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Duodenal Abnormalities at MR Small-Bowel Follow-Through

¹ All authors: Department of Radiology, University College Hospital, Galway, Ireland.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —34-year-old man with nonspecific abdominal pain. Axial MRI small-bowel follow-through reveals abnormal anterior relationship of third part of duodenum relative to superior mesenteric vessels (white arrows, A). Compression and torsion of duodenum as it courses anteriorly results in beak sign (arrowhead, A). At same level, superior mesenteric vein passes posterior to superior mesenteric artery, creating "swirl sign" (black arrow, A). Further distally, duodenum courses posteriorly around mesenteric vessels, providing corkscrew appearance (white arrows, B and C). High cecum (curved black arrows, A–C) and terminal ileum (curved white arrow, B and C) are shown. These findings are typical of malrotation.

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —34-year-old man with nonspecific abdominal pain. Axial MRI small-bowel follow-through reveals abnormal anterior relationship of third part of duodenum relative to superior mesenteric vessels (white arrows, A). Compression and torsion of duodenum as it courses anteriorly results in beak sign (arrowhead, A). At same level, superior mesenteric vein passes posterior to superior mesenteric artery, creating "swirl sign" (black arrow, A). Further distally, duodenum courses posteriorly around mesenteric vessels, providing corkscrew appearance (white arrows, B and C). High cecum (curved black arrows, A–C) and terminal ileum (curved white arrow, B and C) are shown. These findings are typical of malrotation.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —34-year-old man with nonspecific abdominal pain. Axial MRI small-bowel follow-through reveals abnormal anterior relationship of third part of duodenum relative to superior mesenteric vessels (white arrows, A). Compression and torsion of duodenum as it courses anteriorly results in beak sign (arrowhead, A). At same level, superior mesenteric vein passes posterior to superior mesenteric artery, creating "swirl sign" (black arrow, A). Further distally, duodenum courses posteriorly around mesenteric vessels, providing corkscrew appearance (white arrows, B and C). High cecum (curved black arrows, A–C) and terminal ileum (curved white arrow, B and C) are shown. These findings are typical of malrotation.

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —62-year-old man with incidentally detected diverticulum. MRI small-bowel follow-through shows diverticulum arising from descending (second) duodenal segment (black arrows) and direct continuity with duodenal wall (white arrow, B) and lumen. Presence of wide neck facilitates inflow of ingested polyethylene glycol contrast material. Air–fluid level is seen on axial view (B).

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —62-year-old man with incidentally detected diverticulum. MRI small-bowel follow-through shows diverticulum arising from descending (second) duodenal segment (black arrows) and direct continuity with duodenal wall (white arrow, B) and lumen. Presence of wide neck facilitates inflow of ingested polyethylene glycol contrast material. Air–fluid level is seen on axial view (B).

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —67-year-old man with history of duodenal mobilization during recent abdominal aortic aneurysm repair (star). Abdominal CT (not shown) was initially performed for evaluation of sudden severe epigastric pain with intractable vomiting, and revealed gastric and proximal duodenal dilation in presence of a duodenal mass. Axial (A) and coronal (B) MRI small-bowel follow-through acquisitions, performed to characterize mass, show coiled-spring appearance of duodenal intussusception (straight white arrows). Duodenal wall is thickened (straight black arrow, A) with surrounding edema (curved white arrow, A) and fat stranding (curved black arrow, A). Duodenum is dilated proximal to intussusception, despite nasogastric decompression.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —67-year-old man with history of duodenal mobilization during recent abdominal aortic aneurysm repair (star). Abdominal CT (not shown) was initially performed for evaluation of sudden severe epigastric pain with intractable vomiting, and revealed gastric and proximal duodenal dilation in presence of a duodenal mass. Axial (A) and coronal (B) MRI small-bowel follow-through acquisitions, performed to characterize mass, show coiled-spring appearance of duodenal intussusception (straight white arrows). Duodenal wall is thickened (straight black arrow, A) with surrounding edema (curved white arrow, A) and fat stranding (curved black arrow, A). Duodenum is dilated proximal to intussusception, despite nasogastric decompression.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —Axial MRI small-bowel follow-through in 40-year-old woman with severe hypoproteinemia and peritoneal metastases of unknown primary. Images show diffuse duodenal and jejunal mural and mucosal fold thickening (straight white arrows), ascites (straight black arrows), peritoneal carcinomatosis (curved black arrows), and subcutaneous edema (curved white arrows).

