MKSAP Quiz: Hospitalization for sudden-onset, cramping abdominal pain

This month's quiz asks readers to determine appropriate testing for a 60-year-old woman admitted to the hospital with sudden-onset, cramping abdominal pain of moderate severity in the right lower quadrant.

A 60-year-old woman is admitted to the hospital with sudden-onset, cramping abdominal pain of moderate severity in the right lower quadrant, followed several hours later by a bloody bowel movement. She has coronary artery disease; medications are atorvastatin, metoprolol, sublingual nitroglycerin, and low-dose aspirin.

On physical examination, the patient appears comfortable. Pulse rate is 110/min; BMI is 35. Other vital signs are normal. The abdomen is nondistended with normal bowel sounds. Deep palpation elicits tenderness in the right lower quadrant with no rebound or guarding.

A CT scan without contrast shows thickening of the ascending colon. Colonoscopy results show a segment of subepithelial hemorrhage, edema, and erythema from the cecum to the hepatic flexure.

Which of the following is the most appropriate test to perform next?

A. CT angiography
B. Doppler ultrasonography of mesenteric vessels
C. MR angiography
D. Selective catheter angiography.

MKSAP Answer and Critique

The correct answer is A. CT angiography. This content is available to MKSAP 18 subscribers as Question 61 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.

CT angiography is the best next test for this patient, whose clinical presentation with the sudden onset of right-sided, cramping abdominal pain followed by a bloody bowel movement is typical of isolated right-colon ischemia. A CT scan showing thickening of the ascending colon and the colonoscopy features are helpful in confirming this diagnosis. The most common cause of colon ischemia is a nonocclusive low-flow state in the colonic microvasculature. Most cases of colonic ischemia involve the left colon, which is supplied by the inferior mesenteric artery; as with ischemia involving the right colon, the diagnosis is clinical and supported by CT and colonoscopy. Patients with left-sided colonic ischemia tend to heal well with conservative therapy alone, whereas isolated right-colon ischemia can be the harbinger of acute mesenteric ischemia caused by a focal thrombus or embolus of the superior mesenteric artery. This artery supplies both the small intestine and right colon, and the consequences of acute mesenteric ischemia involving the small bowel are severe, with mortality rates that can approach 60%. For this reason, patients with isolated right-colon ischemia require urgent, noninvasive imaging of the mesenteric vasculature to assess the extent of ischemia and nature of the intervention. CT angiography is the recommended method of imaging for diagnosing acute mesenteric ischemia because it can be obtained rapidly. CT angiography visualizes the origins and length of the vessels, characterizes the extent of occlusion, and aids in planning revascularization.

Doppler ultrasonography of the mesenteric vessels is an effective, low-cost tool that can assess the proximal visceral vessels but has limited ability to visualize distal vessels. It is best reserved for the evaluation of patients with chronic mesenteric ischemia, which typically presents with postprandial abdominal pain, sitophobia, and weight loss.

MR angiography provides information about mesenteric arterial flow and avoids the potential harms of radiation and use of contrast that are associated with CT angiography; however, MR angiography takes longer to perform, lacks the required resolution to identify arterial occlusion, and can overestimate the severity of stenosis.

Selective catheter angiography was the standard method for diagnosing mesenteric ischemia; however, it is now used after a revascularization plan has been chosen because CT angiography can be obtained rapidly and is noninvasive.

Key Point

  • Isolated right-colon ischemia may be a warning sign of acute mesenteric ischemia caused by embolism or thrombosis of the superior mesenteric artery and should be evaluated using CT angiography.