bowel wall thickening at ct
TRANSCRIPT
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Bowel wall thickening at CT: simplifying the diagnosis
Insights into ImagingApril 2014
Journal Club -July 2015Dr Priyanka VishwakarmaSenior Resident PDCC
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• simplified algorithm-based approach to the thickening of the small and large bowel wall detected on routine computed tomography (CT) of the abdomen
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What is Normal?
small bowel wall <3 mm despite luminal distentioncolonic wall can vary from 1 to 2 mm when the lumen
is well distended to 5 mm when the wall is contracted or the lumen is collapsed
The mucosa is the most intensely enhancing layer of the bowel wall and when enhanced may appear as a distinct layer.
submucosa is less vascularised and is seldom seen as a separate structure on CT scans unless it is oedematous, haemorrhagic or infiltrated by fat
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Narrow the differential diagnosis: 1. length of involvement, -benign VS malignantfocal < 5 cmsegmental 6-40 cmDiffuse > 40 cm2. degree of thickening, 3. symmetric versus asymmetric involvement, 4. pattern of attenuation 5. perienteric abnormalities
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Malignant tumours •stomach and colon
•proximal segments of bowel
•chronic onset
•greater than 3 cm in thickness
•mild pericolonic fat stranding
•Heterogeneous enhancement
•regional adenopathy and distant metastasesColon cancer
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Exceptions to asymmetric and hetrogenous thickening not due to malignat cause
1.Gastrointestinal tuberculosis
eccentric wall thickening or a mass-like lesion
Discontinous areas
Low attenuattion adenopathy
Luminal Narrowing
IC Valve involement
Peritonitis
Hepatosplenic dissemination
Thoracic TB
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2.Crohn’s
right colon and the terminal ileum
eccentric or asymmetric because of preferential involvement along the mesenteric border of the bowel wall
Skip areas
Transmural-fistulas and abcessesProliferation of fat along mesentric border
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Regular Symmetric focal thickening not benign
well-differentiated or small adenocarcinomas
focal extension
no significantperienteric fat stranding
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Perienteric abnormalities (fat stranding) disproportionately greater than the degree of bowel wall thickening
mainly four conditions: 1) diverticulitis, 2) epiploic appendagitis, 3) omental infarction and 4) appendicitis
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Engorgement of the mesenteric vessels (“centipede” sign)
presence of fluid at the base of the sigmoid mesentery (“comma sign”) are two indicative signs of the inflammatory process
Lack of lymph nodesHomogenous enhancement
Diverticulitis
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• Epiploic Appendagitis• fat-density lesion
corresponding to the inflamed appendix with surrounding inflammatory changes
• Characteristic location adjacent to colon
• The engorged or thrombosed vessel may be seen as a high-attenuation focus within the fatty lesion -central dot sign
• Mild reactive thickening of the colonic wall
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Centered in omentum
common on the right side of the omentum and may clinically simulate appendicitis or cholecystitis
inhomogeneous fatty mass
Reactive Colonic Thickening
Omental infarction
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Dilated fluid filled appendix
Diameter > 6mm
Retrocaecal Appendacitis
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Segmental/Diffuse Thickening
• extension of 6-40 cm or greater than 40 cm• Benign• Thickness < 10 mm
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exception -small bowel lymphoma
segmental distribution
circumferential symmetric thickening of the bowel wall
homogeneous low attenuation after intravenous contrast
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3 attenuation patterns after intravenous contrast administration
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Stratified pattern of attenuation
• two (double halo sign) or three (the target sign) concentric and symmetric layers of alternating densities
high-density layers correspond to the hyperemic mucosa and serosa, respectively, while the low-density layer presumably represents the oedematous submucosa
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1.Bowel Ischemia• degree of thickness and pattern of attenuation of the
ischaemic bowel vary according to three main factors: (1) pathogenesis of the ischaemia (arterial-occlusive, veno-
occlusive or hypoperfusion); (2) severity of the ischaemia (transient ischaemia of the mucosa
and/or submucosa versus transmural bowel wall necrosis); (3) superimposed haemorrhage or infection
• ischaemic bowel wall may also appear paper thin, particularly in cases of acute arterial occlusion
• Intestinal pneumatosis and gas in the mesenteric or portal veins are indicative of severe ischaemia and are usually associated with the thinning rather than thickening of the small bowel wall due to bowel wall necrosis
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Acute small bowel ischaemia.
