Diagnostic Value of Iodine Mapping Photon-Counting Computed Tomography (PCCT) in Early Small Bowel Ischemia Caused by a Rare Uterine Fibrotic Band

Diagnostic Value of Iodine Mapping Photon-Counting Computed Tomography (PCCT) in Early Small Bowel Ischemia Caused by a Rare Uterine Fibrotic Band | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Diagnostic Value of Iodine Mapping Photon-Counting Computed Tomography (PCCT) in Early Small Bowel Ischemia Caused by a Rare Uterine Fibrotic Band Mustafa Sadeq Alghazzawi, Bakhos Alhaddad, Mohammed Ziyad Abubacker, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8852492/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Small bowel ischemia remains difficult to diagnose early, especially when caused by extrinsic mechanical compression rather than vascular occlusion. Photon counting Computed Tomography (PCCT) allows iodine-based perfusion assessment with significantly improved spectral resolution. Case presentation: A 55-year-old woman with multiple comorbidities presented with acute severe lower abdominal pain and vomiting. Conventional imaging revealed a closed-loop small bowel obstruction without definitive evidence of ischemia. PCCT iodine mapping demonstrated a sharply demarcated segment of absent iodine enhancement in a distal ileal loop, indicating loss of perfusion in that segment. Urgent exploratory laparotomy identified a dense fibrous uterine band causing complete obstruction and an ischemic 40 cm ileal loop, which required resection with primary anastomosis. Conclusion: PCCT iodine mapping enabled early identification of bowel ischemia when standard CT was nondiagnostic. This case highlights PCCT’s growing value in emergency abdominal imaging. Fibrotic bad Bowel Ischemia Iodine Mapping Photon Counting CT Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Introduction Small bowel ischemia is a life-threatening condition with reported mortality rates exceeding 50% when diagnosis is delayed. Early symptoms are nonspecific, and laboratory values such as leukocytosis, lactate, and CRP may remain normal until late stages, limiting clinical detection. [ 1 ] Conventional CT is the first line modality, yet its early-stage diagnostic sensitivity remains limited, sometimes as low as 64%, particularly before mucosal necrosis or pneumatosis develop. [ 1 ] Dual energy CT (DECT) introduced iodine-based perfusion mapping, improving sensitivity in early ischemia. [ 2 ] However, DECT detectors are still energy integrating and subject to noise and reduced spectral precision. Photon counting CT (PCCT) represents a major technological advancement. PCCT directly counts individual X-Ray photons and sorts them by energy, enabling higher spatial resolution, reduced electronic noise, and more accurate iodine quantification. [ 3 ] This makes PCCT particularly useful for detecting subtle perfusion changes, including early ischemia. Fibrotic uterine origin bands represent an exceptionally rare etiology of small bowel obstruction and ischemia. Pelvic adhesions occur in more than 50% of women following Caesarean delivery. [ 5 ] Yet reports of uterine fibrotic bands producing closed loop ischemia are extremely scarce. This case demonstrates how PCCT iodine maps identified critical ischemia despite standard images appearing inconclusive. Case Presentation A 55-year-old woman presented to the Emergency Department with acute, severe abdominal pain that had begun earlier that morning. The pain was continuous and predominantly localized in the lower abdomen. She reported two episodes of vomiting and one bowel movement on the day of presentation. There was no history of fever or urinary symptoms. She described experiencing a similar episode of abdominal pain approximately two months earlier. The patient had multiple chronic comorbidities, including type 2 diabetes mellitus, ischemic heart disease status post percutaneous coronary intervention, hypertension, dyslipidemia, depression, and overweight. She was a lifelong non-smoker. Her regular medications included Insulin, Ezetimibe / Atorvastatin, Acetylsalicylic acid, Bisoprolol, and Evolocumab. She had a surgical history of a cesarean section and a laparoscopic sleeve gastrectomy. On clinical examination, the patient was alert but in moderate distress due to pain. She was hemodynamically stable. Abdominal examination revealed generalized guarding and central abdominal tenderness, with a firm lower abdomen more pronounced on the right side. Laboratory Investigations showed Potassium of 3.2 mmol/L, Creatinine of 51 µmol/L, Urea of 2.7 mmol/L, WBC count of 12.9 ×10⁹/L, Hemoglobin of 13.4 g/dL, CRP of 1.5 mg/L, and Random blood sugar of 159 mg/dL. Initial non-contrast CT abdomen demonstrated mildly distended, fluid-filled distal ileal loops in the pelvis, measuring up to 2.2 cm, with mild mucosal thickening and associated mesenteric congestion. These findings were concerning for early vascular compromise or a developing small bowel obstruction. A small volume of pelvic free fluid was also noted. Figures (1) Figure (1) Coronal CT scan (without contrast) showed a fibrotic band extending from the fundus of uterus upward to the site of transitional zone (blue arrow), with focal segment of distal small bowel with early ischemic changes (yellow arrow). Contrast-enhanced CT abdomen and pelvis with oral and intra-venous contrast revealed Increased free intraperitoneal fluid. Oral contrast limited to the proximal small bowel, which appeared normal. A distal small bowel loop in the left lower abdomen showing significant wall edema and poor enhancement on arterial and venous phases. Marked mesenteric congestion around the affected loop. Fibrotic band extending from the fundus of uterus, up to the site of transitional zone. No