Imaging Pearls ❯ Small Bowel ❯ Inflammatory Disease
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- “Small-intestine infection may be seen as symmetric and homogeneous thickening of the ileal wall, which may be focal or diffuse on CT. A feathery pattern of mucosal thickening may also be seen on ultrasound. Sometimes colonic involvement can be seen in the absence of ileal involvement and may be patchy or continuous. Salmonella enteritis may even simulate pseudomembranous colitis, with toxic megacolon as a known complication. Enlarged mesenteric nodes may be seen adjacent to the involved segment of intestine. Gastrointestinal bleeding and perforation are important complications and occur frequently in the terminal ileum. Active bleeding may be visualized in the form of intravascular contrast extravasation on CT angiography studies.”
Spectrum of Imaging Findings in Salmonella Infections
Tiffany Hennedige et al.
AJR 2012; 198:W534–W539 - “Ascites, localized or generalized mesenteric stranding, thickening, and adenopathy are frequent manifestations of Salmonella infection. Salmonella infections have a predilection for the gastrointestinal tract. Involvement of the terminal ileum or the proximal colon with mesenteric lymphadenopathy may be specific imaging findings.”
Spectrum of Imaging Findings in Salmonella Infections
Tiffany Hennedige et al.
AJR 2012; 198:W534–W539 - “A wide spectrum of radiologic manifestations due to Salmonella infection may be encountered, especially in endemic areas and immunocompromised patients. However, the imaging findings in Salmonella infection are not unique and can mimic other infective diseases. Knowledge of radiologic manifestations is important to aid in early diagnosis and timely initiation of appropriate management. In our experience, in the appropriate clinical setting, radiologic findings of thickened terminal ileum or proximal colon with mesenteric lymphadenopathy are specific for Salmonella infection.”
Spectrum of Imaging Findings in Salmonella Infections
Tiffany Hennedige et al.
AJR 2012; 198:W534–W539
- MDCT scans with intravenous contrast are considered the preferred imaging modality, both for its accuracy which enables to detect acute complications [4]. MDCT of non-complicated SBD disease frequently show clusters, and even isolated round and regular duodenal or jejunoileal outpouchings with air-fluid levels, debris, or enteric content [30]. Normal small vowel wall will have its characteristic and uniform concentric thickness (close to 3 cm) when not distended, but on diverticulum it will be reduced to 1 or 2 mm depending on the degree of bowel distension. Occasionally, the thin and smooth diverticulum wall, lacking valvulae conniventes, can be challenging to identify.
Small Bowel Diverticular Disease
Carlos Yánez Benítez F. Coccolini, F. Catena (eds.),
Textbook of Emergency General Surgery, https://doi.org/10.1007/978-3-031-22599-4_75 - Inflammatory acute diverticulitis complications are characterized by irregular bowel wall thickening of close or neighboring bowels and peri-diverticular fat stranding . In cases of asymmetric wall thickening, differential diagnosis of small bowel malignancy must also be considered. To help distinguish inflammation from malignancy, three elements can help: bowel enhancement patterns, mesentery characteristics, and regional lymph node patterns. In acute diverticulitis, a normal bowel wall enhancement (high inner attenuation, the middle layer of low attenuation, and a highly attenuated outer layer) suggests diverticulitis rather than malignancy . The presence of mesentery engorgement and fluid also suggests an inflammatory process. Last, reactive, and small nodes are seen in diverticulitis, where large or solitary lymphadenopathy close to a segmental wall thickening is more suggestive of malignancy.
Small Bowel Diverticular Disease
Carlos Yánez Benítez F. Coccolini, F. Catena (eds.),
Textbook of Emergency General Surgery, https://doi.org/10.1007/978-3-031-22599-4_75 - In perforated SBD disease there are marked mesenteric abnormalities, extraluminal air, free fluid, or peri-diverticular abscess. In severe cases, the abundance of local inflammatory changes, fluid, and gas can sometimes obscure the diverticulum’s localization. Though uncommon, additional findings in perforated diverticulitis are abscess formation between small bowel loops or close to the abdominal wall, hepatic abscess, and even portal vein thrombosis.
Small Bowel Diverticular Disease
Carlos Yánez Benítez F. Coccolini, F. Catena (eds.),
Textbook of Emergency General Surgery, https://doi.org/10.1007/978-3-031-22599-4_75 - Take-Home Messages
* SBD is usually asymptomatic and uncomplicated, found incidentally during imaging studies or surgical procedures. MDCT scan is the preferred diagnostic imaging modality that allows not only the presence and location of SBD but also can diagnose complications (inflammation, perforation, and bleeding).
* Meckel diverticulum is present in close to 2% of the general population and is the most common congenital anomaly of the gastrointestinal tract.
* Non-operative management with bowel rest, IV antibiotics, parenteral nutrition support, localized abscess percutaneous drainage, and close follow-up are acceptable options in selected surgical high-risk cases without diffuse peritonitis. However, surgery should not be delayed when in presence of diffuse peritonitis, toxic general condition, or failure of non-operative management occur.
- “The use of diverse types of drugs can result in a variety of acute and chronic complications that affect almost any organ. The bowel is one of the organs impacted by the side effects of medications. Imaging frequently plays a crucial role in the detection and characterization of complications occurring in the bowel. They include pseudomembranous colitis or antibiotic-associated colitis; angioedema induced by angiotensin-converting enzyme inhibitors; nonsteroidal anti-inflammatory drug-induced enteropathy; cocaine toxicity; clozapine-induced hypomobility; and bowel toxicity induced by chemotherapeutic agents. It is imperative that radiologists are fully aware of these complications and toxicities as well as the relevant findings.”
Drug‐induced bowel complications and toxicities: imaging findings and pearls
Sitthipong Srisajjakul et al.
Abdominal Radiology (2022) https://doi.org/10.1007/s00261-022-03452-1 - "Pseudomembranous colitis (PMC) is a form of acute colitis. It usually presents as a complication of antibiotic treatment, especially clindamycin and second- and third-generation cephalosporins and fluoroquinolones. Other possible but less common causes of PMC are abdominal surgery, uremia, colonic obstruction, and prolonged hypotension. A clostridium difficile (C. difficile) infection with toxin production (toxins A [enterotoxin] and B [cytotoxin]) is the culprit in most cases of PMC. Pathologically, the toxins stimulate the immune system by recruiting neutrophils to invade the colonic mucosa.”
Drug‐induced bowel complications and toxicities: imaging findings and pearls
Sitthipong Srisajjakul et al.
Abdominal Radiology (2022) https://doi.org/10.1007/s00261-022-03452-1 - "CT is immensely helpful in diagnosing PMC, particularly when the disease is not clinically suspected. The most common CT finding is wall thickening, which usually ranges from 3 to 32 mm in diameter (mean 14.7 mm). The degree of wall thickening is generally greater than other inflammatory or infectious forms of colitis, and is typically diffuse in distribution. The accordion sign, when detected, is highly suggestive of PMC, but it can only be detected in advanced cases.”
Drug‐induced bowel complications and toxicities: imaging findings and pearls
Sitthipong Srisajjakul et al.
Abdominal Radiology (2022) https://doi.org/10.1007/s00261-022-03452-1 - "Imaging findings include diffuse thickening of the small bowel wall, hyperenhancement of the mucosal layer, and submucosal edema (target sign). Long segments of the small bowel tend to be involved, with a jejunal predilection. Other associated findings are fluid accumulation that results in dilatation of the small bowel lumen, preservation of luminal transit, mesenteric vascular engorgement, and ascites. Scheirey et al. described a straightened small bowel wall, which was believed to be related to a primary increase in tissue turgor (i.e., stiffening) of the small bowel wall.”
Drug‐induced bowel complications and toxicities: imaging findings and pearls
Sitthipong Srisajjakul et al.
Abdominal Radiology (2022) https://doi.org/10.1007/s00261-022-03452-1 - "Important clues are ascites that are almost always present in ACE-inhibitor-induced intestinal angioedema. It is not dose related or caused by a particular ACEIs [20, 21]. Segmental thickening of the small bowel wall in intestinal angioedema is common in cases where there is a history of hereditary angioedema. The thickening of the bowel wall is always an indicator of this condition in patients receiving ACEIs who develop unexplained acute abdominal pain. Angioedema of the face, lips, neck, and oropharynx usually does not coexist.”
Drug‐induced bowel complications and toxicities: imaging findings and pearls
Sitthipong Srisajjakul et al.
Abdominal Radiology (2022) https://doi.org/10.1007/s00261-022-03452-1 - “Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to inhibit prostaglandin synthesis. However, they can damage enterocytes and villous microcirculation, leading to an inflammatory reaction and eventually ulceration. Ulceration often occurs circumferentially, which can later result in circumferential fibrosis or diaphragms. NSAID-induced enteropathy has a variety of clinical presentations, including abdominal pain, gastrointestinal (GI) bleeding, iron deficiency, and bowel obstruction. A history of NSAIDs usage may not initially be disclosed.”
Drug‐induced bowel complications and toxicities: imaging findings and pearls
Sitthipong Srisajjakul et al.
Abdominal Radiology (2022) https://doi.org/10.1007/s00261-022-03452-1 - "The most frequent CT finding is diaphragmatic stricture The ileum is more commonly involved than the jejunum. Focal areas of mucosal hyperenhancement may represent ulceration. NSAID strictures are usually multiple, circumferential, symmetric, ring-shaped, and noticeably short (approxi- mately 0.5–1 cm in length). All of these characteristics differentiate NSAID strictures from those found in Crohn’s disease. The latter strictures involve longer segments, are more asymmetric and patchy, and more frequently involve the terminal ileum.”
Drug‐induced bowel complications and toxicities: imaging findings and pearls
Sitthipong Srisajjakul et al.
Abdominal Radiology (2022) https://doi.org/10.1007/s00261-022-03452-1 
Drug‐induced bowel complications and toxicities: imaging findings and pearls
Sitthipong Srisajjakul et al.
Abdominal Radiology (2022) https://doi.org/10.1007/s00261-022-03452-1- “Various chemotherapeutic antineoplastic agents can cause GI perforation, such as fluorouracil, mitomycin C, cisplatin, and vincristine . Molecular-targeted therapies for the treatment of colorectal and ovarian cancers, particularly bevacizumab, have frequently been reported to induce GI perforation. These agents can cause tumor lysis and necrosis, ischemia due to arterial microembolism, and an inflammatory response, all of which subsequently lead to perforation.”
Drug‐induced bowel complications and toxicities: imaging findings and pearls
Sitthipong Srisajjakul et al.
Abdominal Radiology (2022) https://doi.org/10.1007/s00261-022-03452-1
- “The small intestine is involved in more than 70% of cases of generalized amyloidosis. Amyloid is deposited around small blood vessels in the submucosa and can result in occlusion, ischemia, and ultimately infarction of the bowel wall. Amyloid is also deposited between fibers within the muscular layers of the bowel wall, often resulting in decreased motility. Decreased small-bowel motility and fold thickening may be observed on barium examination of the small bowel. Some investigators have suggested that different chemical types of amyloid protein may produce distinguishing radiologic changes on enteroclysis. Clinical symptoms are directly related to the site and extent of involvement. Definitive diagnosis requires histologic identification of the amyloid material in the affected tissues.”
