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A Pattern Approach to the Abnormal Small Bowel: Observations at MDCT and CT Enterography

¹ All authors: Department of Radiology, Division of Abdominal Imaging, NYU Medical Center, 560 First Ave., Ste. HW 207, New York, NY 10016.

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —30-year-old woman with normal CT findings at enterography. Coronal reformatted image of small bowel using neutral oral and IV contrast agents shows normal small bowel (arrows). Note wall of small bowel is thin, measuring 1-2 mm, and shows uniform mural enhancement. Moreover, normal fold pattern of jejunum (many folds) is distinguished from that of ileum (few folds).

View larger version (169K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —60-year-old man with excellent small-bowel distention on CT using positive oral contrast material. Coronal reformatted image of small bowel shows normal small bowel. Note wall of small bowel (arrows) is barely perceptible.

View larger version (166K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —47-year-old man with ileal Crohn's disease. Axial CT image with positive intraluminal oral contrast material shows loop of thickened ileum (arrow). However, pattern of enhancement is obscured by contrast material.

View larger version (174K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —47-year-old man with ileal Crohn's disease. Axial CT image with neutral intraluminal oral contrast material shows same loop of ileum is thickened (arrow), but now pattern of enhancement is readily seen with mucosal hyperenhancement indicative of active Crohn's disease.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4 —35-year-old woman with target appearance in small bowel due to lupus vasculitis. Axial CT image in this patient with systemic lupus erythematosus shows marked mural thickening (> 1 cm) (long arrow) and target appearance after contrast administration. Note edematous changes in right kidney due to lupus nephritis (short arrow).

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —45-year-old woman with target appearance in small bowel due to acute radiation enteritis. Axial CT image in patient, who has cervical cancer and just finished 4-week course of radiation therapy. Note moderate mural thickening (5-10 mm) (arrow) and target appearance after contrast administration.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —45-year-old woman with target appearance in small bowel due to acute radiation enteritis. Coronal reformatted image shows segmental involvement of abnormal loop in pelvis (long arrow) and normal-appearing loop in abdomen (short arrow). Inflammatory process was localized to loops of small bowel in pelvis within radiation field; findings were attributed to acute radiation enteritis.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —80-year-old man with target appearance in small bowel due to superior mesenteric artery (SMA) embolus. Axial CT image in patient who has atrial fibrillation and abdominal pain shows mild to moderate mural thickening ( 5 mm) (long arrows) and target appearance diffusely throughout small bowel and ascending colon (short arrow).

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —80-year-old man with target appearance in small bowel due to superior mesenteric artery (SMA) embolus. Axial CT image shows filling defect (long arrow) in SMA and wedge-shaped perfusion defect (short arrow) in left kidney. Findings are consistent with intestinal ischemia due to embolus.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —80-year-old man with target appearance in small bowel due to superior mesenteric artery (SMA) embolus. Intraoperative image shows diffuse infarction of small bowel and cecum (arrows). Patient subsequently died.

View larger version (150K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —31-year-old man with segmental thickening of terminal ileum due to allergic angioedema. Axial CT image in patient with acute abdominal pain shows multiple loops of moderately thickened (6 mm) small bowel (arrows). Determining whether enhancement pattern shows target appearance is difficult due to positive intraluminal contrast material. However, subtle increase is seen in attenuation of serosal layer of small bowel.

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —31-year-old man with segmental thickening of terminal ileum due to allergic angioedema. Coronal reformatted image better shows segmental area (30 cm) of thickening of terminal and distal ileum (arrows). Pattern of thickening suggests a submucosal process. In light of submucosal appearance, differential diagnosis includes vasculitis, angioedema, and infection.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —31-year-old man with segmental thickening of terminal ileum due to allergic angioedema. Small-bowel series in same patient performed 24 hours later confirms submucosal disease with preservation of mucosa (arrow). Stool cultures were negative for pathogens, as were laboratory tests for vasculitis. Fecal material did show many Charcot-Leyden crystals, suggesting allergic edema. Patient improved over several days.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8 —76-year-old man with acute abdominal pain. Axial CT image shows marked thickening (11 mm) of short segment (15 cm) of ileum (arrows) and target appearance of wall. Patient was receiving warfarin with an international normalized ratio of 7. Findings are consistent with acute submucosal hemorrhage.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —79-year-old man with segmental thickening of jejunum due to lymphoma. Axial CT image in patient with abdominal pain shows moderate thickening (9 mm) of loop of jejunum (arrow) and adjacent abscess (arrowhead).