pneumatosis or portal venous gas were noted. Patent superior mesenteric artery and superior mesenteric vein. Indeterminate transition point. These findings were equivocal for bowel ischemia. The impression was closed-loop small bowel obstruction with suspected vascular compromise, likely secondary to adhesions, with progressive features concerning for bowel ischemia. Figures (2) Figure (2): Right image : coronal CT scan (oral and IV contrast) showed a fibrotic band (yellow arrow) extending from the fundus of uterus (blue arrow) upward to the site of transitional zone. Left image : sagittal CT scan (oral and IV contrast) showed a fibrotic band extending from the fundus of uterus upward to the site of transitional zone. PCCT Iodine Mapping revealed a 30–50 cm segment of distal ileum with complete absence of iodine enhancement, with a sharply defined cutoff compared to adjacent normally enhanced loops. This pattern strongly suggested severe perfusion failure despite nondiagnostic conventional CT findings. Figures (3,4,5,6) Figure (3): Right image : axial PCCT scan (oral and IV contrast) iodine mapping showed a normal mucosal iodine uptake (yellow arrow). Left image : axial conventional CT scan (oral and IV contrast) showed faint normal mucosal contrast uptake (yellow arrow). Figure (4) comparative axial images between iodine mapping image (upper image) and conventional CT scan image (lower image) , yellow arrow showed focal segment of small bowel devoted from iodine /contrast uptake, blue arrow showed normal mucosal enhancement. Figure (5) comparative coronal images between iodine mapping image (Upper image) and conventional CT scan image (Lower image) , blue arrow showed focal segment of small bowel devoted from iodine /contrast uptake, yellow arrow showed normal mucosal enhancement. Figure (6) comparative sagittal images between iodine mapping image (Upper image) and conventional CT scan image (Lower image) , yellow arrow showed focal segment of small bowel devoted from iodine /contrast uptake, blue arrow showed normal mucosal enhancement. The patient underwent an urgent exploratory laparotomy, which revealed a large volume of serous peritoneal fluid and an ischemic loop of small bowel centrally located within the peritoneal cavity. A dense fibrous band extending from the right posterior uterine wall to the posterior abdominal wall near the right iliac fossa was identified, causing complete small bowel obstruction. The fibrous band was divided and excised. The compromised small bowel segment measured approximately 40 cm and was located about 1 meter proximal to the ileocecal junction. Despite repeated application of warm saline and observation for 25 minutes, there was no meaningful improvement in perfusion. A resection of the non-viable segment was therefore performed, followed by side-to-side anastomosis using a linear stapler. The staple line was reinforc ed with a second layer of sutures. A pelvic drain was placed. The procedure was completed without intraoperative complications. Figure (7) Intraoperative image demonstrating an ischemic segment of small bowel with a clearly defined transition point to adjacent normal-appearing small intestine. Figure (8) Intraoperative image illustrating the pelvic fibrous band responsible for causing small bowel obstruction. The patient showed gradual improvement postoperatively. Her nasogastric tube and Foley catheter were removed on postoperative day 1. She passed flatus on postoperative day 2 and had her first bowel movement on day 3. During recovery, she developed a chest infection, which was evaluated and treated by pulmonology, then she was discharged on postoperative day 6 in stable condition. Gross examination of the band revealed an irregular, firm tissue fragment measuring 1.5 x 1 x 0.5 cm. Microscopical examination of the band revealed a vascularized fibrous tissue band. Figures (9) Figure (9): The constricting band (Hematoxylin & Eosin, 4X) The microscopic examination of the ischemic small bowel segment revealed small bowel villous mucosa with marked ischemic necrotic changes and inflammation, consistent with the clinical diagnosis of small bowel obstruction. Figures (10) Figure (10): Small bowel wall with ischemic necrosis (Hematoxylin & Eosin, 4X) Discussion Small bowel ischemia continues to be one of the most challenging abdominal emergencies to diagnose early. Clinical presentation is often nonspecific, and laboratory markers remain limited in sensitivity. Conventional CT, although essential, frequently lacks sensitivity in early stages, as typical hallmarks such as pneumatosis and portal venous gas appear late. [ 1 ] PCCT provides significant advantages in this setting due to its ability to detect subtle enhancement differences and quantify iodine concentration with high precision. Compared to DECT, PCCT offers superior energy resolution, reduced noise, and improved contrast to noise ratios. These factors contribute to better visualization of bowel wall perfusion abnormalities. [ 3 ] Recent studies demonstrate that PCCT iodine mapping can detect ischemia earlier than conventional CT, particularly in cases where mural enhancement abnormalities are too subtle for standard detectors. Shaheen et al. reported improved visualization of non-enhancing segments in cases of bowel infarction using PCCT iodine maps. [ 4 ] Similarly, Giraud et al. showed that iodine quantification improves sensitivity in suspected small bowel ischemia. [ 2 ] This case further supports these findings: while conventional PCCT images appeared inconclusive, iodine maps revealed a complete lack of enhancement in a diseased segment, providing diagnostic clarity. This timely detection enabled urgent surgical intervention, preventing perforation and further