Uncommon Inflammatory Diseases of the Small Bowel: CT Findings
Karen M. Horton and Elliot K. Fishman
AJR 1998;170:385-388 - “CT findings are nonspecific but typically include diffuse symmetric wall thickening of the affected small bowel. Significant decreased motility of small-bowel loops is typically present, likely resulting from infiltration of the muscular layer with amyloid. Transit of oral contrast agent through the bowel will be slow. Adenopathy or amyloid infiltration of other organs (e.g., the liver) may be present and help in the differential diagnosis. When present, the adenopathy is usually not bulky or of low density as in Whipple’s disease. Also, the lack of significant dilatation or hypersecretion allows distinction from celiac disease.”
Uncommon Inflammatory Diseases of the Small Bowel: CT Findings
Karen M. Horton and Elliot K. Fishman
AJR 1998;170:385-388 - “The clinical diagnosis of gastrointestinal amyloidosis can be challenging in patients in whom the presence of this disease entity has not yet been established. Rarely does AL-amyloid present in the gastrointestinal tract as acute GI hemorrhage without other systemic symptoms. Cardiac involvement, seen in 90% of the cases, is marked by congestive heart failure (CHF) and arrhythmias due to restrictive cardiomyopathy. Diastolic dysfunction contributing to heart failure is apparent on echocardiography.”
Rare presentation of primary (AL) amyloidosis as gastrointestinal hemorrhage without systemic involvement.
Ali MF, Patel A, Muller S, Friedel D
World J Gastrointest Endosc. 2014;6(4):144-147. - “Gastrointestinal manifestations appear to be less common in AL amyloidosis, with biopsy diagnosed disease and clinically apparent disease occurring in only 8% and 1% respectively of 769 patients in a retrospective review. Despite the infrequency of gastrointestinal manifestations, the small intestine is the site of greatest deposition when there is involvement. Duodenal amyloidosis results in scalloped edges, duodenitis, ulcers, masses, hypotonia, and dilatation. Endoscopic findings commonly include a fine granular appearance, polyps, erosions, ulcerations, and mucosal friability. Clinical signs and symptoms may include hemorrhage, obstruction, and infarction amongst others. Bleeding occurs as a presenting symptom in 25%-45% of patients with amyloidosis and may be caused by ischemia or infarction, by ulceration or an infiltrated lesion, or from generalized oozing without a particular source.”
Rare presentation of primary (AL) amyloidosis as gastrointestinal hemorrhage without systemic involvement.
Ali MF, Patel A, Muller S, Friedel D
World J Gastrointest Endosc. 2014;6(4):144-147. - "Sclerosing mesenteritis is a rare inflammatory condition of unknown cause that affects the root of the mesentery. The mesenteric fat is involved with a variable amount of inflammation, fatty necrosis, and fibrosis. When the inflammation predominates (so-called mesenteric panniculitis), patients generally present with acute pain. On CT images, mesenteric panniculitis appears as a focal area of increased attenuation within the mesenteric fat surrounded by a pseudocapsule, an appearance that has been described as "the misty mesentery". Areas of fibrosis within the inflamed fat appear as linear bands of soft-tissue attenuation ."
Mesenteric Neoplasms: CT Appearances of Primary and Secondary Tumors and Differential Diagnosis
Sheth S, Horton KM, Garland MR, Fishman EK
RadioGraphics Mar 2003, Vol. 23, No. 2:457–473 - “At CT, the most common manifestation of mesenteric carcinoid tumors is that of an enhancing soft-tissue mass with linear bands radiating in the mesenteric fat . Radiologic-pathologic correlation has shown that these radiating strands of soft tissue do not generally represent tumor infiltration along neurovascular bundles but rather result from the intense fibrotic proliferation and desmoplastic reaction in the mesenteric fat and the adjacent mesenteric vessels caused by the release of serotonin and other hormones from the primary tumor ."
Mesenteric Neoplasms: CT Appearances of Primary and Secondary Tumors and Differential Diagnosis
Sheth S, Horton KM, Garland MR, Fishman EK
RadioGraphics Mar 2003, Vol. 23, No. 2:457–473
- “ 20 patients had GVHD clinical Stage I-II and 21 had Stage III-IV. 39 (95%) had abnormal CT appearances. The most consistent finding was bowel wall thickening: small (n=14, 34%) or large (n=5, 12%) bowel, or both (n=20, 49%). Other manifestations included bowel dilatation (n=7, 17%), mucosal enhancement (n=6, 15%) and gastric wall thickening (n=9, 38%). Extra-intestinal findings included mesenteric stranding (n=25, 61%), ascites (n=17, 41%), biliary abnormalities (n=12, 29%) and urinary excretion of orally administered gastrografin (n=12, 44%). Diffuse small-bowel thickening and any involvement of the large bowel were associated with severe clinical presentation. Diffuse small-bowel disease correlated with poor prognosis.”
CT in the clinical and prognostic evaluation of acute graft-vs-host disease of the gastrointestinal tract.
Shimoni A, et al.
Br J Radiol. 2012 Aug;85(1016):e416-23. - "Allogeneic stem-cell transplantation (SCT) has been used increasingly to treat haematopoietic disorders and haematological malignancies . Among the complications of SCT, graft-vs-host disease (GVHD) is one of the major causes of morbidity and mortality. Intestinal GVHD is one of the most frequent features of acute GVHD. Gastrointestinal (GI) symptoms include abdominal pain, nausea, vomiting and profuse diarrhoea . The diagnosis and grading of the disease are based on a spectrum of clinical and laboratory features. Clinical parameters such as the quantity of diarrhoea are used to determine the clinical severity of GI GVHD. These are, however, not very accurate, as assessment of the volume of diarrhoea is inconvenient and inaccurate.”
CT in the clinical and prognostic evaluation of acute graft-vs-host disease of the gastrointestinal tract.
Shimoni A, et al.
Br J Radiol. 2012 Aug;85(1016):e416-23. - “Intestinal CT abnormalities included bowel wall thickening, defined as >3 mm, and bowel wall dilatation, defined as region of small bowel with a diameter >2.5 cm, or of large bowel >8.0 cm. Extent of bowel involvement was defined as segmental (≤40 cm) or diffuse (>40 cm).Intestinal mucosal enhancement and attenuation patterns of bowel wall were assessed as well. The latter included the “water halo sign” (defined as a line of decreased attenuation within the bowel wall), the “accordion sign” (defined as broad transverse bands in the colon that trap oral contrast ) and pneumatosis intestinalis.”
CT in the clinical and prognostic evaluation of acute graft-vs-host disease of the gastrointestinal tract.
Shimoni A, et al.
Br J Radiol. 2012 Aug;85(1016):e416-23. - "Pneumatosis intestinalis was observed in only one of our patients. It has been rarely reported in patients with GVHD, believed to be a benign entity related to high-dose steroids and chemotherapy. Occasionally it is asymptomatic and detected incidentally. Gas may also be detected in the retroperitoneum or peritoneal cavity, as was the case in our patient.”
CT in the clinical and prognostic evaluation of acute graft-vs-host disease of the gastrointestinal tract.
Shimoni A, et al.
Br J Radiol. 2012 Aug;85(1016):e416-23. - “Graft-versus-host disease occurs when functionally competent T lymphocytes are introduced into an immunocompromised recipient . Acute graft-versus-host disease presents within the first 100 days of allogeneic bone marrow transplantation and is one of the major complications of this procedure. The skin, gastrointestinal tract, and liver are the principal targeted organs in patients with acute graft-versus-host disease. Symptoms of this disease are often nonspecific and include abdominal cramping, diarrhea, fever, nausea, and vomiting. The differential diagnosis includes gastrointestinal infections, neutropenic enterocolitis, and, during the early posttransplantation period, sequelae of chemotherapy and radiation treatment.”
CT Features with Pathologic Correlation of Acute Gastrointestinal Graft-Versus-Host Disease After Bone Marrow Transplantation in Adults
Babak N. Kalantari et al.
American Journal of Roentgenology. 2003;181: 1621-1625. - “The predominant CT findings in the intestines of patients with acute gastrointestinal graft-versus-host disease are summarized in Table 1. Bowel wall thickening was present in at least one site in all cases. All 22 patients had small-bowel wall thickening detectable on CT, whereas 13 (59%) of the 22 patients had thickening of the walls in both the small and large bowels . Wall thickening had a discontinuous distribution in nine patients (41%), with normal portions of bowel separating the involved segments. No predilection for involvement of specific sections of the small or large bowel by the disease was observed. Bowel-loop dilatation was present in five patients (23%) and always occurred proximal to the thickened wall segments . Bowel mucosal enhancement was identified in seven (54%) of the 13 patients in whom enhancement was assessed; serosal enhancement was noted in four (31%) of the 13 patients. Abnormally enhancing bowel segments were always thickened.”
- In our series, bowel wall thickening was the most common finding, present in all patients with biopsy-confirmed acute gastrointestinal graft-versus-host disease. On CT scans, all patients had small-bowel involvement, and 59% of patients also had wall thickening of the large bowel. The areas of thickening corresponded histologically with submucosal edema and scattered inflammatory cells. The wall thickening was discontinuous in 41% of the patients, with normal bowel segments separating focally affected portions. We do not believe that this discontinuous pattern of bowel involvement has been previously described in studies of acute gastrointestinal graft-versus-host disease Bowel-loop dilatation, when present, was universally found proximal to a thickened bowel wall segment. The specificity of these findings for diagnosis of graft-versus-host disease as opposed to other causes of enteritis, however, requires further investigation.
CT Features with Pathologic Correlation of Acute Gastrointestinal Graft-Versus-Host Disease After Bone Marrow Transplantation in Adults
Babak N. Kalantari et al.
American Journal of Roentgenology. 2003;181: 1621-1625. - “In summary, the CT appearance of acute gastrointestinal graft-versus-host disease in adults includes bowel wall thickening with or without proximal dilatation, engorgement of the vasa recta, mesenteric fat stranding, mucosal and serosal enhancement, gallbladder–biliary tract abnormalities, and ascites. The CT findings associated with high grade graft-versus-host disease were thickening of the distal esophagus, ileum, or ascending colon, as well as increasing numbers of thickened bowel wall segments.”
CT Features with Pathologic Correlation of Acute Gastrointestinal Graft-Versus-Host Disease After Bone Marrow Transplantation in Adults
Babak N. Kalantari et al.
American Journal of Roentgenology. 2003;181: 1621-1625. - "Acute radiation enteritis occurs in a majority of patients. They present with diarrhea, tenesmus, cramping and incontinence. Diarrhea may start as early as 3 weeks from the start of radiation treatment. These symptoms usually resolve with cessation of the radiation treatment. In the acute phase, the primary effect of radiation is on mucosal stem cells within the intestinal crypts. Radiation therapy can cause damage to these stem cells and as a result cause mucosal atrophy with intestinal inflammation and edema and decreased absorptive area. On abdominal radiographs, dilated small bowel loops with thickened walls can be seen. On CT, thickened small intestinal walls with the target sign may be seen.”
