemia reported in the literature include arterial occlusion, mesenteric or portal vein thrombosis, bowel dilatation, engorgement of mesenteric veins and mesenteric edema, intramural gas (intestinal pneumatosis), mesenteric or portal venous gas, lack of bowel wall enhancement, and infarction of other abdominal organs (eg, liver, spleen, or kidneys).
 
** Bowel dilatation reflects the interruption of peristaltic activity in ischemic segments. It is a common but nonspecific finding in bowel ischemia.
** Engorgement of mesenteric veins reflects venous congestion secondary to stasis.
** Owing to the edema that accompanies bowel ischemia, the mesenteric fat may be abnormally increased in attenuation.
** Intramural gas is a less common but more specific CT sign of ischemic bowel disease. The intramural gas is caused by dissection of luminal gas into the bowel wall across the compromised mucosa.
** Mesenteric or portal venous gas is an even less common CT manifestation of ischemic bowel disease and represents the propagation of intramural gas into the mesenteric venous system. Free intraperitoneal gas is an ominous CT sign in ischemic bowel disease because it indicates perforation of an infarcted bowel segment.
 
'''Patient #1: CT images of patient with ischemic bowel demonstrates pneumatosis and portal venous gas'''
<gallery>
Image:
 
Bowel-infarction-CT-01.jpg
 
Image:
 
Bowel-infarction-CT-02.jpg
 
Image:
 
Bowel-infarction-CT-03.jpg
 
</gallery>
 
'''Patient #2: CT images demonstrate mesenteric ischemia with marked atherosclerosis of arteries'''
 
<gallery>
Image:
 
Ischemicbowel.PNG|By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=18076957
 
Mesenteric ischemia 101.jpg
 
Image:
 
Mesenteric ischemia 102.jpg
 
Image:
 
Mesenteric ischemia 103.jpg
 
Image:
 
Mesenteric ischemia 104.jpg
 
Image:
 
Mesenteric ischemia 105.jpg
 
Image:
 
Mesenteric ischemia 106.jpg
 
</gallery>


==References==
==References==


{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 23:21, 20 January 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Feham Tariq, MD [2]

Overview

Computerised axial tomographic angiography should be performed as soon as possible in order to diagnose mesenteric ischemia becasue of its ability to define the arterial anatomy and demonstrate the site of occlusion.

CT

  • Computerised axial tomographic angiography (CTA) without intravenous contrast should be the first investigation done for the diagnosis of mesenteric ischemia regardless of the etiology.[1][2]
  • Intravenous contrast is avoided for the following reasons:[3][4][5][6][7][8][9]
    • It can obscure the vessels
    • Delays the diagnosis
    • Hides the bowel wall enhancement
  • CTA shows the following findings consistent with mesenteric ischemia, which are as follows:[10][11][12][13][14]

Early radiological features:

Late radiological features:

Radiological feature Mesenteric arterial occlusion Mesenteric venous thrombosis Non occlusive mesenteric ischemia
Bowel wall Thinning ("paper thin wall") Thickening No change in the bowel wall
Attenuation of bowel wall on unenhanced CT Not characteristic Low with edema, high with hemorrhage Not characteristic
Bowel dilation Not apparent Moderate to prominent Not apparent
Mesenteric vessels Filling defect in the artery or absence of flow Venous filling defect Areas of focal narrowing in major branches with a string-of-beads appearance, reduced or absent flow in the smaller vessels, and an absent submucosal "blush."
Mesentery Normal until bowel infarction has occurred Hazy with ascites Normal until bowel infarction has occurred
Mesenteric ischemia
Source: Wikimedia commons [16]
☃☃adiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/19680">rID: 19680</a>