View larger version (180K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —79-year-old man with segmental thickening of jejunum due to lymphoma. Coronal reformatted CT image better shows segmental (15-cm) area of homogeneous thickening (long arrows). Note enlarged lymph node in adjacent mesentery (short arrow). Differential diagnosis includes Crohn's disease and lymphoma.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C —79-year-old man with segmental thickening of jejunum due to lymphoma. Surgical specimen reveals segmental primary small-bowel lymphoma (arrows).

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —76-year-old man with diminished enhancement of multiple loops of small bowel. Coronal reformatted CT image in patient with closed-loop small-bowel obstruction due to transmesenteric hernia shows cluster of small-bowel loops with diminished enhancement (short arrows) when compared with loops that are not in closed loop (long arrows).

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —76-year-old man with diminished enhancement of multiple loops of small bowel. Surgical resection shows infarcted small bowel (arrow).

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11 —49-year-old man with target appearance in segmental distribution due to acute Crohn's disease. Coronal reformatted CT image shows moderate mural thickening (5-10 mm) with target appearance in ulcerated segment of terminal ileum (long arrows). Additional findings supporting diagnosis of Crohn's disease include fibrofatty proliferation and prominent vasa recta (short arrow).

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —77-year-old man with focal thickening of jejunum due to diverticulitis. Coronal CT enterography image in patient with abdominal pain shows focal (2 cm) area of jejunal thickening centered on small out-pouching (arrow) with adjacent perienteric fat stranding. Note adjacent mesenteric abscess (arrowheads). Differential diagnosis includes foreign body perforation, perforated neoplasm, and diverticulitis.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —77-year-old man with focal thickening of jejunum due to diverticulitis. Coronal CT enterography image in same patient several centimeters caudal to A clearly shows a proximal jejunal diverticulum (arrow). Note normal small bowel (arrowheads). Surgery confirmed perforated diverticulitis (arrow).

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13 —62-year-old woman with diffuse small-bowel thickening due to encasement and obstruction of superior mesenteric vein (SMV) by neuroendocrine tumor. Coronal reformatted CT image shows encasement of SMV by neoplasm (arrowheads) and mild diffuse edema throughout small bowel (arrows).

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14 —50-year-old man with abdominal pain. Axial CT image shows short segment (15 cm) of marked (25 mm) mural thickening in distal ileum (arrows) with homogeneous enhancement. Small-bowel lymphoma was confirmed at surgery.

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15A —Differentiating mucosal from submucosal disease. Coronal reformatted image of terminal ileum in 27-year-old man with surgically proven perforated appendicitis shows moderate to marked thickening of terminal ileum (arrow). Mucosa is smooth, and at surgery secondary edema of terminal ileum was present due to perforated appendix and abscess (arrowhead).

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15B —Differentiating mucosal from submucosal disease. Coronal reformatted image of terminal ileum in 34-year-old man with endoscopically proven Crohn's disease shows moderated to marked thickening and irregularity of terminal ileum mucosa (arrow) consistent with multiple ulcerations. Note adjacent abscess (arrowhead).

View larger version (151K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16A —55-year-old woman with serosal disease due to carcinoid tumor. Coronal reformatted CT image shows tethering of multiple loops of small bowel (arrows) toward partially calcified mass in mesentery (arrowhead).

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16B —55-year-old woman with serosal disease due to carcinoid tumor. Spot compression view from small-bowel series shows tethering and spiculation of folds (arrows) along mesenteric surface of bowel. Carcinoid tumor was removed at surgery. Tumor incites desmoplastic reaction, resulting in appearance of small-bowel serosa.

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