Imaging of complications of oncological therapy in the gastrointestinal system.
Viswanathan C et al.
Cancer Imaging. 2012 May 7;12(1):163-72. - "Chronic radiation enteritis is typically seen at least 8–12 months after radiation therapy. They may occur years after radiation therapy. In some cases, the symptoms of chronic enteritis can worsen with time. These patients typically present with diarrhea, malabsorption, fistulae, partial or complete small bowel obstruction. These changes are related to increased collagen deposition within the wall making it thickened and fixed. There is also injury to the blood vessels (endarteritis) with occlusion of the vessel lumen causing ischemia. Radiation changes more commonly occur in the terminal ileum which is relatively fixed in position and also in patients following surgery due to adhesions, which may render the small bowel relatively immobile.”
Imaging of complications of oncological therapy in the gastrointestinal system.
Viswanathan C et al.
Cancer Imaging. 2012 May 7;12(1):163-72. - "Chronic radiation enteritis can manifest on CT as small bowel wall thickening and edema, ulcerations, stricture formation, fistula and abscess formation. As the ulcers heal, there can be fibrosis with narrowing of the intestinal lumen and stricture formation or even obstruction. Even if the intestine appears normal, patients are at risk of spontaneous perforation. Increased density in the mesentery can also be seen.”
Imaging of complications of oncological therapy in the gastrointestinal system.
Viswanathan C et al.
Cancer Imaging. 2012 May 7;12(1):163-72. - "Acute radiation colitis or proctitis can commonly occur during radiation therapy. They present with pain, diarrhea, tenesmus, cramping, bleeding and incontinence. These symptoms usually resolve after radiation therapy is stopped. CT performed during the acute phase of radiation injury can demonstrate non-specific colonic or rectal wall thickening and inflammatory fat stranding. The colonic folds may appear to have a saw tooth appearance. There can be increased attenuation to the perirectal fat and perirectal fascial thickening seen on CT.”
Imaging of complications of oncological therapy in the gastrointestinal system.
Viswanathan C et al.
Cancer Imaging. 2012 May 7;12(1):163-72. - "Radiation change within the liver is typically seen within 2–8 weeks of completing radiotherapy. Radiation-induced liver disease is seen in 5–10% of patients who receive radiation to their liver in doses exceeding 30–35 Gy. Patients may present with anicteric ascites, hepatomegaly and elevated liver enzymes[. Typically, findings usually resolve in 4–6 months, but a small portion of patients progress to chronic liver failure. Pathologically, the findings are very similar to veno-occlusive disease, with congestion of the lobules and injury to the endothelial cells. On CT, the area of radiation change is lower in signal due to the edema and there may be a linear demarcation known as the straight line sign.”
Imaging of complications of oncological therapy in the gastrointestinal system.
Viswanathan C et al.
Cancer Imaging. 2012 May 7;12(1):163-72. - “Radiation enteritis is damage to small and/or large intestine secondary to radiation. Different terms like radiation colitis, radiation enteropathy, radiation mucositis, and pelvic radiation disease have been used to describe this phenomenon. Radiation proctitis is a different term that is used to describe the involvement of rectum and sigmoid colon. Radiotherapy is used as a treatment for many cancers. Radiation enteritis can be acute or chronic. The chronic form usually develops between 3 months to 30 years after treatment.”
Bhutta BS, Fatima R, Aziz M
Radiation Enteritis. [Updated 2021 Feb 7].
StatPearls; 2021 Jan- - “Mesenteric changes include increased attenuation of the mesentery to about 20 HU and thickening of the perirectal fibrous tissue with an increase in the perirectal fat . The presacral space widens because of the increase in perirectal fat and fibrous tissue. Symmetrically proliferated fat immediately adjacent to the rectum and higher-attenuation fibrous tissue surrounding it create the so-called halo effect. A fibrous connection between the sacrum and rectum may also be visualized.”
Complications of radiation therapy: CT evaluation.
D A Bluemke, E K Fishman, J E Kuhlman, E S Zinreich
Radiographics. 1991 Jul;11(4):581-600 - “Distention of the bowel lumen with contrast material is critical for evaluating radiation-induced changes. Loops of bowel that have a thickened, serpentine appearance from irradiation are often adherent or matted. Discrete masses are normally not observed; such an appearance would warrant further investigation to exclude re- currence or metastasis of tumor. Low-attenuation zones, secondary to edema and inflammation, may be seen in the submucosal region.”
Complications of radiation therapy: CT evaluation.
D A Bluemke, E K Fishman, J E Kuhlman, E S Zinreich
Radiographics. 1991 Jul;11(4):581-600 - “Chemotherapy-induced enteritis is commonly seen with traditional cytotoxic chemotherapies such as 5-fluorouracil (5-FU), oral capecitabine (Xeloda), paclitaxel, irinotecan and oxaliplatin. When these patients are on a combination therapy such as FOLFOX (5-FU, leucovorin and oxaliplatin) or FOLFIRI (5-FU, leucovorin and irinotecan), these side effects can be additive. These patients can present with diarrhea, distension and generalized abdominal pain. This is believed to be related to the direct effect of chemotherapy on rapidly dividing cells in the small bowel mucosa. Involvement is usually diffuse.”
Imaging of complications of oncological therapy in the gastrointestinal system.
Viswanathan C et al.
Cancer Imaging. 2012 May 7;12(1):163-72. - • Classic chemotherapy agents target rapidly proliferating cells; molecularly targeted therapies target specific key cell membrane and intracellular molecules.
• Radiologists may more easily recognize the manifestations of chemotherapy toxicities by understanding the mechanisms of action of the chemotherapeutic agents.
• The radiologist should be aware that toxicities can be asymptomatic and that radiologists are instrumental in reporting early manifestations of toxicities to referring physicians. - “Cytotoxic chemotherapy agents usually interfere with RNA and DNA synthesis or cell division and, therefore, affect cell growth by various mechanisms of action. Some of the most commonly used drugs include classic agents such as cyclophosphamide (an alkylating agent), cisplatin (a DNA intercalating agent), fl uorouracil (5-FU; an antimetabolite), doxorubicin (an anthracycline), vincristine (a mitotic spindle inhibitor), and bleomycin. Some of the more recently developed cytotoxic agents include gemcitabine (another antimetabolite), oxaliplatin (a cisplatin analog), paclitaxel and docetaxel (the “taxanes,” which are mitotic spindle poisons), and irinotecan (a topoisomerase inhibitor).”
CT Findings of Chemotherapy induced Toxicity: What Radiologists Need to Know about the Clinical and Radiologic Manifestations of Chemotherapy Toxicity
Torres JM et al.
Radiology 2011; 258:41–56 
CT Findings of Chemotherapy induced Toxicity: What Radiologists Need to Know about the Clinical and Radiologic Manifestations of Chemotherapy Toxicity
Torres JM et al.
Radiology 2011; 258:41–56- “Chemotherapy-induced enteritis is common with cytotoxic chemotherapy. Toxicities associated with epidermal growth factor–targeted therapies include enteritis and acneiform skin rash. Oncologists may report the rash in the clinical history to provide additional information to the interpreting radiologist. Pneumatosis intestinalis is a nonspecific radiologic finding, which may have an important adverse outcome if not recognized, depending on its cause. Both symptomatic and asymptomatic pneumatosis intestinalis have been described with numerous classic chemotherapy agents and have been reported with targeted therapy as well.”
CT Findings of Chemotherapy induced Toxicity: What Radiologists Need to Know about the Clinical and Radiologic Manifestations of Chemotherapy Toxicity
Torres JM et al.
Radiology 2011; 258:41–56 - “Chemotherapy-induced enteritis, manifesting as abdominal pain, bloating, and diarrhea, is one of the most common toxicities associated with the classic cytotoxic agents. It is due to nonspecific targeting of the rapidly dividing cells in the gastrointestinal mucosa. Several chemotherapy agents used in the treatment of metastatic colorectal cancer, including 5-FU plus leucovorin, which is administered systemically, and fl oxuridine, which is most commonly administered by means of hepatic arterial infusion, can cause enteritis. The enteritis may be diffuse or predominantly involve the distal ileum ”
CT Findings of Chemotherapyinduced Toxicity: What Radiologists Need to Know about the Clinical and Radiologic Manifestations of Chemotherapy Toxicity
Torrisi JM et al.
Radiology 2011; 258:41–56 - “Incidence of diarrhea and neutropenia. When irinotecan is used in combination with 5-FU and leucovorin (ie, FOLFIRI), there is an increased risk of gastrointestinal complications. The radiographic findings may include dilated bowel, air-fluid levels, and bowel wall thickening. The typical appearance of enteritis on CT images includes submucosal edema and hyperemia of the mucosa and serosa to yield a target sign. Other entities such as ischemia and radiation enteritis can have a similar appearance. Bowel wall thickening can also be uniform in attenuation.”
CT Findings of Chemotherapyinduced Toxicity: What Radiologists Need to Know about the Clinical and Radiologic Manifestations of Chemotherapy Toxicity
Torrisi JM et al.
Radiology 2011; 258:41–56 - “Pneumatosis intestinalis is a radiologic finding of subserosal or submucosal gas in the small- or large bowel wall. It is most commonly due to a disruption in mucosal integrity, which can occur in necrotizing enterocolitis, bowel ischemia, bowel infarction, and neutropenic colitis or during cytotoxic or immunosuppressive therapy. This finding can occur with many classic chemotherapy agents, such as those used for treatment of hematologic malignancies, and has been recently described with bevacizumab. Pneumatosis can be asymptomatic and encountered at routine surveillance imaging.”
CT Findings of Chemotherapyinduced Toxicity: What Radiologists Need to Know about the Clinical and Radiologic Manifestations of Chemotherapy Toxicity
Torrisi JM et al.
Radiology 2011; 258:41–56 - “Gastrointestinal perforation is an infrequent but potentially fatal toxicity related to bevacizumab therapy. The pathogenesis of bowel perforation is unknown, but suggested mechanisms include ischemia than in those of colon cancer (5.4% vs 1.7%). Early reports suggested that the risk of gastrointestinal perforation is linked to whether the primary tumor is intact (in the case of colorectal cancer) or whether there is bowel involvement (in the case of ovarian cancer). However, authors of subsequent reviews note perforation can happen anywhere along the gastrointestinal tract and can occur during treatment of malignancies that lack disease within the peritoneal cavity.”
CT Findings of Chemotherapyinduced Toxicity: What Radiologists Need to Know about the Clinical and Radiologic Manifestations of Chemotherapy Toxicity
Torrisi JM et al.
Radiology 2011; 258:41–56 - “Gastrointestinal stromal tumors are typically large, hypervascular, enhancing masses on contrast enhanced CT images and often contain areas of necrosis or hemorrhage at the time of presentation. Chemotherapyinduced intratumoral hemorrhage is often clinically suspected owing to decreases in hemoglobin during the first 4–8 weeks of imatinib treatment and has been observed in up to 5% of patients with bulky gastrointestinal stromal tumors undergoing treatment with imatinib.”