References

  1. ↑ Sreenarasimhaiah J (2005). "Chronic mesenteric ischemia". Best Pract Res Clin Gastroenterol. 19 (2): 283–95. doi:10.1016/j.bpg.2004.11.002. PMID 15833694.
  2. ↑ Yikilmaz, Ali; Karahan, Okkes Ibrahim; Senol, Serkan; Tuna, Ibrahim Sacit; Akyildiz, Hizir Yakup (2011). "Value of multislice computed tomography in the diagnosis of acute mesenteric ischemia". European Journal of Radiology. 80 (2): 297–302. doi:10.1016/j.ejrad.2010.07.016. ISSN 0720-048X.
  3. ↑ Li KC (1997). "Magnetic resonance angiography of the visceral arteries: techniques and current applications". Endoscopy. 29 (6): 496–503. doi:10.1055/s-2007-1004254. PMID 9342567.
  4. ↑ Laissy JP, Trillaud H, Douek P (2002). "MR angiography: noninvasive vascular imaging of the abdomen". Abdom Imaging. 27 (5): 488–506. doi:10.1007/s00261-001-0063-2. PMID 12172987.
  5. ↑ Fleischmann D (2003). "Multiple detector-row CT angiography of the renal and mesenteric vessels". Eur J Radiol. 45 Suppl 1: S79–87. PMID 12598031.
  6. ↑ Bradbury MS, Kavanagh PV, Chen MY, Weber TM, Bechtold RE (2002). "Noninvasive assessment of portomesenteric venous thrombosis: current concepts and imaging strategies". J Comput Assist Tomogr. 26 (3): 392–404. PMID 12016369.
  7. ↑ Horton KM, Fishman EK (2003). "The current status of multidetector row CT and three-dimensional imaging of the small bowel". Radiol Clin North Am. 41 (2): 199–212. PMID 12659334.
  8. ↑ 8.0 8.1 Kim AY, Ha HK (2003). "Evaluation of suspected mesenteric ischemia: efficacy of radiologic studies". Radiol Clin North Am. 41 (2): 327–42. PMID 12659341.
  9. ↑ Mitsuyoshi A, Obama K, Shinkura N, Ito T, Zaima M (2007). "Survival in nonocclusive mesenteric ischemia: early diagnosis by multidetector row computed tomography and early treatment with continuous intravenous high-dose prostaglandin E(1)". Ann Surg. 246 (2): 229–35. doi:10.1097/01.sla.0000263157.59422.76. PMC 1933563. PMID 17667501.
  10. ↑ Ofer A, Abadi S, Nitecki S, Karram T, Kogan I, Leiderman M; et al. (2009). "Multidetector CT angiography in the evaluation of acute mesenteric ischemia". Eur Radiol. 19 (1): 24–30. doi:10.1007/s00330-008-1124-5. PMID 18690454.
  11. ↑ Aschoff AJ, Stuber G, Becker BW, Hoffmann MH, Schmitz BL, Schelzig H; et al. (2009). "Evaluation of acute mesenteric ischemia: accuracy of biphasic mesenteric multi-detector CT angiography". Abdom Imaging. 34 (3): 345–57. doi:10.1007/s00261-008-9392-8. PMID 18425546.
  12. ↑ Qiang JW, Li RK, Feng XY, Liao ZH, He C, Feng Q; et al. (2010). "[Multidetector-row CT evaluation of acute bowel ischemia induced by embolization of superior mesenteric artery in experimental porcine models]". Zhonghua Wei Chang Wai Ke Za Zhi. 13 (2): 151–5. PMID 20186630.
  13. ↑ Barmase M, Kang M, Wig J, Kochhar R, Gupta R, Khandelwal N (2011). "Role of multidetector CT angiography in the evaluation of suspected mesenteric ischemia". Eur J Radiol. 80 (3): e582–7. doi:10.1016/j.ejrad.2011.09.015. PMID 21993179.
  14. ↑ Rosow DE, Sahani D, Strobel O, Kalva S, Mino-Kenudson M, Holalkere NS; et al. (2005). "Imaging of acute mesenteric ischemia using multidetector CT and CT angiography in a porcine model". J Gastrointest Surg. 9 (9): 1262–74, discussion 1274-5. doi:10.1016/j.gassur.2005.07.034. PMC 3807105. PMID 16332482.
  15. ↑ Jang, Kyung Mi; Min, Kwangseon; Kim, Min Jeong; Koh, Sung Hye; Jeon, Eui Yong; Kim, In-Gyu; Choi, Dongil (2010). "Diagnostic Performance of CT in the Detection of Intestinal Ischemia Associated With Small-Bowel Obstruction Using Maximal Attenuation of Region of Interest". American Journal of Roentgenology. 194 (4): 957–963. doi:10.2214/AJR.09.2702. ISSN 0361-803X.
  16. ↑ "File:Ischemicbowel.PNG - Wikimedia Commons". External link in |title= (help)
Retrieved from "https://www.wikidoc.org/index.php?title=Mesenteric_ischemia_CT&oldid=1431524"