diffuse thickening of the small bowel loops with a target app engorgement of the mesenteric root vessels
and ascites
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Bowel ischaemia secondary to vasculitis
mesenteric ischaemic changes occur in young patients
involve unusual sites such as the stomach, duodenumand rectum, and is
not confined to a single vascular territory.
systemic clinical manifestations
systemic lupus erythaematosus
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2.IBDCrohn’s
concentric wall thickening of small bowel loops with a stratified appearance indicating active disease
fistula
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3.Infectious/
Pseudomembranous
• The degree of bowel wall thickness in pseudomembranous and CMV colitis is usually greater
• pericolic fat stranding is often disproportionately mild
• haustral folds are significantly thickened and protrude into the bowel lumen, they can trap the positive oral contrast material, an appearance known as the “accordion sign”
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Clinical history is imp in specific entities such as-
• graft-versus-host disease in patients submitted to allogeneic bone marrow transplantation,
• acute radiation enteritis or colitis in patients submitted to radiation therapy,
• bowel wall oedema in patients with a history of angioedema, and
• oedema of the right colon in cirrhotic patients
• Other causes-• Infilteration of submucosa by tumor or fat-linitus plastica• Fat in submucosa in chronic inflammatory pathologies
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White pattern of attenuation• intense enhancement of the bowel wall >/= venous vessels
Ischaemia –1. hyperaemia (i.e. mesenteric venous occlusion with outflow
obstruction)2. hyperperfusion (i.e. reperfusion after occlusive or nonocclusive
ischaemia) of the bowel wall and is a good prognostic factor, indicating viability
3. “shock bowel”-increased vascular permeability of the bowel wall
Inflammatory bowel disease
intramural haemorrhage in patients with bowel ischaemia, bleeding diathesis or undergoing anticoagulation therapy – check Non Contrast sections
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Shock bowel in a patient with significant
haemorrhage due to bleeding
oesophageal varices
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Crohn’s disease
homogeneous hyperenhancement (arrows) of a thickened and stenotic ileal loop indicating active disease
proximal dilatation of the small bowel loops (asterisk) due to the obstruction
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Grey pattern of attenuation
• diminished enhancement of the bowel wall = muscle
• least specific + clinical• Acute onset• mesenteric venous occlusion • bowel obstruction, where the bowel oedema
is more pronounced due to venous congestion • ischaemic colitis, a common cause of
abdominal pain in the elderly
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Ischemic colitispartial occlusion of the superior mesenteric artery
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Key Points• Thickening of the bowel wall may be focal (<5 cm) and
segmental (6-40cm)or diffuse ( >40 cm) in extension.• • Focal, irregular and asymmetrical thickening of the bowel
wall suggests a malignancy.• • Perienteric fat stranding disproportionally more severe than
the degree of wall thickening suggests an inflammatory condition.
• • Regular, symmetric and homogeneous wall thickening is more frequently due to benign conditions, but can also be caused by neoplasms such as well-differentiated adenocarcinoma and lymphoma.
• • Segmental or diffuse bowel wall thickening is usually caused by ischaemic, inflammatory or infectious conditions and the attenuation pattern is helpful in narrowing the differential diagnosis.
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Thanks !
Reference:Fernandes T, Oliveira MI, Castro R, et al. (2014)
Bowel wall thickening at CT: simplifying the diagnosis. Insights Imaging 5(2):195–208