complications. Fibrotic bands arising from the uterus are exceptionally uncommon. Although pelvic adhesions after Caesarean delivery are common, [ 5 ] Fibrotic uterine origin bands producing strangulating obstruction are sparsely documented. Closed loop obstruction from such bands can produce rapid onset ischemia despite preserved mesenteric perfusion, making imaging-based perfusion assessment essential. The ability of PCCT to distinguish perfused from non-perfused loops makes it uniquely suited for such complex scenarios where mechanical obstruction may not show overt CT signs. This case underscores the emerging role of PCCT as a powerful early diagnostic tool in emergency abdominal radiology. Photon-counting detector CT (PCCT) provides several advantages over conventional energy‑integrating detector CT (EID‑CT), particularly for iodine mapping, due to its improved spatial resolution, spectral accuracy, and noise performance. The following key advantages are supported by peer‑reviewed literature: The first key advantage is the Improved spatial resolution, achieved through smaller detector pixels and direct photon conversion, resulting in substantially higher spatial resolution, improving visualization of fine structures and small lesions. [ 6 ] In addition, PCCT provides superior contrast resolution and iodine quantification as energy-resolving detectors allow highly accurate iodine mapping and improved material decomposition, enhancing lesion detection and characterization. [ 7 , 8 ] The technology also reduces image noise and improved dose efficiency by minimizing the electronic noise and improves contrast‑to‑noise ratio (CNR), enabling lower radiation dose or lower iodine contrast volumes while maintaining diagnostic quality. [ 9 , 10 ] Moreover, several clinical studies have demonstrated a 20–25% reduction in iodinated contrast media usage with equal or superior diagnostic quality. [ 10 ] PCCT further improves spectral imaging, artifact reduction, and material discrimination, as the intrinsic multi-energy data enabling better separation of iodine, calcium, and soft tissue, and reducing beam-hardening and metal artifacts. [ 7 , 10 ] Finally, these advantages translate into enhanced performance across multiple clinical applications, as PCCT improves chest, cardiac, abdominal, musculoskeletal, and pediatric imaging through combined gains in contrast, resolution, and dose efficiency. [ 9 ] Conclusion PCCT iodine mapping enabled early recognition of small bowel ischemia secondary to a rare uterine fibrotic band. When conventional CT is equivocal, PCCT offers critical diagnostic insight by precisely evaluating bowel perfusion. Incorporating PCCT into emergency imaging protocols may significantly improve outcomes in suspected ischemia. Abbreviations CT : Computed Tomography DECT: Dual energy Computed Tomography EID ‑CT : Energy‑integrating detector Computed Tomography PCCT : Photon-Counting Computed Tomography Declarations Author Contributions Mustafa Sadeq Alghazzawi: Study concept and design, Data collection and analysis, Writing the paper. Bakhos Alhaddad: Study concept and design, Revision of the manuscript, Writing the paper. Mohammed Ziyad Abubacker: Revision of the manuscript, Final approval of the paper. Thair Salman Abdullah: Critical revision of the manuscript, Final approval of the paper. Abdul Azim Hussain: Critical revision of the manuscript, Final approval of the paper. Rafif Mahmood Al Saady: Writing the histopathological section, Revision of manuscript. Patient Consent Statement written informed consent were obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Conflict of Interest / Funding Statement The authors declare no conflicts of interest and no funding was received for this study. Ethical Approval Statement Ethical approval for the publication of this case report was obtained from the Medical Research and Ethics Committee at Al Ahli Hospital, Doha, Qatar. Written informed consent was obtained from the patient for the use of clinical information and imaging data for academic publication, with all personal identifiers removed to ensure confidentiality. References Menke J. Diagnostic accuracy of multidetector CT in acute mesenteric ischemia. Radiology. 2010;256(1):93–101. Giraud R, Hetzel J, Bader H, et al. Assessment of small bowel ischemia using dual-energy CT iodine concentration. Diagn Interv Imaging. 2025;106(4):126–34. Schwarz F et al. Photon-counting CT: abdominal applications. Br J Radiol. 2024. Shaheen NH, et al. Photon-counting CT for diagnosis of bowel infarction. Radiol Case Rep. 2022;17(5):1674–7. Attard JA, MacLean AR. Adhesive small bowel obstruction. Can J Surg. 2007;50(4):291–300. Willemink MJ, Persson M, Pourmorteza A, Pelc NJ, Fleischmann D. Photon-counting CT: technical principles and clinical prospects. Radiology. 2018;289(2):293–312. https://doi.org/10.1148/radiol.2018172656 . Nehra AK, Rajendran K, Baffour FI, Mileto A, Rajiah PS, Horst KK, et al. Seeing more with less: clinical benefits of photon-counting detector CT. Radiographics. 2023;43(5):e220158. https://doi.org/10.1148/rg.220158 . Sandfort V, Persson M, Pourmorteza A, Noël PB, Fleischmann D, Willemink MJ. Spectral photon-counting CT in cardiovascular imaging. J Cardiovasc Comput Tomogr. 2021;15(3):218–25. https://doi.org/10.1016/j.jcct.2020.12.005 . Rønning M, Johansen E, Rusandu A. Photon-counting CT versus energy-integrating detector CT for cardiac imaging: a systematic review of in vivo human studies on image quality and radiation dose. BMC Med Imaging. 2025;25:295. https://doi.org/10.1186/s12880-025-01825-8 . Hall J. Abdominal CT study shows 20% reduction in iodine contrast with photon-counting CT. Diagn Imaging. 