CT Findings of Chemotherapyinduced Toxicity: What Radiologists Need to Know about the Clinical and Radiologic Manifestations of Chemotherapy Toxicity
Torrisi JM et al.
Radiology 2011; 258:41–56 - “In the acute setting, CT findings of acute radiation enteritis may include mucosal hyperenhancement, wall thickening, and ulcer formation. Localized inflammatory changes including interloop edema, regional free fluid, and pneumatosis may also be seen. Chronic findings include submucosal thickening, stricturing, fistula formation, and luminal narrowing secondary to chronic intimal inflammation. The diagnosis of acute radiation enteritis primarily remains one of exclusion and depends largely on clinical history and the time course. However, recognition is helpful as these changes may be reversible, resolving with time following completion of therapy.”
CT Findings of Acute Small-Bowel Entities
Sugi MD et al.
RadioGraphics 2018; 38:1352–1369 - "Acute regional or diffuse spontaneous hemorrhage in the small bowel is relatively rare but has been described in patients undergoing anticoagulation therapy or with bleeding diatheses. The most common location of acute small-bowel bleeding is in the jejunum (69%). However, hemorrhage can be diffuse or even multifocal, uncommonly causing hematoma formation across multiple segments of small bowel. On CT images, hemorrhage may manifest as circumferential thickening of the bowel wall of varying length and is often most evident on CT images obtained without intravenous contrast material. A potential secondary consequence is bowel obstruction owing to mass effect, although most of these patients are managed conservatively.”
CT Findings of Acute Small-Bowel Entities
Sugi MD et al.
RadioGraphics 2018; 38:1352–1369 - • On intravenous contrast-enhanced CT images of the abdomen and pelvis, the “target” or “double halo” sign represents mural stratification caused by hyperenhancement of both the inner mucosa and the outer muscularis propria/serosa, with a middle layer of low-attenuating submucosal edema.
• Dilated loops of small bowel (>3 cm in diameter) with pa- per-thin walls should raise strong suspicion for acute vascular compromise owing to thromboembolic disease.
• Mechanical obstruction of two points along a short segment of small bowel in a single location can lead to a twisted C- or U-shaped configuration, the typical appearance seen in closed-loop small-bowel obstruction at CT.
CT Findings of Acute Small-Bowel Entities
Sugi MD et al.
RadioGraphics 2018; 38:1352–1369 - • Vasculitis should be considered under certain circumstances, namely in young patients, when the affected segments of small bowel are atypical in distribution (eg, in the duodenum or a patchy distribution across multiple vascular territories) and when there is associated systemic involvement by a similar process.
• CT findings of ACE inhibitor–induced angioedema include circumferential wall thickening (most commonly involving the jejunum), mural stratification, straightening of bowel loops, interloop or mesenteric edema, and ascites.
CT Findings of Acute Small-Bowel Entities
Sugi MD et al.
RadioGraphics 2018; 38:1352–1369
- “Diverticula can be present in any location along the gastrointestinal (GI) tract. In order of decreasing frequency, they are found in the colon, duodenum, esophagus, stomach, jejunum, and ileum. While small bowel diverticulosis is less common than colonic diverticulosis, up to 60 % of patients with small bowel diverticular disease have coexisting diverticula within the colon [4–7]. Small bowel diverticula (SBD) can be broadly categorized into jejunoileal diverticula (JID) and the more common duodenal diverticula.”
Small bowel diverticulitis: an imaging review of an uncommon entity
Darren L. Transue et al.
Emerg Radiol (2017) 24:195–205 - “SBD are often asymptomatic and discovered incidentally on imaging. Despite the perception of rarity, SBD can present with a range of symptomatic complications such as diverticulitis, perforation, obstruction, abscess, anemia, or volvulus. DD may cause pancreatic or biliary complications. SBD located on the mesenteric border near the mesenteric arterial branches increases the likelihood of hemorrhagic complications.”
Small bowel diverticulitis: an imaging review of an uncommon entity
Darren L. Transue et al.
Emerg Radiol (2017) 24:195–205 - “Most SBD are acquired, asymptomatic, and incidentally found, regardless of location. DD are five times more common than JID with an incidence as high as 20 % on autopsy series and up to 6 % of upper gastrointestinal radiographic studies. During endoscopic retrograde cholangiopancreatography (ERCP), nearly one fourth of patients have been reported to have a duodenal diverticulum. Between 2 and 10 % of patients undergoing upper GI series or endoscopy are reported to have JID. Multiple radiographic series have reported JID incidence between 0.5 and 2.3 %, with the highest incidence being reported by using CT enteroclysis by Maglinte et al.”
Small bowel diverticulitis: an imaging review of an uncommon entity
Darren L. Transue et al.
Emerg Radiol (2017) 24:195–205 - “Similarly, 6–10 % of patients with JID develop acute complications; however, in patients with isolated jejunal diverticulosis, the complication rate has been reported as high as 30 % . The most common jejunoileal complication is uncomplicated diverticulitis. JID can have more serious complications including hemorrhage, adhesions, fistula formation, perforation, and peritonitis. In fact, jejunoileal diverticulitis is almost 18 times more likely to perforate and form an abscess than DD.”
Small bowel diverticulitis: an imaging review of an uncommon entity
Darren L. Transue et al.
Emerg Radiol (2017) 24:195–205 - “The most serious complication in SBD is gangrene and perforation with a resultant mortality as high as 40 %, usually a result of delayed diagnosis and advanced patient age. Chronically, patients with JID can have intermittent gastrointestinal bleeding, bacterial overgrowth, pseudoobstruction, blind loop syndrome, jejunal dyskinesia, and chronic diverticulitis with formation of an enterolith. Chronic malabsorption is also a long-term complication.”
Small bowel diverticulitis: an imaging review of an uncommon entity
Darren L. Transue et al.
Emerg Radiol (2017) 24:195–205 - “Findings of SBD involve the presence of discrete, rounded duodenal or jejunoileal outpouchings, which can contain air, simple fluid, debris, or enteric contrast. Oftentimes, they have a barely discernable, smooth wall and are seen in profile, but in patients with extensive disease, differentiating overlapping small bowel loops from diverticula can be difficult. The lack of valvulae conniventes or intraluminal contents may be helpful for differentiating diverticula over 3 cm from adjacent small bowel segments.”
Small bowel diverticulitis: an imaging review of an uncommon entity
Darren L. Transue et al.
Emerg Radiol (2017) 24:195–205 - “Asymmetric small bowel wall thickening adjacent to a diverticulum with peridiverticular mesenteric fat stranding is characteristic of acute diverticulitis .”
Small bowel diverticulitis: an imaging review of an uncommon entity
Darren L. Transue et al.
Emerg Radiol (2017) 24:195–205 - “SBD is an uncommon entity rarely described and discussed in literature. Radiologists should be aware of the entity and key imaging findings of SBD in order to distinguish it from other inflammatory and neoplastic conditions of the bowel thus preventing unnecessary exploratory laparotomy.”
Small bowel diverticulitis: an imaging review of an uncommon entity
Darren L. Transue et al.
Emerg Radiol (2017) 24:195–205 - “Diverticulosis of the jejunum and ileum is an uncommon entity, with a reported prevalence on conventional barium studies of 0.3-1.9% and at autopsy of 0.3-1.3% . However, a recently published study using enterocylsis found diverticula ofthejejunum and ileum in 2.3% of patients studied by this technique. Small-bowel diverticula found incidentally on small-bowel series or barium enema are usually asymptomatic. Acute complications including diverticulitis, perforation, obstruction, and hemorrhage are relatively rare, occurring in 6.5-1 0.4% of patients.”
Small-bowel diverticulitis: CT findings
S Greenstein, B Jones, EK Fishman, JL Cameron and SS Siegelman
American Journal of Roentgenology. 1986;147: 271-274 - “While diverticulitis of the small bowel is a rare cause of inflammatory disease of the gastrointestinal tract, this condition is associated with a high mortality, which in part is due to a delay in the correct diagnosis. The CT findings in jejunal diverticulitis, although not specific, may suggest this diagnosis. The CT findings in ileal diverticulitis can probably not be differentiated from those of other inflammatory processes in the right lower quadrant. Diverticulitis of the small bowel should be included in the differential diagnosis of intraabdominal inflammatory processes.”
Small-bowel diverticulitis: CT findings
S Greenstein, B Jones, EK Fishman, JL Cameron and SS Siegelman
American Journal of Roentgenology. 1986;147: 271-274 - “Jejunal diverticula have characteristic findings on CT, appearing as discrete round or ovoid, contrast-, fluid-, or air-containing structures outside the expected lumen of the small bowel, with a smooth, barely discernible wall and no recognizable smallbowel folds. Not infrequently, these structures are seen to communicate directly with an adjoining small-bowel loop, a feature best recognized by scrolling the images. Our experience suggests that jejunal diverticulosis can often be recognized on the basis of the characteristic CT features of this condition.”
Jejunal Diverticulosis: Findings on CT in 28 Patients
Florian Fintelman, Marc S. Levine Stephen E. Rubesin
AJR 2008; 190:1286–1290 - “In conclusion, jejunal diverticula have characteristic findings on CT, appearing as discrete round or ovoid, contrast-, fluid-, or air containing structures outside the expected lumen of the small bowel, with a smooth, barely discernible wall and no recognizable small-bowel folds. Not infrequently, these structures are seen to communicate directly with an adjoining small-bowel loop, a feature best recognized by scrolling the images. Our experience suggests that jejunal diverticulosis can often be recognized on the basis of the characteristic CT features of this condition.”
Jejunal Diverticulosis: Findings on CT in 28 Patients
Florian Fintelman, Marc S. Levine Stephen E. Rubesin
AJR 2008; 190:1286–1290
- “Duodenal pathology is an infrequent cause of acute abdominal pain for which patients present to the emergency department. Critical pathology on multidetector CT (MDCT) may be overlooked if the radiologist does not carefully evaluate the duodenum as part of the search pattern. Optimal MDCT protocols include intravenous contrast with multiplanar reconstructions (MPRs). A variety of etiologies ranging from infection to malignancy can involve the duodenum, for which interrogation with MPRs is most helpful given the anatomy and complex relationship with surrounding structures.”
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Mikhael Polotsky, Harshna V. Vadvala, Elliot K. Fishman, Pamela T. Johnson
Emergency Radiology (2020) 27:195–203 - "Acute duodenitis may be the result of infectious or non- infectious causes. Noninfectious duodenitis is most often caused by secondary involvement from acute pancreatitis. Other common noninfectious causes include NSAID use and ingestion of hard liquor. Crohn’s disease rarely involves the duodenum. Helicobacter pylori is the most common infectious cause of duodenitis invari- ably associated with concurrent or prior peptic ulcers.”
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Mikhael Polotsky, Harshna V. Vadvala, Elliot K. Fishman, Pamela T. Johnson
Emergency Radiology (2020) 27:195–203 - “Duodenal diverticuli could be confused with either a pancreatic mass or an abscess, and when prior scans are available, comparison with older exams reveals the presence of a diverticulum to avoid this diagnostic error.”
