Case #5 Answers & Discussion
Contributed by Dr. Duy
Your Score and Answers
| Question | Correct Answer | Your Answer | Your Score |
|---|---|---|---|
| What is the most likely diagnosis? | Bowel Ischemia | 1/1 | |
| What is the most likely diagnosis? | Ulcerative colitis | 1/1 | |
| Which of the following is associated with ulcerative colitis? | A and B (Colorectal carcinoma & Primary sclerosing cholangitis) | 1/1 | |
| In a culture of safety, the term “second victim” refers to who? | The healthcare worker who caused the error | 1/1 |
Findings
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CT images show a thrombus in the SMV (red arrow). Bowel loops are thickened and hypoenhancing (green arrow). There is also mesenteric edema (blue arrow)
CT shows pancolitis (red arrows). There is also bilateral, symmetric sacroiliitis (blue arrows).
Veno-occlusive mesenteric ischemia
- Bowel ischemia can be caused by arterial occlusion, venous occlusion, or systemic hypotension.
- Veno-occlusive ischemia is less common than arterial-occlusive mesenteric ischemia
- Bowel blood inflow is preserved, but back pressure from the occluded vein prevents outflow.
- This causes bowel wall thickening, fluid, and mesenteric edema.
- Bowel wall enhancement is variable, and can be hyperenhancing or hypoenhancing.
- Lactic acid is unreliable, but maybe elevated in late stages.
- Normal lactate does NOT exclude ischemia.
Ulcerative Colitis
- Inflammatory disease of the mucosa and submucosa
- CT shows bowel wall thickening with mural stratification
- Ulcerations can be seen.
- Pseudopolyps, which are islands of tissue surrounded by ulceration, can be seen in severe disease.
- UC involves the colon, starting at the rectum and progressing proximally.
- “Backwash ileitis” can also be seen.
- It can be difficult to differentiate from C. difficile colitis, however look for associations to favor ulcerative colitis.
- Associations include primary sclerosing cholangitis, colon cancer, seronegative spondyloarthropathy, and uveitis.
The second victim
- When an error occurs, the healthcare worker who caused the adverse event may feel guilty or traumatized.
- In a just culture model, the appropriate response to human error is to console the individual and change the system to prevent such an error for happening again.
References
- Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD. Acute mesenteric ischemia: a clinical review. Arch Intern Med. 2004 May 24;164(10):1054-62. doi: 10.1001/archinte.164.10.1054. PMID: 15159262.
- Florim, S et al. “Acute mesenteric ischaemia: a pictorial review.” Insights into imaging vol. 9,5 (2018): 673-682. doi:10.1007/s13244-018-0641-2
- “ABR 2019 noninterpretive skills study guide”, https://www.theabr.org/wp-content/uploads/2018/11/NIS-Study-Guide-2019.pdf
- Ulcerative Colitis Mark J. Roggeveen, Mikhail Tismenetsky, and Robert Shapiro, RadioGraphics 2006 26:3, 947-951