2024. Si-Mohamed S, Bar-Ness D, Sigovan M, Cormode DP, Coulon P, Coche E, et al. Review of initial experience with experimental spectral photon-counting CT. Nucl Instrum Methods Phys Res A. 2017;873:27–35. https://doi.org/10.1016/j.nima.2017.04.014 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8852492","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":592673755,"identity":"b5cfae8c-c4fb-4ad2-beda-3a4aea4bca58","order_by":0,"name":"Mustafa Sadeq Alghazzawi","email":"data:image/png;base64,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","orcid":"","institution":"Al-Ahli Hospital","correspondingAuthor":true,"prefix":"","firstName":"Mustafa","middleName":"Sadeq","lastName":"Alghazzawi","suffix":""},{"id":592673758,"identity":"f671f800-4775-4dc0-9541-50484a66b80a","order_by":1,"name":"Bakhos Alhaddad","email":"","orcid":"","institution":"Al-Ahli Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bakhos","middleName":"","lastName":"Alhaddad","suffix":""},{"id":592673762,"identity":"3279161b-128a-486f-8970-21b77285a228","order_by":2,"name":"Mohammed Ziyad Abubacker","email":"","orcid":"","institution":"Al-Ahli Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"Ziyad","lastName":"Abubacker","suffix":""},{"id":592673776,"identity":"65a3ca6f-020e-45e8-89fc-4b06617430b9","order_by":3,"name":"Thair S. 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arrow).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8852492/v1/888f07db597e95dd23e4810a.png"},{"id":102910227,"identity":"99547906-ca25-43e6-bba9-1784a2e69670","added_by":"auto","created_at":"2026-02-18 09:57:51","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":518886,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRight image: \u003c/strong\u003ecoronal CT scan (oral and IV contrast) showed a fibrotic band (yellow arrow) extending from the fundus of uterus (blue arrow) upward to the site of transitional zone. \u003cstrong\u003eLeft image:\u003c/strong\u003esagittal CT scan (oral and IV contrast) showed a fibrotic band extending from the fundus of uterus upward to the site of transitional zone.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8852492/v1/3dd443f5bc704ec3d6cfab66.jpeg"},{"id":102910172,"identity":"5b38cb45-6f98-42cb-aaa3-64ead5ed1bbe","added_by":"auto","created_at":"2026-02-18 09:57:44","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":460220,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRight image:\u003c/strong\u003e axial PCCT scan (oral and IV contrast) iodine mapping showed a normal mucosal iodine uptake (yellow arrow). \u003cstrong\u003eLeft image:\u003c/strong\u003e axial conventional CT scan (oral and IV contrast) showed faint normal mucosal contrast uptake (yellow arrow).\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8852492/v1/8b13f54996a572d937007e95.jpeg"},{"id":102910235,"identity":"da54a799-d006-44ab-bf9e-357ae07d52fc","added_by":"auto","created_at":"2026-02-18 09:57:57","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1309266,"visible":true,"origin":"","legend":"\u003cp\u003ecomparative axial images between iodine mapping image \u003cstrong\u003e(upper image)\u003c/strong\u003e and conventional CT scan image \u003cstrong\u003e(lower image)\u003c/strong\u003e, yellow arrow showed focal segment of small bowel devoted from iodine /contrast uptake, blue arrow showed normal mucosal enhancement.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8852492/v1/aaaea9c6cbef55dc73649ce0.png"},{"id":102910222,"identity":"7c67e7e7-19f1-416c-9673-252ef9786de2","added_by":"auto","created_at":"2026-02-18 09:57:50","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":962441,"visible":true,"origin":"","legend":"\u003cp\u003ecomparative coronal images between iodine mapping image \u003cstrong\u003e(Upper image)\u003c/strong\u003e and conventional CT scan image \u003cstrong\u003e(Lower image)\u003c/strong\u003e, blue arrow showed focal segment of small bowel devoted from iodine /contrast uptake, yellow arrow showed normal mucosal enhancement.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8852492/v1/e252585df082b74880a06811.png"},{"id":102910001,"identity":"bce1bddd-99aa-4a69-96e7-70a2dd1d96d2","added_by":"auto","created_at":"2026-02-18 09:57:33","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":981222,"visible":true,"origin":"","legend":"\u003cp\u003ecomparative sagittal images between iodine mapping image \u003cstrong\u003e(Upper image)\u003c/strong\u003eand conventional CT scan image \u003cstrong\u003e(Lower image)\u003c/strong\u003e, yellow arrow showed focal segment of small bowel devoted from iodine /contrast uptake, blue arrow showed normal mucosal enhancement.\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8852492/v1/85fcca1f4696224fadcb48e7.png"},{"id":102910174,"identity":"8f46a1fb-9743-44ff-9d4e-4f8a06da0ce2","added_by":"auto","created_at":"2026-02-18 09:57:45","extension":"jpeg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":800534,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative image demonstrating an ischemic segment of small bowel with a clearly defined transition point to adjacent normal-appearing small intestine.\u003c/p\u003e","description":"","filename":"floatimage7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8852492/v1/5c665424c849c239ce64052c.jpeg"},{"id":102910193,"identity":"1afc97e4-7c51-4fdb-83da-119050a41770","added_by":"auto","created_at":"2026-02-18 09:57:49","extension":"jpeg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":610192,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative image illustrating the pelvic fibrous band responsible for causing small bowel obstruction.\u003c/p\u003e","description":"","filename":"floatimage8.