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Mikhael Polotsky, Harshna V. Vadvala, Elliot K. Fishman, Pamela T. Johnson
Emergency Radiology (2020) 27:195–203 - “Acute duodenal obstruction can result from primary duodenal or other periampullary tumors. Clinical symptoms include nausea, vomiting, and the inability to tolerate oral intake. Approximately 20% of small bowel neoplasms arise in the duodenum. The most common symptomatic benign neoplasm of the duodenum is a benign gastrOintestinal stromal tumor (GIST). GIST appears as a heterogeneous mass, with varying degrees of enhancement based on the size, and can be exophytic or cause narrowing of the bowel lumen.”
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Mikhael Polotsky, Harshna V. Vadvala, Elliot K. Fishman, Pamela T. Johnson
Emergency Radiology (2020) 27:195–203 - "The most common primary malignancy of the duode- num is adenocarcinoma, with 50–70% of small bowel adenocarcinomas occurring either in the duodenum or proximal jejunum. Lymphomatous involvement of the duodenum can occur with both primary duodenal lymphoma and involvement from systemic disease. The duodenum can also be obstructed by local extension of other malignancies, for example, pancreatic adenocarcinoma or gallbladder cancer.”
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Mikhael Polotsky, Harshna V. Vadvala, Elliot K. Fishman, Pamela T. Johnson
Emergency Radiology (2020) 27:195–203
- “Duodenal pathology is an infrequent cause of acute abdominal pain for which patients present to the emergency department. Critical pathology on multidetector CT (MDCT) may be overlooked if the radiologist does not carefully evaluate the duodenum as part of the search pattern. Optimal MDCT protocols include intravenous contrast with multiplanar reconstructions (MPRs). A variety of etiologies ranging from infection to malignancy can involve the duodenum, for which interrogation with MPRs is most helpful given the anatomy and complex relationship with surrounding structures. The purpose of this review article is to highlight the importance of CT acquisition with multiplanar reconstructions and review the spectrum of emergent duodenal pathology, with the goal of ensuring accurate and timely diagnosis to best guide patient management.”
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Polotsky M, Vadvala HV, Fishman EK, Johnson PT
Emergency Radiology https://doi.org/10.1007/s10140-019-01735-7 - "When administered with IV contrast, PO water enables better visualization of the finer details of duodenal wall than positive oral contrast agents, facilitating identification of mucosal enhancement, fold thickening, submucosal edema, and focal abnormalities such as ulcer. Water is also better tolerated than positive contrast agents, and a faster administration time is helpful in the emergency setting. If a perforation or fistula is suspected, then positive oral contrast is pre- ferred; however, positive oral contrast is not necessary to make the diagnosis of duodenal perforation if IV con- trast, thin sections, and multiplanar reconstructions are used.”
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Polotsky M, Vadvala HV, Fishman EK, Johnson PT
Emergency Radiology https://doi.org/10.1007/s10140-019-01735-7 
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Polotsky M, Vadvala HV, Fishman EK, Johnson PT
Emergency Radiology https://doi.org/10.1007/s10140-019-01735-7- "Duodenal ulcers usually involve the duodenal bulb and are most commonly peptic ulcer [6]. Less common etiologies include Zollinger-Ellison syndrome. CT findings of Zollinger- Ellison include thickened rugal folds and multiple gastric nodules, and the causative gastrinoma (usually < 1 cm) is most often located in the gastrinoma triangle.Giant duodenal ulcers (> 2 cm) have a high risk of bleeding, perforation, and obstruction.”
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Polotsky M, Vadvala HV, Fishman EK, Johnson PT
Emergency Radiology https://doi.org/10.1007/s10140-019-01735-7
- “Duodenal pathology is an infrequent cause of acute abdominal pain for which patients present to the emergency department. Critical pathology on multidetector CT (MDCT) may be overlooked if the radiologist does not carefully evaluate the duodenum as part of the search pattern. Optimal MDCT protocols include intravenous contrast with multiplanar reconstructions (MPRs). A variety of etiologies ranging from infection to malignancy can involve the duodenum, for which interrogation with MPRs is most helpful given the anatomy and complex relationship with surrounding structures. The purpose of this review article is to highlight the importance of CT acquisition with multiplanar reconstructions and review the spectrum of emergent duodenal pathology, with the goal of ensuring accurate and timely diagnosis to best guide patient management.”
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Polotsky M, Vadvala HV, Fishman EK, Johnson PT
Emergency Radiology https://doi.org/10.1007/s10140-019-01735-7 - "When administered with IV contrast, PO water enables better visualization of the finer details of duodenal wall than positive oral contrast agents, facilitating identification of mucosal enhancement, fold thickening, submucosal edema, and focal abnormalities such as ulcer. Water is also better tolerated than positive contrast agents, and a faster administration time is helpful in the emergency setting. If a perforation or fistula is suspected, then positive oral contrast is pre- ferred; however, positive oral contrast is not necessary to make the diagnosis of duodenal perforation if IV con- trast, thin sections, and multiplanar reconstructions are used.”
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Polotsky M, Vadvala HV, Fishman EK, Johnson PT
Emergency Radiology https://doi.org/10.1007/s10140-019-01735-7
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Polotsky M, Vadvala HV, Fishman EK, Johnson PT
Emergency Radiology https://doi.org/10.1007/s10140-019-01735-7- "Duodenal ulcers usually involve the duodenal bulb and are most commonly peptic ulcer [6]. Less common etiologies include Zollinger-Ellison syndrome. CT findings of Zollinger- Ellison include thickened rugal folds and multiple gastric nodules, and the causative gastrinoma (usually < 1 cm) is most often located in the gastrinoma triangle.Giant duodenal ulcers (> 2 cm) have a high risk of bleeding, perforation, and obstruction.”
Duodenal emergencies: utility of multidetector CT with 2D multiplanar reconstructions for challenging but critical diagnoses
Polotsky M, Vadvala HV, Fishman EK, Johnson PT
Emergency Radiology https://doi.org/10.1007/s10140-019-01735-7
- “Systemic lupus erythematosus is an autoimmune disease caused by immune complex deposition that classically affects young women. The disease process often involves the joints, kidneys, gastrointestinal tract, and skin. Lupus may affect vasculature of the entire gastrointestinal tract, but the SMA distribution is involved most commonly. Polyarteritis nodosa is a medium-vessel fibrinoid necrotizing vasculitis that occurs in middle-aged to older adults. Classically, it causes microaneurysms and erosion of the arterial wall, most commonly affecting the kidneys, gastrointestinal tract, and liver.”
High-Value Multidetector CT Angiography of the Superior Mesenteric Artery: What Emergency Medicine Physicians and Interventional Radiologists Need to Know.
Ghodasara N, Liddell R, Fishman EK, Johnson PT.
Radiographics. 2019 Mar-Apr;39(2):559-577. - Segmental arterial mediolysis is a nonatherosclerotic and noninflammatory arteriopathy characterized by lysis of the smooth muscle of the outer media that results in dissecting aneurysms and intramural hematomas. Unlike those of most vasculitis's, inflammatory or immune markers are most often normal. Middle-aged and elderly patients are affected most commonly and can present with abdominal pain, distention, decreased hemoglobin level, bowel ischemia, or shock. Imaging findings of segmental arterial mediolysis are similar to those of other vasculitis's, although it classically results in alternating aneurysm and stenosis of the abdominal splanchnic arteries, without involvement of other vessels.
High-Value Multidetector CT Angiography of the Superior Mesenteric Artery: What Emergency Medicine Physicians and Interventional Radiologists Need to Know.
Ghodasara N, Liddell R, Fishman EK, Johnson PT.
Radiographics. 2019 Mar-Apr;39(2):559-577. - “CT angiographic findings of vasculitis include circumferential arterial wall thickening, luminal narrowing, and microaneurysms. Long-segment smooth tapering without evidence of atherosclerotic disease usually is seen in vasculitis. A beaded appearance of the SMA may be seen with multiple aneurysms. The extent of the disease must be detailed, because focal disease can be managed with surgical or endovascular treatment, and diffuse disease is managed medically.”
High-Value Multidetector CT Angiography of the Superior Mesenteric Artery: What Emergency Medicine Physicians and Interventional Radiologists Need to Know.
Ghodasara N, Liddell R, Fishman EK, Johnson PT.
Radiographics. 2019 Mar-Apr;39(2):559-577. - Colonic diverticulosis and angiodysplasia can be differentiated readily at multidetector CT, which is of prognostic importance, because bleeding recurs in up to 85% of untreated patients with angiodysplasia, while only 25% of untreated diverticular patients experience recurrent bleeding.
High-Value Multidetector CT Angiography of the Superior Mesenteric Artery: What Emergency Medicine Physicians and Interventional Radiologists Need to Know.
Ghodasara N, Liddell R, Fishman EK, Johnson PT.
Radiographics. 2019 Mar-Apr;39(2):559-577. - “Neurofibromatosis type 1 (NF1) is one of the most fascinating and common human mendelian disorders, affecting approximately one in 3000 persons. From the initial artist renderings of patients with NF1 in the 15th century and the earliest medical reports in 18th century, to the complex molecular genetic studies of the late 20th century, physicians and lay persons alike have been fascinated with this disease because of its diverse manifestations and the unusual and bizarre physical appearances associated with the disease.”
Abdominal Neoplasms in Patients with Neurofibromatosis Type 1: Radiologic-Pathologic Correlation
Angela D. Levy et al.
RadioGraphics 2005; 25:455– 480 - “NF1 belongs to a group of disorders referred to as phakomatoses. These disorders (NF1, neurofibromatosis type 2, tuberous sclerosis, Sturge-Weber syndrome, and neurocutaneous melano- sis) have selective involvement of tissues of ectodermal origin (central nervous system, eye, and skin). All of these disorders, with the exception of Sturge-Weber syndrome, have an autosomal dominant inheritance pattern.”
Abdominal Neoplasms in Patients with Neurofibromatosis Type 1: Radiologic-Pathologic Correlation
Angela D. Levy et al.
RadioGraphics 2005; 25:455– 480
- What is Losartan?
Losartan is used to treat high blood pressure (hypertension) and to help protect the kidneys from damage due to diabetes. It is also used to lower the risk of strokes in patients with high blood pressure and an enlarged heart. Losartan belongs to a class of drugs called angiotensin receptor blockers (ARBs). It works by relaxing blood vessels so that blood can flow more easily. - Angiotensin Receptor Blockers: Complications
Angioedema is a clinical description of inflammation- mediated edema in the dermis or subcutaneous tissue owing to increased permeability across capillaries. This may involve the skin and respiratory and gastrointestinal tracts and generally resolves after 24 hours. - Angiotensin Receptor Blockers: Complications
The pathophysiology of angioedema may be allergic (type 1 hypersensitivity reaction) or kinin-induced (activation of endothelial cells by bradykinin via the B-2 receptor).1 ACE-I block bradykinin degradation leading to ACE-I–induced angioedema, which has been well-described. - Angiotensin Receptor Blockers: Complications
ARB-induced angioedema most commonly affects the lips, tongue, face, and upper airway. Intestinal involvement is not well-recognized. The incidence of ARB-induced angioedema is unknown and the risk of recurrent angioedema is underreported. In fact, losartan prescription information reported angioedema as a rare adverse event in the postmarketing experience. This mainly involved the larynx, glottis, pharynx, face, lips, and tongue, but not the intestine. ARBs would not be expected to alter bradykinin levels, but elevated levels in those receiving losartan have been reported. - Angiotensin Receptor Blockers: Complications
Intestinal ARB-induced angioedema is underrecognized by health care professionals. Raising awareness of this disease entity and having a high index of suspicion, especially in the setting of unexplained abdominal pain and use of ARB, is crucial to establish an early diagnosis. Elimination of the causative agent is a basic step in the management of such cases. - “Small bowel angioedema induced by angiotensin-converting enzyme (ACE) inhibitors is a rare clinicopathologic entity. It frequently poses a diagnostic challenge and is often not recognized before surgical exploration.”
