Ultrasound diagnosis of non-occlusive intestinal ischemia in pancreatic necrosis

Relevance. It is known that acute severe pancreatitis (ASP) is accompanied by water-electrolyte metabolism disorders with the development of dehydration, hypercoagulation, hypoperfusion of internal organs, which leads to a natural lesion of the microcirculatory bed of the intestinal wall, contributes to the development of non-occlusive intestinal ischemia and is accompanied by a high risk of sepsis and death.

Objective: to identify the features of ultrasound diagnostics of non-occlusive intestinal ischemia in acute severe pancreatitis and compare with morphological data of autopsy.

Materials and methods. The results of intestinal ultrasound examination in 25 patients with acute severe pancreatitis were analyzed. Inclusion criteria: acute severe pancreatitis, assessment of the severity of patients according to the SOFA scale - 5-12 points, APACHE 2 - 15-38 points. Abdominal examination was performed using a mid-range ultrasound device (SAMSUNG HS-60 RUS) with a 3.5 MHz convex and 7.5 MHz linear transducers. Two groups of patients were divided based on the timing of intestinal ischemic changes: Group 1 — early intestinal ischemia (up to 7 days after the onset of the disease) — 18 patients; Group 2 — late intestinal ischemia (from 7 days onward) — 7 patients. Morphological and histological studies were performed in 22 cases.

Results. According to ultrasound data, all patients with OLT showed signs of intestinal paresis with small intestinal lumen dilation up to 3.5 cm and no peristalsis from the first day of hospital stay. Mesenteric tissues were of medium echogenicity and had a layered structure. On days 3–7 from the moment of admission to the hospital, ultrasound examination revealed changes in the walls of the small intestine against the background of intestinal paresis: a spasmodic fragment of the small intestine without peristalsis was located, flattened on the infiltrated mesentery of increased echogenicity. In 3 cases, blood flow in the walls of the small intestine was not obtained in the color Doppler mode, in 8 cases, arterial blood flow was traced only along the mesenteric edge of the intestine. In the later stages (7–21 days), signs of edema of the small intestinal wall with single small hyperechoic inclusions in the wall structure (gas bubbles) were revealed. Changes in the colon with thickening of the walls of various sections up to 7–10 mm, wall structure of decreased echogenicity with infiltration of the submucosal layer. It was not possible to obtain an arterial spectrum in the color Doppler mode. Histological changes in the intestinal mucosa ranged from acute necrobiotic to complete necrotic. Thus, in some areas of the colon and small intestine, acute vascular changes with hemorrhages in the colonic mucosa predominated, while in others, complete mucosal necrosis with complete structural disruption was observed.

Conclusion. Dynamic color Doppler ultrasound allows for the assessment of the condition of the small and large intestinal walls, which allows for the determination of the presence of inflammatory or ischemic changes in the walls of the small and large intestines. 

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