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8852492/v1/ae1d289788e311e7953643c8.jpeg"},{"id":102910155,"identity":"4cfa9233-8b54-4c6a-a1a4-fd71caf815df","added_by":"auto","created_at":"2026-02-18 09:57:40","extension":"jpeg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":77520,"visible":true,"origin":"","legend":"\u003cp\u003eThe constricting band (Hematoxylin \u0026amp; Eosin, 4X)\u003c/p\u003e","description":"","filename":"floatimage9.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8852492/v1/0b8289486329ce0077939c0d.jpeg"},{"id":102910139,"identity":"e722f94f-c2a2-4bd4-8779-375cf07c726a","added_by":"auto","created_at":"2026-02-18 09:57:35","extension":"jpeg","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":221097,"visible":true,"origin":"","legend":"\u003cp\u003eSmall bowel wall with ischemic necrosis (Hematoxylin \u0026amp; Eosin, 4X)\u003c/p\u003e","description":"","filename":"floatimage10.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8852492/v1/d92b90ddf7c887193ff07875.jpeg"},{"id":103056174,"identity":"310ff7d5-b5b7-4c30-a7e3-59a9dde7abb8","added_by":"auto","created_at":"2026-02-20 08:56:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7850867,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8852492/v1/ca79af39-bf0f-4504-9471-10d7cdff5a67.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnostic Value of Iodine Mapping Photon-Counting Computed Tomography (PCCT) in Early Small Bowel Ischemia Caused by a Rare Uterine Fibrotic Band","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSmall bowel ischemia is a life-threatening condition with reported mortality rates exceeding 50% when diagnosis is delayed. Early symptoms are nonspecific, and laboratory values such as leukocytosis, lactate, and CRP may remain normal until late stages, limiting clinical detection. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Conventional CT is the first line modality, yet its early-stage diagnostic sensitivity remains limited, sometimes as low as 64%, particularly before mucosal necrosis or pneumatosis develop. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDual energy CT (DECT) introduced iodine-based perfusion mapping, improving sensitivity in early ischemia. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] However, DECT detectors are still energy integrating and subject to noise and reduced spectral precision.\u003c/p\u003e \u003cp\u003ePhoton counting CT (PCCT) represents a major technological advancement. PCCT directly counts individual X-Ray photons and sorts them by energy, enabling higher spatial resolution, reduced electronic noise, and more accurate iodine quantification. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] This makes PCCT particularly useful for detecting subtle perfusion changes, including early ischemia.\u003c/p\u003e \u003cp\u003eFibrotic uterine origin bands represent an exceptionally rare etiology of small bowel obstruction and ischemia. Pelvic adhesions occur in more than 50% of women following Caesarean delivery. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Yet reports of uterine fibrotic bands producing closed loop ischemia are extremely scarce.\u003c/p\u003e \u003cp\u003eThis case demonstrates how PCCT iodine maps identified critical ischemia despite standard images appearing inconclusive.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 55-year-old woman presented to the Emergency Department with acute, severe abdominal pain that had begun earlier that morning. The pain was continuous and predominantly localized in the lower abdomen. She reported two episodes of vomiting and one bowel movement on the day of presentation. There was no history of fever or urinary symptoms. She described experiencing a similar episode of abdominal pain approximately two months earlier.\u003c/p\u003e \u003cp\u003eThe patient had multiple chronic comorbidities, including type 2 diabetes mellitus, ischemic heart disease status post percutaneous coronary intervention, hypertension, dyslipidemia, depression, and overweight. She was a lifelong non-smoker.\u003c/p\u003e \u003cp\u003eHer regular medications included Insulin, Ezetimibe / Atorvastatin, Acetylsalicylic acid, Bisoprolol, and Evolocumab.\u003c/p\u003e \u003cp\u003eShe had a surgical history of a cesarean section and a laparoscopic sleeve gastrectomy.\u003c/p\u003e \u003cp\u003eOn clinical examination, the patient was alert but in moderate distress due to pain. She was hemodynamically stable. Abdominal examination revealed generalized guarding and central abdominal tenderness, with a firm lower abdomen more pronounced on the right side.\u003c/p\u003e \u003cp\u003eLaboratory Investigations showed Potassium of 3.2 mmol/L, Creatinine of 51 \u0026micro;mol/L, Urea of 2.7 mmol/L, WBC count of 12.9 \u0026times;10⁹/L, Hemoglobin of 13.4 g/dL, CRP of 1.5 mg/L, and Random blood sugar of 159 mg/dL.\u003c/p\u003e \u003cp\u003eInitial non-contrast CT abdomen demonstrated mildly distended, fluid-filled distal ileal loops in the pelvis, measuring up to 2.2 cm, with mild mucosal thickening and associated mesenteric congestion. These findings were concerning for early vascular compromise or a developing small bowel obstruction. A small volume of pelvic free fluid was also noted. Figures\u0026nbsp;(1)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (1)\u003c/strong\u003e \u003cp\u003eCoronal CT scan (without contrast) showed a fibrotic band extending from the fundus of uterus upward to the site of transitional zone (blue arrow), with focal segment of distal small bowel with early ischemic changes (yellow arrow).