Small Bowel Angioedema Secondary to Angiotensin-Converting Enzyme Inhibitors
Inayat F, Hurairah A
Cureus. 2016 Dec 8(12): e943 - “Angioedema is an infrequent adverse effect associated with the use of ACE inhibitors. Approximately 0.1-0.7% of patients taking ACE inhibitors develop angioedema, and it frequently affects the face, particularly the mucous membranes of the oropharynx, and upper airway. However, ACE inhibitor-induced small bowel angioedema is rare and its incidence is not well described . These patients usually present with nonspecific symptoms such as abdominal pain, nausea, vomiting, and diarrhea . On the radiologic assessment of the abdomen, free fluid is often present with small bowel edema.”
Small Bowel Angioedema Secondary to Angiotensin-Converting Enzyme Inhibitors
Inayat F, Hurairah A
Cureus. 2016 Dec 8(12): e943 - “ACE inhibitors are a leading cause of drug-induced angioedema in the United States, accounting for 20% to 40% of all the emergency department visits for angioedema annually . ACE inhibitor-associated angioedema frequently involves the lips, tongue, face, and upper airway with a well-known female predominance. However, intestinal angioedema secondary to ACE inhibitors is a rare clinical entity.”
Small Bowel Angioedema Secondary to Angiotensin-Converting Enzyme Inhibitors
Inayat F, Hurairah A
Cureus. 2016 Dec 8(12): e943 - The differentials of visceral angioedema include bowel wall ischemia, aortic rupture, vasculitis, trauma, malignancy, infections (viz. enteritis), peritonitis, appendicitis, and perforated viscus [5-6]. In patients with bowel wall ischemia, arterial or venous occlusion may be present, and such patients usually have a history of mesenteric insufficiency. Intramural hemorrhage may appear very similar to ACE inhibitor-induced visceral angioedema on contrast-enhanced computed tomography.
Small Bowel Angioedema Secondary to Angiotensin-Converting Enzyme Inhibitors
Inayat F, Hurairah A
Cureus. 2016 Dec 8(12): e943 - The management of patients with symptomatic small bowel angioedema from ACE inhibitors is mainly supportive. In a majority of the cases, symptoms usually resolve in 24-48 hours after discontinuation of the culprit medication. The efficacy of antihistamines and fresh frozen plasma needs to be evaluated with ACE inhibitor-induced intestinal angioedema in cases refractory to simply stopping the medication.
Small Bowel Angioedema Secondary to Angiotensin-Converting Enzyme Inhibitors
Inayat F, Hurairah A
Cureus. 2016 Dec 8(12): e943 - Small bowel angioedema is usually not life threatening. However, it is not uncommon for these patients to receive antibiotics or have a surgical exploration due to diagnostic confusion. In patients with bowel wall angioedema who undergo extensive surgical resection of the bowel, multiple morbidities are encountered, which can be entirely avoided by a timely and correct identification of ACE inhibitor-induced angioedema. Occasionally, the diagnosis is made after symptoms return following reinitiation of the ACE inhibitors after hospital discharge. Therefore, a high index of clinical suspicion should be maintained in patients on therapy with ACE inhibitors presenting with gastrointestinal symptoms.
Small Bowel Angioedema Secondary to Angiotensin-Converting Enzyme Inhibitors
Inayat F, Hurairah A
Cureus. 2016 Dec 8(12): e943 - “CT scan of the abdomen revealed markedly thickened antrum of the stomach, duodenum and jejunum, along with fluid in the abdominal and pelvic cavity. Angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema was suspected, and anti-hypertensive medications were discontinued. Her symptoms improved within the next 24 hours, and repeat CT after 72 hours revealed marked improvement in stomach and small bowel thickening and resolution of ascites. The recognition of angiotensin-converting enzyme (ACE) and angiotensin receptor blocker (ARB) intestinal angioedema constitutes a challenge to primary care physicians, internists, emergency room personal and surgeons.”
Angiotensin-converting enzyme (ACE) inhibitor-associated angioedema of the stomach and small intestine: a case report.
Shahzad G1, Korsten MA, Blatt C, Motwani P.
Mt Sinai J Med. 2006 Dec;73(8):1123-5. - “Angiotensin-converting enzyme (ACE) inhibitors are used for treatment of hypertension.These medications inhibit the breakdown of bradykinin. Bradykinin activates the nitric oxide system, leading to increased vascular permeability and capillary leakage. Edema of the face, oropharynx, lips, and tongue is a known side effect; however, visceral edema can also occur, either in addition to these sites or in isolation. ACE inhibitor–induced bowel angioedema most frequently affects middle-aged women and commonly manifests as abrupt-onset abdominal pain and nausea, with vomiting and sometimes diarrhea. Symptoms usually occur within the first 7 days of initiating or alter- ing ACE-inhibitor therapy, but onset has been reported as many as 10 years later.”
Imaging of Drug-induced Complications in the Gastrointestinal System.
McGettigan MJ1, Menias CO1, Gao ZJ1, Mellnick VM1, Hara AK1.
Radiographics. 2016 Jan-Feb;36(1):71-87 - “Angiotensin-converting enzyme (ACE) inhibitors are used for treatment of hypertension. These medications inhibit the breakdown of bradykinin. Bradykinin activates the nitric oxide system, leading to increased vascular permeability and capillary leakage. Edema of the face, oropharynx, lips, and tongue is a known side effect; however, visceral edema can also occur, either in addition to these sites or in isolation.”
Imaging of Drug-induced Complications in the Gastrointestinal System.
McGettigan MJ1, Menias CO1, Gao ZJ1, Mellnick VM1, Hara AK1.
Radiographics. 2016 Jan-Feb;36(1):71-87 - In the small bowel, the increased vascular permeability affects the vasa vasorum, causing bowel wall edema, bowel wall thickening, and straightening of the involved segment. At CT, there is decreased attenuation in the submucosal layer. This accentuates the higher attenuation of the mucosa and serosa, leading to mural stratification, which is even more pronounced at contrast-enhanced CT . At magnetic resonance (MR) imaging, T2-weighted images show increased signal intensity from edema in the submucosal layer of the involved bowel segment. The jejunum is the most frequent site of involvement. Ascites, mesenteric edema, and fluid retention in the small bowel lumen are frequent findings in patients who present with acute symptoms.
Imaging of Drug-induced Complications in the Gastrointestinal System.
McGettigan MJ1, Menias CO1, Gao ZJ1, Mellnick VM1, Hara AK1.
Radiographics. 2016 Jan-Feb;36(1):71-87 - “In the small bowel, the increased vascular permeability affects the vasa vasorum, causing bowel wall edema, bowel wall thickening, and straightening of the involved segment. At CT, there is decreased attenuation in the submucosal layer. This accentuates the higher attenuation of the mucosa and serosa, leading to mural stratification, which is even more pronounced at contrast-enhanced CT . The jejunum is the most frequent site of involvement. Ascites, mesenteric edema, and fluid retention in the small bowel lumen are frequent findings in patients who present with acute symptoms.”
Imaging of Drug-induced Complications in the Gastrointestinal System.
McGettigan MJ1, Menias CO1, Gao ZJ1, Mellnick VM1, Hara AK1.
Radiographics. 2016 Jan-Feb;36(1):71-87 - Segmental small bowel mural stratification can be seen with small-vessel vasculitis, small-vessel ischemia, chemotherapy-induced enteritis, and radiation therapy. ACE inhibitor–induced angioedema should be considered if these conditions are excluded and there is an appropriate clinical history. ACE inhibitor–induced angioedema rarely manifests as bowel obstruction, usually has only mild adjacent inflammatory fat stranding, and follows a nonvascular distribution. Furthermore, ACE inhibitor–induced angioedema is reversible with cessation of the medication.
Imaging of Drug-induced Complications in the Gastrointestinal System.
McGettigan MJ1, Menias CO1, Gao ZJ1, Mellnick VM1, Hara AK1.
Radiographics. 2016 Jan-Feb;36(1):71-87
- “Right lower quadrant pain is one of the most common indications for imaging evaluation of the abdomen in the emergency department setting. This article reviews important imaging findings associated with acute appendicitis as well as major differential considerations including: mesenteric adenitis, Meckel diverticulum, neutropenic colitis, right-sided diverticulitis, epiploic appendagitis, omental infarction, and inflammatory bowel diseaseRight lower quadrant pain is one of the most common indications for imaging evaluation of the abdomen in the emergency department setting. This article reviews important imaging findings associated with acute appendicitis as well as major differential considerations including: mesenteric adenitis, Meckel diverticulum, neutropenic colitis, right-sided diverticulitis, epiploic appendagitis, omental infarction, and inflammatory bowel disease.”
Evaluating the Patient with Right Lower Quadrant Pain. Patel NB, Wenzke DR. Radiol Clin North Am. 2015 Nov;53(6):1159-70
- “ Duodenal atresia, the most common congenital gastrointestinal obstruction, is caused by a failure of recanalization of the intestinal tract during the second month of fetal life. Infants with duodenal atresia present with bilious vomiting early in the neonatal period. The atretic segment is most often just beyond the ampulla of Vater. If the atresia is proximal to the ampulla of Vater, the vomiting is nonbilious. Atresia is complete in 40% to 60% of cases. It is commonly associated with prematurity (46%), maternal polyhydramnios (33%), Down syndrome (24%), annular pancreas (33%) and malrotation (28%).”
Imaging Spectrum of Non-neoplastic Duodenal Diseases Sitthipong S et al. Clinical Imaging (in press) - “Normal position of duodenojejunal flexure is to the left of the left-sided pedicles of the vertebral body at the level of the duodenal bulb on frontal views. The advantage of CT is to show not only intestinal malrotation (i.e., duodenojejunal flexure fails to cross the midline and locates below the level of the duodenal bulb), but also to detect other associated extra-intestinal imaging features, such as reverse location of superior mesenteric artery (SMA) and vein. This is a useful indicator; however, some patients will have normal vascular orientation.”
Imaging Spectrum of Non-neoplastic Duodenal Diseases Sitthipong S et al. Clinical Imaging (in press) - “Important complications are mid-gut volvulus and ischemic change from torsion of small bowel on shortened mesentery. However, normal anatomic variations that mimic malrotation may be encountered on frontal views, in particular on the upper GI series. Common variations include laxity of ligament of Treitz due to ageing process; displacement by splenomegaly, liver transplantation, and renal agenesis; and, inferior displacement of duodenojejunal flexure in premature infant due to relatively mobile ligament of Treitz by the adjacent distended stomach or bowel. False-negative findings due to misinterpretation of the duodenal course as indication of normal variation rather than malrotation have been reported.”
