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Everything you need to know about Computed Tomography (CT) & CT Scanning

Small Bowel: Inflammatory Disease Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Small Bowel ❯ Inflammatory Disease

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  • “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
© 1999-2019 Elliot K. Fishman, MD, FACR. All rights reserved.