\u003c/p\u003e \u003c/p\u003e \u003cp\u003eContrast-enhanced CT abdomen and pelvis with oral and intra-venous contrast revealed Increased free intraperitoneal fluid. Oral contrast limited to the proximal small bowel, which appeared normal. A distal small bowel loop in the left lower abdomen showing significant wall edema and poor enhancement on arterial and venous phases. Marked mesenteric congestion around the affected loop. Fibrotic band extending from the fundus of uterus, up to the site of transitional zone. No pneumatosis or portal venous gas were noted. Patent superior mesenteric artery and superior mesenteric vein. Indeterminate transition point. These findings were equivocal for bowel ischemia. The impression was closed-loop small bowel obstruction with suspected vascular compromise, likely secondary to adhesions, with progressive features concerning for bowel ischemia. Figures\u0026nbsp;(2)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure (2): Right image\u003c/b\u003e: coronal CT scan (oral and IV contrast) showed a fibrotic band (yellow arrow) extending from the fundus of uterus (blue arrow) upward to the site of transitional zone. \u003cb\u003eLeft image\u003c/b\u003e: sagittal CT scan (oral and IV contrast) showed a fibrotic band extending from the fundus of uterus upward to the site of transitional zone.\u003c/p\u003e \u003cp\u003ePCCT Iodine Mapping revealed a 30\u0026ndash;50 cm segment of distal ileum with complete absence of iodine enhancement, with a sharply defined cutoff compared to adjacent normally enhanced loops. This pattern strongly suggested severe perfusion failure despite nondiagnostic conventional CT findings. Figures\u0026nbsp;(3,4,5,6)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure (3): Right image\u003c/b\u003e: axial PCCT scan (oral and IV contrast) iodine mapping showed a normal mucosal iodine uptake (yellow arrow). \u003cb\u003eLeft image\u003c/b\u003e: axial conventional CT scan (oral and IV contrast) showed faint normal mucosal contrast uptake (yellow arrow).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (4)\u003c/strong\u003e \u003cp\u003ecomparative axial images between iodine mapping image \u003cb\u003e(upper image)\u003c/b\u003e and conventional CT scan image \u003cb\u003e(lower image)\u003c/b\u003e, yellow arrow showed focal segment of small bowel devoted from iodine /contrast uptake, blue arrow showed normal mucosal enhancement.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (5)\u003c/strong\u003e \u003cp\u003ecomparative coronal images between iodine mapping image \u003cb\u003e(Upper image)\u003c/b\u003e and conventional CT scan image \u003cb\u003e(Lower image)\u003c/b\u003e, blue arrow showed focal segment of small bowel devoted from iodine /contrast uptake, yellow arrow showed normal mucosal enhancement.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (6)\u003c/strong\u003e \u003cp\u003ecomparative sagittal images between iodine mapping image \u003cb\u003e(Upper image)\u003c/b\u003e and conventional CT scan image \u003cb\u003e(Lower image)\u003c/b\u003e, yellow arrow showed focal segment of small bowel devoted from iodine /contrast uptake, blue arrow showed normal mucosal enhancement.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe patient underwent an urgent exploratory laparotomy, which revealed a large volume of serous peritoneal fluid and an ischemic loop of small bowel centrally located within the peritoneal cavity. A dense fibrous band extending from the right posterior uterine wall to the posterior abdominal wall near the right iliac fossa was identified, causing complete small bowel obstruction. The fibrous band was divided and excised. The compromised small bowel segment measured approximately 40 cm and was located about 1 meter proximal to the ileocecal junction. Despite repeated application of warm saline and observation for 25 minutes, there was no meaningful improvement in perfusion. A resection of the non-viable segment was therefore performed, followed by side-to-side anastomosis using a linear stapler. The staple line was reinforc ed with a second layer of sutures. A pelvic drain was placed. The procedure was completed without intraoperative complications.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure (7)\u003c/strong\u003e \u003cp\u003eIntraoperative image demonstrating an ischemic segment of small bowel with a clearly defined transition point to adjacent normal-appearing small intestine.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure (8)\u003c/b\u003e Intraoperative image illustrating the pelvic fibrous band responsible for causing small bowel obstruction.\u003c/p\u003e \u003cp\u003eThe patient showed gradual improvement postoperatively. Her nasogastric tube and Foley catheter were removed on postoperative day 1. She passed flatus on postoperative day 2 and had her first bowel movement on day 3.\u003c/p\u003e \u003cp\u003eDuring recovery, she developed a chest infection, which was evaluated and treated by pulmonology, then she was discharged on postoperative day 6 in stable condition.\u003c/p\u003e \u003cp\u003eGross examination of the band revealed an irregular, firm tissue fragment measuring 1.5 x 1 x 0.5 cm. Microscopical examination of the band revealed a vascularized fibrous tissue band. Figures\u0026nbsp;(9)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure (9): The constricting band (Hematoxylin \u0026amp; Eosin, 4X)\u003c/p\u003e \u003cp\u003eThe microscopic examination of the ischemic small bowel segment revealed small bowel villous mucosa with marked ischemic necrotic changes and inflammation, consistent with the clinical diagnosis of small bowel obstruction. Figures\u0026nbsp;(10)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure (10): Small bowel wall with ischemic necrosis (Hematoxylin \u0026amp; Eosin, 4X)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSmall bowel ischemia continues to be one of the most challenging abdominal emergencies to diagnose early. Clinical presentation is often nonspecific, and laboratory markers remain limited in sensitivity. Conventional CT, although essential, frequently lacks sensitivity in early stages, as typical hallmarks such as pneumatosis and portal venous gas appear late. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePCCT provides significant advantages in this setting due to its ability to detect subtle enhancement differences and quantify iodine concentration with high precision. Compared to DECT, PCCT offers superior energy resolution, reduced noise, and improved contrast to noise ratios. These factors contribute to better visualization of bowel wall perfusion abnormalities. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eRecent studies demonstrate that PCCT iodine mapping can detect ischemia earlier than conventional CT, particularly in cases where mural enhancement abnormalities are too subtle for standard detectors. Shaheen et al. reported improved visualization of non-enhancing segments in cases of bowel infarction using PCCT iodine maps. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Similarly, Giraud et al. showed that iodine quantification improves sensitivity in suspected small bowel ischemia. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThis case further supports these findings: while conventional PCCT images appeared inconclusive, iodine maps revealed a complete lack of enhancement in a diseased segment, providing diagnostic clarity. This timely detection enabled urgent surgical intervention, preventing perforation and further complications.\u003c/p\u003e \u003cp\u003eFibrotic bands arising from the uterus are exceptionally uncommon. Although pelvic adhesions after Caesarean delivery are common, [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Fibrotic uterine origin bands producing strangulating obstruction are sparsely documented. Closed loop obstruction from such bands can produce rapid onset ischemia despite preserved mesenteric perfusion, making imaging-based perfusion assessment essential.\u003c/p\u003e \u003cp\u003eThe ability of PCCT to distinguish perfused from non-perfused loops makes it uniquely suited for such complex scenarios where mechanical obstruction may not show overt CT signs. This case underscores the emerging role of PCCT as a powerful early diagnostic tool in emergency abdominal radiology.\u003c/p\u003e \u003cp\u003ePhoton-counting detector CT (PCCT) provides several advantages over conventional energy‑integrating detector CT (EID‑CT), particularly for iodine mapping, due to its improved spatial resolution, spectral accuracy, and noise performance. The following key advantages are supported by peer‑reviewed literature: The first key advantage is the Improved spatial resolution, achieved through smaller detector pixels and direct photon conversion, resulting in substantially higher spatial resolution, improving visualization of fine structures and small lesions. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] In addition, PCCT provides superior contrast resolution and iodine quantification as energy-resolving detectors allow highly accurate iodine mapping and improved material decomposition, enhancing lesion detection and characterization. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] The technology also reduces image noise and improved dose efficiency by minimizing the electronic noise and improves contrast‑to‑noise ratio (CNR), enabling lower radiation dose or lower iodine contrast volumes while maintaining diagnostic quality. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Moreover, several clinical studies have demonstrated a 20\u0026ndash;25% reduction in iodinated contrast media usage with equal or superior diagnostic quality. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] PCCT further improves spectral imaging, artifact reduction, and material discrimination, as the intrinsic multi-energy data enabling better separation of iodine, calcium, and soft tissue, and reducing beam-hardening and metal artifacts. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Finally, these advantages translate into enhanced performance across multiple clinical applications, as PCCT improves chest, cardiac, abdominal, musculoskeletal, and pediatric imaging through combined gains in contrast, resolution, and dose efficiency. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePCCT iodine mapping enabled early recognition of small bowel ischemia secondary to a rare uterine fibrotic band. When conventional CT is equivocal, PCCT offers critical diagnostic insight by precisely evaluating bowel perfusion. Incorporating PCCT into emergency imaging protocols may significantly improve outcomes in suspected ischemia.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCT\u003c/strong\u003e: Computed Tomography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDECT:\u0026nbsp;\u003c/strong\u003eDual energy Computed Tomography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEID\u003c/strong\u003e\u003cstrong\u003e‑CT\u003c/strong\u003e: Energy‑integrating detector Computed Tomography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePCCT\u003c/strong\u003e: Photon-Counting Computed Tomography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMustafa Sadeq Alghazzawi: Study concept and design, Data collection and analysis, Writing the paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBakhos Alhaddad: Study concept and design, Revision of the manuscript, Writing the paper.\u003c/p\u003e\n\u003cp\u003eMohammed Ziyad Abubacker:\u0026nbsp;Revision of the manuscript, Final approval of the paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThair Salman Abdullah: Critical revision of the manuscript, Final approval of the paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAbdul Azim Hussain: Critical revision of the manuscript, Final approval of the paper.