Imaging Spectrum of Non-neoplastic Duodenal Diseases Sitthipong S et al. Clinical Imaging (in press) - “Paraduodenal hernia is the most common type of internal hernia that can be classified as a congenital type and normal aperture subtype. It is characterized by a protrusion of small bowel into the retroperitoneal space through defects in the peritoneum near the third and fourth part of the duodenum. There are two types - right and left, with the latter observed in about 75% of cases. Both types manifest with nonspecific symptoms, such as postprandrial pain, vomiting, and bowel obstruction. Left paraduodenal hernia occurs when bowel protrudes through Landzert's fossa, which is located posterior to the fourth part of the duodenum.”
Imaging Spectrum of Non-neoplastic Duodenal Diseases Sitthipong S et al. Clinical Imaging (in press) - “Duodenal duplication cyst most frequently occurs at the medial wall of the second and third part of the duodenum. It typically appears as a well-circumscribed cystic lesion with fluid density that does not communicate with the duodenal lumen. Microscopically, it is a cyst that is lined with mucosa and that is surrounded by a muscular layer. Duodenal duplication cyst is a congenital malformation resulting from incomplete recanalization of the alimentary tract during early fetal life. Its discovery is mostly incidental; however, it may occasionally cause biliary obstruction, pancreatitis, or superimposed infection. In rare cases, carcinoma can occur within the duplication cysts.”
Imaging Spectrum of Non-neoplastic Duodenal Diseases Sitthipong S et al. Clinical Imaging (in press) - “The duodenum is the second most common site of diverticula after the colon, formed by pulsion of the mucosa and submucosa that herniate through the muscular defect. Duodenal diverticula often occur at the medial wall of the second part of duodenum, and they rarely become inflamed in contrast to diverticula occurring elsewhere in the bowel, due to their larger size and the regular flow of relatively sterile and liquid luminal contents. However, diverticulitis, perforation, or hemorrhage may be encountered. Biliary tract complication or so-called Lemmel syndrome, which is defined as obstructive jaundice caused by juxtapapillary or periampullary diverticulum, can occur if located within 2.5 cm of the ampulla of Vater.”
Imaging Spectrum of Non-neoplastic Duodenal Diseases Sitthipong S et al. Clinical Imaging (in press) - “By way of an important clinical consideration, difficulty may be encountered in cannulation of the bile duct during endoscopic retrograde cholangiopancreatography (ERCP) if the ampulla drains into the diverticulum. This condition is easy to diagnose if the diverticulum is full of air, but may be confused and misinterpreted as pancreatic cystic tumor or choledochal cyst if the lumen is completely filled with fluid. Continuity between duodenal lumen and diverticula is a helpful imaging feature.”
Imaging Spectrum of Non-neoplastic Duodenal Diseases Sitthipong S et al. Clinical Imaging (in press) - “Intraluminal duodenal diverticula (IDD) usually occur in the second or third part of the duodenum. IDD are formed by aberration of embryologic luminal recanalization and are comprised of diaphragm or web within the lumen of duodenum. An aperture allows movement of some food contents through the diaphragm, but duodenal peristalsis and intraluminal pressure lead to progressive ballooning of the diaphragm. The classic appearance on barium examination is windsock sign. The usefulness of CT to diagnose IDD has recently been reported. CT combined with post-processing software, such as curve planar reformation, can nicely depict the IDD and their attachment.”
Imaging Spectrum of Non-neoplastic Duodenal Diseases Sitthipong S et al. Clinical Imaging (in press) - “Duodenitis is defined as inflammation of duodenal mucosa with no discrete ulcer formation. This condition has both infectious and noninfectious causes. The most common infectious cause is Helicobacter pylori. Other potential infectious causes include mycobacterium tuberculosis and cryptosporidium. Cryptosporidium Duodenitis is exclusively seen in HIV patients. Two main noninfectious causes are alcohol and NSAIDs abuse.”
Imaging Spectrum of Non-neoplastic Duodenal Diseases Sitthipong S et al. Clinical Imaging (in press) - “Duodenal ulcer is normally caused by Helicobacter pylori infection, it occurs most frequently in the duodenal bulb, and it is more common than gastric ulcer. Classic features on barium examination include solitary or multiple pockets of barium filling the ulcer crater , edematous collar of mucosal swelling (in contrast to rolled edges of malignant ulcer), and radiating folds of mucosa at the edge of the ulcer. Complications include stricture, bleeding, and perforation. CT is the modality of choice in cases of perforated duodenal ulcer. Duodenal wall thickening, periduodenal fluid, and retroperitoneal air or free intraperitoneal air are the important imaging findings on CT in perforated duodenal ulcer.”
Imaging Spectrum of Non-neoplastic Duodenal Diseases Sitthipong S et al. Clinical Imaging (in press)
- “When there has been thrombosis of a major vein, such as the superior mesenteric vein, cross- sectional imaging generally shows a long segment of symmetric small bowel wall thickening with mucosal hyperenhancement and submucosal low attenuation caused by edema. There is often adjacent mesenteric fat edema as well as ascites. If intravenous contrast has been injected, thrombus in the vein will be identified. Depending on the de- gree of ischemia and infarction, there may be pneumatosis and/or portal venous gas.”
Acute Infectious and Inflammatory Enterocolitides Baker ME Radiol Clin N Am 53 (2015) 1255–1271 - “When a small bowel obstruction is caused by stenotic disease, there is often concomitant acute inflammation. In these cases, the bowel is dilated upstream from a short segment (<2–3 cm) of thick-walled, hyperenhancing bowel. The hyperenhancement may be striated or homo- geneous and there are dilated vasa recta. There may be other associated mesenteric changes of edema, fluid, and penetrating disease with either fistulae or an abscess.”
Acute Infectious and Inflammatory Enterocolitides Baker ME Radiol Clin N Am 53 (2015) 1255–1271 - “With adhesive disease without ischemia or a closed loop, the bowel wall at the transition point is normal. There is no wall thickening or hyperenhancement and the adjacent mesentery is normal as well. When there is ischemia or a closed loop obstruction, the affected segments are dilated up stream to the obstructions and there are variable degrees of wall thinning or thickening, mesenteric edema, and peritoneal fluid.”
Acute Infectious and Inflammatory Enterocolitides Baker ME Radiol Clin N Am 53 (2015) 1255–1271 - “In general, infections can affect both the small and large bowel. In the colon, most infections can cause a pancolitis. Right-sided disease tends to occur in Campylobacter, Salmonella, Yersinia, tuberculosis, and amebiasis. Left-sided disease tends to occur in schistosomiasis, shigellosis, herpes, gonorrhea, syphilis, and lymphogranuloma venereum. Cytomegalovirus (CMV) and Escherichia coli tend to be diffuse.”
Acute Infectious and Inflammatory Enterocolitides Baker ME Radiol Clin N Am 53 (2015) 1255–1271 - “Whipple disease is an infectious enteritis caused by a bacillus now called Tropheryma whipplei. The disease usually occurs in white men and commonly has extraintestinal manifestations, especially migratory arthritis. On small bowel imaging there are thickened, nodular folds. CT can show low-attenuation mesenteric and retroperitoneal lymph nodes much like those seen in Mycobacterium avium-intracellulare and unusually in lymphoma.”
Acute Infectious and Inflammatory Enterocolitides Baker ME Radiol Clin N Am 53 (2015) 1255–1271 - “Small bowel diverticulitis is an uncommon to rare entity similar in presentation to large bowel diverticulitis. The disease can occur in either the jejunum or ileum and presents with acute abdominal pain, localized tenderness, fever, and leukocytosis. CT shows focal small bowel wall thickening with adjacent soft tissue stranding in the mesenteric fat and sometimes a perienteric abscess.”
Acute Infectious and Inflammatory Enterocolitides Baker ME Radiol Clin N Am 53 (2015) 1255–1271
- "The small bowel feces sign is a CT manifestation of small bowel obstruction: particulate material mixed with gas bubbles in the small bowel, similar to the appearance of stool in the colon. This altered appearance presumably reflects stasis and resultant absorption of more fluid than normal in the small bowel. It usually occurs proximal to the site of obstruction, thus helpful in locating a transition point in some cases."
The small bowel feces sign
Scott Berl, Adrian Dawkins, David DiSantis
Abdom Radiol (2016) 41:794-795 - "The sign has a positive predictive value of 82% and has been reported in approximately 7-8% of cases of small bowel obstruction."
The small bowel feces sign
Scott Berl, Adrian Dawkins, David DiSantis
Abdom Radiol (2016) 41:794-795
- Chemotherapy Induced Enteritis: Facts
• can occur in 50-80% of patients depending on the chemotherapy regimen
• Imaging appearance and patients symptoms may vary on a case to case basis
• Small bowel most commonly involved especially ileum
• CT findings include "halo" and associated mesenteric involvement - Graft vs Host Disease: Small Bowel Findings
• mucosal injury mainly become manifest in the distal ileum and proximal colon
• CT findings may look similar to changes from chemotherapy or even ischemic enteritis
• CT appearance of "double halo" sign is common
• Inflammation of mesentery common
- “ACE inhibitor–induced bowel angioedema most frequently affects middle-aged women and commonly manifests as abrupt-onset abdominal pain and nausea, with vomiting and sometimes diarrhea. Symptoms usually occur within the first 7 days of initiating or altering ACE-inhibitor therapy, but onset has been reported as many as 10 years later .”
Imaging of Drug-induced Complications in the Gastrointestinal System McGettigan MJ et al. RadioGraphics 2016; 36:71–87 - “Angiotensin-converting enzyme (ACE) inhibitors are used for treatment of hy- pertension.These medications inhibit the breakdown of bradykinin. Bradykinin activates the nitric oxide system, leading to increased vas- cular permeability and capillary leakage. Edema of the face, oropharynx, lips, and tongue is a known side effect; however, visceral edema can also occur, either in addition to these sites or in isolation.”
Imaging of Drug-induced Complications in the Gastrointestinal System McGettigan MJ et al. RadioGraphics 2016; 36:71–87 - “In the small bowel, the increased vascular permeability affects the vasa vasorum, causing bowel wall edema, bowel wall thickening, and straightening of the involved segment. At CT, there is decreased attenuation in the submucosal layer.This accentuates the higher attenuation of the mucosa and serosa, leading to mural stratification, which is even more pronounced at contrast-enhanced CT.”
Imaging of Drug-induced Complications in the Gastrointestinal System McGettigan MJ et al. RadioGraphics 2016; 36:71–87
- “Important causes of enteritis in patients with HIV include Mycobacterium avium intracellulare (MAI), cytomegalovirus, and Crypto sporidium. MAI more frequently affects the jejunum, causing bowel wall thickening that can be nodular. The finding of low-density, bulky mesenteric and retroperitoneal lymphadenopathy is helpful in suggesting the diagnosis, although Whipple disease and lymphoma can have the same appearance.”
