What is the appropriate management for a patient with prominent jejunal loops, engorged vasa recta, and associated mesenteric fat stranding on CECT abdomen?

Management of Prominent Jejunal Loops with Engorged Vasa Recta and Mesenteric Fat Stranding

This imaging constellation represents active small bowel inflammation or ischemia requiring urgent clinical correlation, laboratory assessment, and potential intervention—immediate anticoagulation should be initiated if mesenteric venous thrombosis is identified, while surgical consultation is mandatory if peritoneal signs or bowel necrosis indicators are present. 1

Understanding the Imaging Findings

The triad of findings you describe has specific clinical implications:

• Engorged vasa recta ("comb sign") indicates either active bowel inflammation or past inflammatory changes, most commonly seen in Crohn's disease but also present in acute mesenteric ischemia 1
• Mesenteric fat stranding (perienteric edema/inflammation) represents increased attenuation in mesenteric fat adjacent to abnormal bowel loops and is associated with elevated C-reactive protein 1
• Prominent jejunal loops suggest bowel wall edema, inflammation, or early obstruction 1, 2

Critical Decision Points

First: Rule Out Life-Threatening Ischemia

Immediately assess for CT signs of bowel necrosis or irreversible ischemia 1, 3:

• High-risk findings requiring emergent surgery: Pneumatosis intestinalis, portal venous gas, intraperitoneal free air, high attenuation bowel wall (intramural hemorrhage), or reduced/absent bowel wall enhancement 1, 4, 5
• Vascular assessment: Look for superior mesenteric artery (SMA) or superior mesenteric vein (SMV) thrombosis, arterial embolism, or dissection 1, 6
• Reduced enhancement of mesenteric arteries or veins predicts bowel ischemia/necrosis with high specificity 3

A critical pitfall: One-third of patients with acute-on-chronic mesenteric ischemia present without specific ischemia CT signs—any intestinal abnormality with SMA obstruction should raise suspicion 7

Second: Identify the Underlying Etiology

If Mesenteric Venous Thrombosis is Present:

Start unfractionated heparin IV or therapeutic-dose LMWH subcutaneously immediately 6:

• This achieves >80% recanalization rates and prevents progression to bowel infarction 6
• Transition to oral anticoagulation (warfarin INR 2-3 or DOAC) after 7-10 days 6
• Continue anticoagulation minimum 6 months 6
• Never delay anticoagulation while awaiting thrombophilia workup 6

If Inflammatory Bowel Disease (Crohn's) is Suspected:

The imaging pattern strongly suggests active Crohn's disease if 1:

• Patient has known IBD history or presents with chronic/recurrent symptoms
• Look for additional findings: bowel wall thickening, strictures, fistulas, abscesses, or fibrofatty proliferation ("creeping fat") 1
• Important: Engorged vasa recta may reflect current inflammation OR past inflammation—clinical correlation with symptoms and inflammatory markers is essential 1

Assess for penetrating complications that occur in unsuspected patients 1:

• Fistulas (simple or complex with "star sign")
• Abscesses (rim-enhancing fluid collections with internal air)
• Inflammatory masses (mixed fat/soft tissue, avoid term "phlegmon") 1

If Small Bowel Obstruction with Ischemia:

CT signs suggesting ischemic SBO requiring surgery 2, 3:

• Reduced bowel wall enhancement (most significant predictor) 3
• Reduced enhancement of mesenteric veins 3
• Lack of mesenteric vein engorgement (paradoxically, engorgement predicts viable bowel) 3
• Mesenteric edema, free fluid, or free air 2

Management Algorithm

If Patient is Hemodynamically Stable WITHOUT Peritoneal Signs:

1. Complete the vascular assessment: Ensure triple-phase CT (non-contrast, arterial, portal venous) was performed to evaluate arterial and venous patency 1

2. Laboratory evaluation: CBC, lactate, CRP, D-dimer, coagulation studies 6

3. Clinical context matters:

   • Recent COVID-19 infection? Consider post-COVID thrombotic syndrome 4
   • Dialysis patient with hypotension? Consider non-occlusive mesenteric ischemia 5
   • History of atrial fibrillation? Consider arterial embolism 1

4. For confirmed MVT without peritonitis: Immediate anticoagulation + serial clinical exams 6

5. For inflammatory findings without ischemia: Gastroenterology consultation, consider MR enterography for better characterization 1

If Patient Has Peritoneal Signs, Pneumoperitoneum, or Intramural Air:

Proceed directly to urgent exploratory laparotomy—do not attempt thrombolysis 1, 6:

• Surgical resection of necrotic bowel is required 4, 5, 2
• Continue heparin perioperatively unless active bleeding occurs 6

If Findings are Equivocal:

Serial imaging and close clinical monitoring 1, 7:

• Repeat CT in 6-12 hours if clinical deterioration occurs
• Be aware of interobserver variability in CT interpretation—when in doubt, obtain surgical consultation 7
• Any intestinal abnormality on CT combined with mesenteric vascular disease should raise high suspicion for ischemia 7

Key Pitfalls to Avoid

• Do not assume engorged vasa recta alone equals active inflammation—it may represent chronic changes 1
• Do not delay anticoagulation in confirmed MVT even if diagnosis is not 100% certain 6
• Do not miss concurrent pulmonary embolism in patients with mesenteric thrombosis, especially post-COVID 4
• Do not rely solely on specific ischemia signs—their absence does not exclude ischemia 7
• In post-bariatric surgery patients, consider internal hernia (Petersen hernia) where engorgement and crowding of mesenteric vessels may be the only clue 1