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Ross B. - May 29, 2021 1:11 AM
I really appreciated this segment! I spoke with one of our radiologists after hearing this sgment., I asked if the CTA protocol changed the ability to interpret the remainder of the images at all, possibly making diagnosing other pathology more difficult. He was of the opinion that the CT with IV contrast during portal venous phase was really very good at diagnosing the majority of pathology including mesenteric ischemia. Is there data compariging these differing modalities and their diagnostic accuracy? I'd hate to order a CTA and miss another diagnosis because of the timing, but it would be equally bad to miss mesenteric ischemia by doing a portal venous phase contrast study...
Joseph M. - June 2, 2021 1:42 PM
Thanks for your interest in the segment. Good question.
It would be unusual to miss other pathology on a CTA because a CTA has more images at more phases and should pick up anything that a plain enhanced CT in the portal venous phase would pick up. Actually, a CTA includes portal venous phase timing as well as arterial phase timing. Frankly, you are just not going to miss other pathology by doing a CTA.
American College of Radiology Appropriateness Criteria in both 2013 and 2018 recommend CTA as first-line imaging for suspected mesenteric ischemia. From the 2013 version, in the section about CTA: "CT imaging of the abdomen also allows accurate evaluation of the entire gastrointestinal and genitourinary tract, helping to exclude most of the other causes of acute and chronic abdominal pain, including cholelithiasis, cholecystitis, pancreatitis, appendicitis, diverticulosis with or without diverticulitis, and nephrolithiasis."
I'm not aware of a specific article comparing simple CT with IV contrast in the portal venous phase to CTA, as all of the newer literature really uses CTA as the new gold standard for suspected mesenteric ischemia.
Long story short, if you have concerns about mesenteric ischemia based on the patient's risk factors, story, exam, etc, I would order a CTA, knowing that it will likely show other pathology if present.