MDCT of the Small Bowel
Tye GA, Desser TS
Appl Radiol. 2012;41(8):6-17. - “MAI more frequently affects the jejunum, causing bowel wall thickening that can be nodular. The finding of low-density, bulky mesenteric and retroperitoneal lymphadenopathy is helpful in suggesting the diagnosis, although Whipple disease and lymphoma can have the same appearance.”
MDCT of the Small Bowel
Tye GA, Desser TS
Appl Radiol. 2012;41(8):6-17. - “Infectious enteritis affecting the distal ileum, often in combination with the cecum, can cause a confusing clinical picture, mimicking appendicitis. Frequent pathogens causing an infectious ileocecitis include Salmonella, Yersinia, Shigella, and Campylobacter.”
MDCT of the Small Bowel
Tye GA, Desser TS
Appl Radiol. 2012;41(8):6-17. - “Lymphoma is the third most common malignant neoplasm of the small bowel and may arise from mucosa-associated lymphoid tissue (MALT). A systemic lymphoma can also affect the small bowel. Lymphoma has a variety of appearances on CT, ranging from a short segment of symmetric bowel wall thickening to a solitary mass infiltrating the surrounding mucosa to multifocal enhancing mucosal nodules.Secondary obstruction is uncommon, although intussusception can be seen. Lymphoma most often affects the ileum.”
MDCT of the Small Bowel
Tye GA, Desser TS
Appl Radiol. 2012;41(8):6-17. - Small Bowel Infections
- Common cause of diarrheal illness in the US
- Vast majority are not imaged with CT
- Can be viral (norovirus, rotavirus), bacterial (Salmonella, E. coli, Clostridium perfringens, C. Dificile), or protozoal (cryptosporidum, microsporidum, etc.)
- Probably most common cause of SB thickening in day-to-day practice - Small Bowel Infections
- Imaging findings not specific
- Variable degree of wall thickening, hyperemia, mesenteric inflammation, ascites
- Bowel wall should still enhance normally
- Usually mucosal hyperemia, but CMV can cause mucosal hypoenhancement, mimicking ischemia - Small Bowel Infections
- Distribution can be suggestive of an organism
- Giardia lamblia tends to involve the proximal small bowel
- Tuberculosis, salmonella, Yersinia, Shigella, and campylobacter can involve the cecum and distal small bowel - Small Bowel Infections
- Infection should usually be on your differential diagnosis, particularly in patients with immunocompromise or HIV
- MAI, CMV, and cryptosporidum
- C. dificile enteritis is much more common that previously thought
- Consider in same patient population as C. dificile colitis
- Same disposition for fat-stranding, edema, ascites, etc.
- Small and Large Bowel Infections
- Common cause of diarrheal illness in the US
- Vast majority are not imaged with CT
- Can be viral (norovirus, rotavirus), bacterial (Salmonella, E. coli, Clostridium perfringens, C. Dificile), or protozoal (cryptosporidum, microsporidum, etc.)
- Probably most common cause of bowel wall thickening in day-to-day practice
- Severe infections with any organism can cause lower GI bleeding; certain organisms more likely - Small Bowel Infections
- Imaging findings not specific
- Variable degree of wall thickening, hyperemia, mesenteric inflammation, ascites
- Distribution can be suggestive of an organism
- Giardia lamblia tends to involve the proximal small bowel
- Tuberculosis, salmonella, Yersinia, Shigella, and campylobacter can involve the cecum and distal small bowel
- Infection should usually be on your differential diagnosis, particularly in patients with immunocompromise or HIV
- MAI, CMV, and cryptosporidum
- “ Imaging plays an important role in the early identification of such complications, which may allow more effective patient management. The aim of this article is to discuss and illustrate the wide spectrum of chemotherapy and radiotherapy induced complications in the abdomen and pelvis.”
Complications of oncologic therapy in the abdomen and pelvis: a review
Ganeshan DM et al.
Abdom Imaging (2013) 36:1-21 - GI Tract Complications: Chemotherapy
- Stomach- ulcers and gastritis
- Small bowel-enteritis with changes including ulceration, target sign, strictures
- Large bowel-pneumatosis (benign or malignant), necrosis, ischemia, neutropenic colitis, pseudomembranous colitis, perforation, typhlitis
- Complications of oncologic therapy in the abdomen and pelvis: a review
Ganeshan DM et al.
Abdom Imaging (2013) 36:1-21 - Typhlitis: Facts
- Triad includes fever, abdominal pain, and neutropenia
- Distension and diffuse circumferential thickening of the cecal wall
- Stranding in pericolonic fat around cecum
- Pneumatosis, perforation or pneumoperitoneum may also occur - GI Tract Complications: Radiation Therapy
- Stomach- ulcers and gastritis
- Small bowel- radiation enteritis which usually resolves 2-6 weeks post therapy
- Large bowel- radiation colitis
- Liver- fatty infiltration in geographic pattern
- Complications of oncologic therapy in the abdomen and pelvis: a review
Ganeshan DM et al.
Abdom Imaging (2013) 36:1-21
- Sclerosing Mesenteritis
- Complex inflammatory disorder of the mesentery
- Can be associated with other inflammatory disorders such as Retroperitoneal fibrosis, sclerosing cholangitis, Reidel thyroiditis, orbital pseudotumor
- Exact cause unknown
- Also known as retractile mesenteritis, systemic nodular panniculitis, liposclerotic mesenteritis and xanthogranulomatous mesenteritis - Sclerosing Mesenteritis
Clinical Presentation
- Pain, obstruction, ischemia, mass, diarrhea
- Elevated ESR
- CT can suggest diagnosis-but usually biopsy needed. - Sclerosing Mesenteritis
- CT Appearance Varies
- Subtle increased density in mesentery
- Solid mass
- Fibrosis and tethering of small bowel and mesenteric vessels
- “ The presence of hepatic venous gas has traditionally been associated with serious clinical disease and a mortality rate of up to 75%; the gas is most often portal venous in location and results from bowel necrosis.”
Hepatic Gas: Widening Spectrum of Causes Detected at CT and US in the Interventional Era
Shah PA et al.
RadioGraphics 2011; 31:1403-1413 - Hepatic Gas on CT: Differential Diagnosis
Iatrogenic Causes
- Bilary gas following sphincterotomy or choledochojejunostomy
- Hepatic artery embolization
- Percutaneous tumor ablation
- Colonoscopy
- Barium enema examination
- Liver biopsy
- Migration of hepatic venous gas (from spinal, or epidual catheter or lumbar puncture)
- Oxidized cellulose - Hepatic Gas on CT: Differential Diagnosis
Noniatrogenic Causes
- Mesenteric infarction
- Necrotizing enterocolitis
- Liver abscess
- Hepatic artery thrombosis in a liver transplant
- Inflammatory bowel disease
- Abdominal trauma
- Emphysematous cholecystitis
- Ascending cholangitis - Right Lower Quadrant Pain: Differential Diagnosis
- Crohn disease
- Infectious enterocolitis
- Neutropenic colitis (Typhlitis)
- Diverticulitis
- Ileal and Meckel Diverticulitis
- Adenocarcinoma or Lymphoma of the Ileum or Cecum
- Epiploic appendagitis
- Omental infarction
- Mesenteric adenitis - Right Lower Quadrant Pain: Differential Diagnosis: Part 2
- Endometriosis
- Ingestion of a foreign body
- Intussuception
- Cecal volvulus
- Ischemic colitis
- Referred pain from renal or ureteral pathology including stone disease and acute pyelonephritis - Abdominal Pain and the ER: Some Facts
- Abdominal pain is the most common cause for an ER visit overall, and second most common in patients over age 15 (chest pain is most common in this age group)
- Abdominal pain accounts for over 8,000,000 of the 119 million ER visits each year - “ Multidetector computed tomography (CT) has emerged as the modality of choice for evaluation of patients with severe acute traumatic and nontraumatic conditions causing right lower quadrant pain.”
Beyond Appendicitis: Common and Uncommon Gastrointestinal Causes of Right Lower Quadrant Pain at Multidetector CT
Purysko AS et al.
RadioGraphics 2011; 31:927-947 - Abdominal Pain and the ER: Some Facts
-Abdominal pain is the most common cause for an ER visit overall, and second most common in patients over age 15 (chest pain is most common in this age group)
-Abdominal pain accounts for over 8,000,000 of the 119 million ER visits each year - Right Lower Quadrant Pain: Differential Diagnosis
-Crohn disease
-Infectious enterocolitis
-Neutropenic colitis (Typhlitis)
-Diverticulitis
-Ileal and Meckel Diverticulitis
-Adenocarcinoma or Lymphoma of the Ileum or Cecum
-Epiploic appendagitis
-Omental infarction
-Mesenteric adenitis - Right Lower Quadrant Pain: Differential Diagnosis: Part 2
-Endometriosis
-Ingestion of a foreign body
-Intussuception
-Cecal volvulus
-Ischemic colitis
-Referred pain from renal or ureteral pathology including stone disease and acute pyelonephritis "In particular the combination of ascites, elevated CA-125 levels, and pelvic and peritoneal masses found in tuberculosis can be easily mistaken for coelomic spread of ovarian cancer."
Tuberculosis: A Benign Imposter
Tan CH et al.
AJR 2010; 194:555-561"Peritoneal involvement in tuberculosis is present in 5% of cases and is usually associated with widespread abdominal disease involving the lymph nodes or bowel."
Tuberculosis: A Benign Imposter
Tan CH et al.
AJR 2010; 194:555-561- Peritoneal Calcification: Causes
- Dialysis
- Prior peritonitis
- Ovarian cancer
- Tuberculosis
- Extravasated barium
- Post surgical heterotopic calcification - GVH-GI Manifestations
- Small bowel wall thickening
- Engorgement of the vasa recta
- Stranding of mesenteric fat
- Large bowel wall thickening
- Ascites
- Periportal edema
- Mucosal and serosal enhancement - "In patients without a small bowel stricture at barium study, more small bowel disease was found at CE when findings were retrospectively compared with barium exam and CT ;’findings."
Small Bowel:Preliminary Comparison of Capsule Endoscopy with Barium Study and CT
Hara AK et al.
Radiology 2004;230:260-265 - Abdominal Compartment Syndrome
- Potentially fatal condition due to pathologic elevation of intraabdominal pressure
- Round abdomen sign with distension
- CT findings include renal compression, bilateral inguinal hernias, compression of IVC by hemorrhage - "CT findings associated with high grade graft vs host disease are thickening of the distal esophagus, ileum, or ascending colon, as well as increasing numbers of thickened bowel wall segments."
CT Features with Pathologic Correlation of Acute GVH Disease After Bone Marrow Transplantation in Adults
Kalantari BN et al.
AJR 2003; 181:1621-1625 - Graft-Versus-Host Disease: Facts
- Occurs when functioning T lymphocytes are introduced into an immunocomprimised recipient
- Acute GVH occurs within the first 100 days of allogenic BMT’s
- Target organs: skin, GI tract, liver
- Clinical presentation: abdominal pain, fever, nausea, vomiting