Non-oklüzif mezenterik iskemi

Özet

Non-oklüzif mezenterik iskemi, özellikle şok, düşük kalp debisi veya vazopresör maruziyeti olan hastada bağırsak kan akımının yaygın azalmasıyla gelişir. BT anjiyografi ana mezenterik damarların açık olduğunu gösterebilir; tanı, küçük dallardaki vazokonstriksiyon ile bağırsak perfüzyon paternini birlikte tanımaya dayanır. Erken dönem bulguları lokalize ve belirsiz olabildiğinden, ana SMA'nın açık olması NOMI'yi dışlamamalıdır. Fark edilmemesi mukozal hasarın transmural nekroza ilerlemesine ve yaygın bağırsak kaybına yol açabilir.

Faz ve pencere

Kontrastsız

Kontrastsız BT'de bağırsak duvarı yüksek yoğunluklu hemorajik nekroz ve intravasküler tromboz açısından taranır; bu faz tek başına NOMI tanısı koşturmaz ancak kontrastlı görüntülerle ayırt etmek için gereklidir.

BTA tanısal

Ana SMA ve SMV açık kalabilir; dallarda incelme, az sayıda opaklaşan periferik arter ve spazm nedeniyle boncuklanma/ani daralma paterni izlenebilir. Arteriyel faz küçük damar ağını incelemek için gereklidir.

Portal tanısal

Bağırsak duvarında yamalı hipoenhancement, ince kağıt görünümü veya reperfüzyona bağlı ödemli kalınlaşma; mezenterik ödem ve sıvı görülebilir. İleri olguda pneumatosis ve portal venöz gaz araştırılır.

Önerilen pencereler: Anjiyo (G 600 / M 150), Batın (G 400 / M 50), Yumuşak doku (G 400 / M 40).

BT bulguları

• Açık ana SMA — ana gövde ve ostiumda organik tıkanma olmaması NOMI lehine temel damar bulgusudur.
• Dallarda vazokonstriksiyon — segmental daralma, düzensiz kalibrasyon ve periferik dalların seyrekleşmesi görülebilir.
• Azalmış distal arter opasifikasyonu — mezenterik arkadlar ve vasa recta bazı segmentlerde ince veya seçilemez hale gelir.
• Yamalı duvar hipoenhancementi — farklı anslarda değişken kontrastlanma, sistemik hipoperfüzyon paternini yansıtır.
• İnce veya kalın bağırsak duvarı — iskemi erken evrede incelme, reperfüzyon ve ödem eşliğinde kalınlaşma yapabilir.
• Mezenterik ödem ve serbest sıvı — damar yatağı ve bağırsak etkilenmesine eşlik eden özgül olmayan ikincil bulgulardır.
• Pneumatosis/portal venöz gaz — duvar içi veya portomezenterik gaz ilerlemiş bağırsak hasarını düşündürür.

Normalde

Normal ince bağırsak duvarı portal fazda anslar boyunca benzer ve homojen kontrastlanır; SMA gövdesinden periferik arkadlara kadar dallar düzenli biçimde incelir. Hastalıklı incelemede ana damar açıklığını korurken periferik dal kalibrasyonunu ve farklı ansların duvar kontrastını normal örüntüyle yan yana kıyaslayın.

Ayırıcı tanı

Arteriyel emboli

ana veya segmental SMA dalında keskin intraluminal dolum defekti ve bölgesel beslenme alanı vardır.

SMA aterotrombozu

ostial plakla birlikte proksimal lümen daralması ya da oklüzyon görülür.

Mezenterik ven trombozu

SMV içi dolum defekti, venöz genişleme ve ödemli kalın bağırsak duvarı ön plandadır.

Şok bağırsak

sistemik hipoperfüzyon veya şok durumlarında bağırsak duvarında diffüz değişiklikler ve vasküler akım azalımı gözlenebilir; bu durumda NOMI'deki gibi belirgin fokal arteriyel spazm bulgusu gerekmez.

Enfeksiyöz enterit, bağırsak duvarı kalınlaşmasının ayırıcı tanısında yer alabilir.

Tuzaklar

• Ana SMA'nın açık olması iskemi yokluğu anlamına gelmez; NOMI'de dikkat periferik dalların kalibresi ve bağırsak duvarı perfüzyonundadır.
• Düşük kardiyak debide zayıf kontrastlanma görüntü kalitesini etkileyebilir; bu durumda iyot belirginliğini artırmak için düşük keV tarama veya çift enerji CT tercih edilmelidir.
• Duvar kalınlaşması reperfüzyon, enfeksiyon veya ödemle de oluşur; segmental hipoenhancement ve periferik vazokonstriksiyonla eşleşmesini arayın.

Kendini dene

1. Vazopresör alan hastada SMA ana gövdesi açık, periferik dallar incelmiş ve jejunumda yamalı hipoenhancement var. En olası tanı?

   • NOMI
   • SMA embolisi
   • SMA aterotrombozu
   • SMV trombozu
   Cevabı göster

   NOMI. Ana damar açıkken yaygın distal vazokonstriksiyon ve yamalı perfüzyon kaybı NOMI paternidir. Emboli ve aterotrombozda anatomik arter tıkanması; SMV trombozunda venöz dolum kusuru beklenir.

2. BT'de kalınlaşmış bağırsak ansları ve mezenterik yağ kirlenmesi var; belirgin periferik arter daralması yok. Hangi alternatif tanı daha olasıdır?

   • Enfeksiyöz enterit
   • NOMI
   • Arteriyel emboli
   • SMA trombozu
   Cevabı göster

   Enfeksiyöz enterit. Duvar kalınlaşması ve çevresel inflamasyon enteritte görülebilir; tipik distal vazokonstriksiyon bulgusu desteklenmiyor. Emboli ve trombozda damar içi tıkanma beklenir, NOMI'de ise düşük akım bağlamında küçük arter spazmı araştırılır.

İlgili konular

• Akut mezenterik arter trombozu
• Mezenterik ven trombozu

Kaynaklar

Bu sayfadaki 40 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 6 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez. İçerik yapay zekâ destekli bir süreçle güncel literatüre göre cümle cümle kaynaklarla karşılaştırıldı, ancak uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.