\u003c/p\u003e\n\u003cp\u003eRafif Mahmood Al Saady: Writing the histopathological section, Revision of manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Consent Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ewritten informed consent were obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest / Funding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest and no funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the publication of this case report was obtained from the Medical Research and Ethics Committee at Al Ahli Hospital, Doha, Qatar. Written informed consent was obtained from the patient for the use of clinical information and imaging data for academic publication, with all personal identifiers removed to ensure confidentiality.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMenke J. Diagnostic accuracy of multidetector CT in acute mesenteric ischemia. Radiology. 2010;256(1):93\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiraud R, Hetzel J, Bader H, et al. Assessment of small bowel ischemia using dual-energy CT iodine concentration. Diagn Interv Imaging. 2025;106(4):126\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwarz F et al. Photon-counting CT: abdominal applications. Br J Radiol. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaheen NH, et al. Photon-counting CT for diagnosis of bowel infarction. Radiol Case Rep. 2022;17(5):1674\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAttard JA, MacLean AR. Adhesive small bowel obstruction. Can J Surg. 2007;50(4):291\u0026ndash;300.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWillemink MJ, Persson M, Pourmorteza A, Pelc NJ, Fleischmann D. Photon-counting CT: technical principles and clinical prospects. Radiology. 2018;289(2):293\u0026ndash;312. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1148/radiol.2018172656\u003c/span\u003e\u003cspan address=\"10.1148/radiol.2018172656\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNehra AK, Rajendran K, Baffour FI, Mileto A, Rajiah PS, Horst KK, et al. Seeing more with less: clinical benefits of photon-counting detector CT. Radiographics. 2023;43(5):e220158. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1148/rg.220158\u003c/span\u003e\u003cspan address=\"10.1148/rg.220158\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandfort V, Persson M, Pourmorteza A, No\u0026euml;l PB, Fleischmann D, Willemink MJ. Spectral photon-counting CT in cardiovascular imaging. J Cardiovasc Comput Tomogr. 2021;15(3):218\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jcct.2020.12.005\u003c/span\u003e\u003cspan address=\"10.1016/j.jcct.2020.12.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eR\u0026oslash;nning M, Johansen E, Rusandu A. Photon-counting CT versus energy-integrating detector CT for cardiac imaging: a systematic review of in vivo human studies on image quality and radiation dose. BMC Med Imaging. 2025;25:295. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12880-025-01825-8\u003c/span\u003e\u003cspan address=\"10.1186/s12880-025-01825-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHall J. Abdominal CT study shows 20% reduction in iodine contrast with photon-counting CT. Diagn Imaging. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSi-Mohamed S, Bar-Ness D, Sigovan M, Cormode DP, Coulon P, Coche E, et al. Review of initial experience with experimental spectral photon-counting CT. Nucl Instrum Methods Phys Res A. 2017;873:27\u0026ndash;35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nima.2017.04.014\u003c/span\u003e\u003cspan address=\"10.1016/j.nima.2017.04.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Fibrotic bad, Bowel Ischemia, Iodine Mapping, Photon Counting CT","lastPublishedDoi":"10.21203/rs.3.rs-8852492/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8852492/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Small bowel ischemia remains difficult to diagnose early, especially when caused by extrinsic mechanical compression rather than vascular occlusion. Photon counting Computed Tomography (PCCT) allows iodine-based perfusion assessment with significantly improved spectral resolution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e A 55-year-old woman with multiple comorbidities presented with acute severe lower abdominal pain and vomiting. Conventional imaging revealed a closed-loop small bowel obstruction without definitive evidence of ischemia. PCCT iodine mapping demonstrated a sharply demarcated segment of absent iodine enhancement in a distal ileal loop, indicating loss of perfusion in that segment. Urgent exploratory laparotomy identified a dense fibrous uterine band causing complete obstruction and an ischemic 40 cm ileal loop, which required resection with primary anastomosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e PCCT iodine mapping enabled early identification of bowel ischemia when standard CT was nondiagnostic. This case highlights PCCT’s growing value in emergency abdominal imaging.\u003c/p\u003e","manuscriptTitle":"Diagnostic Value of Iodine Mapping Photon-Counting Computed Tomography (PCCT) in Early Small Bowel Ischemia Caused by a Rare Uterine Fibrotic Band","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 09:56:39","doi":"10.21203/rs.3.rs-8852492/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7db60c24-7f3c-48ed-9cc3-c4ef1829ac6a","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-20T08:55:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-18 09:56:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8852492","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8852492","identity":"rs-8852492","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}