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —Axial MRI small-bowel follow-through in 40-year-old woman with severe hypoproteinemia and peritoneal metastases of unknown primary. Images show diffuse duodenal and jejunal mural and mucosal fold thickening (straight white arrows), ascites (straight black arrows), peritoneal carcinomatosis (curved black arrows), and subcutaneous edema (curved white arrows).

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —50-year-old man with malnutrition and weight loss. Axial MRI small-bowel follow-through shows diffuse duodenal (white arrow) and jejunal (black arrow) dilation. Note increased distance between attenuated mucosal folds. Laparoscopic evaluation confirmed chronic small-bowel obstruction secondary to adhesions.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6 —34-year-old woman with known Crohn's disease who presented with nausea and vomiting. MRI small-bowel follow-through shows thickening (white arrows) and ulceration (curved black arrows) of third part of duodenum. Separation of small-bowel loops and increased mesenteric fat (straight black arrow) are visualized. Interposed segments of unaffected jejunum and ileum (i.e., skip lesions) are also seen.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7 —32-year-old man with malabsorption, steatorrhea, and weight loss, who was subsequently confirmed on mucosal biopsy to have celiac disease. Axial MRI small-bowel follow-through shows thickened duodenal folds (arrows) and loss of jejunal fold detail, consistent with celiac disease.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8 —70-year-old man with diet-resistant celiac disease. Duodenal and jejunal dilation (black arrows), mucosal fold attenuation (white arrowhead), and ulceration (white arrow) are readily appreciated on MRI small-bowel follow-through. Findings are consistent with ulcerative duodenitis and jejunitis due to celiac disease.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —60-year-old man with acute onset of severe epigastric pain. MRI small-bowel follow-through shows diffuse mural and fold thickening (black arrows), surrounding edema (straight white arrows), and fat stranding (curved white arrow, B), consistent with duodenitis.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —60-year-old man with acute onset of severe epigastric pain. MRI small-bowel follow-through shows diffuse mural and fold thickening (black arrows), surrounding edema (straight white arrows), and fat stranding (curved white arrow, B), consistent with duodenitis.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10 —70-year-old woman with nonspecific abdominal pain. Incidental duodenal polyp (arrow) is readily seen on coronal MRI small-bowel follow-through.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —79-year-old man with duodenal lipoma. MRI small-bowel follow-through shows incidentally detected intraluminal duodenal lipoma (arrows) of similar signal intensity to fat on steady-state free precession image (A) and with signal loss on fat-saturated sequence (B).

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —79-year-old man with duodenal lipoma. MRI small-bowel follow-through shows incidentally detected intraluminal duodenal lipoma (arrows) of similar signal intensity to fat on steady-state free precession image (A) and with signal loss on fat-saturated sequence (B).

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —40-year-old man with epigastric pain. MRI small-bowel follow-through shows large eccentric polypoid mass (straight black arrows) partly obstructing descending portion of duodenum (white arrows indicate proximal mild duodenal dilation), which was found at histology to be a leiomyoma. Ulcerated proximal border (curved black arrows) is well visualized.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —40-year-old man with epigastric pain. MRI small-bowel follow-through shows large eccentric polypoid mass (straight black arrows) partly obstructing descending portion of duodenum (white arrows indicate proximal mild duodenal dilation), which was found at histology to be a leiomyoma. Ulcerated proximal border (curved black arrows) is well visualized.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13 —55-year-old man with suspected gallbladder mass and upper abdominal discomfort. Polypoid periampullary lesion was incidentally detected (arrow) and subsequently confirmed at histology to be tubular adenoma.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14 —50-year-old man with weight loss and upper abdominal fullness. MRI small-bowel follow-through shows shouldered annular "apple core" duodenal mass (white arrow) that was later confirmed to be adenocarcinoma. Proximal duodenal luminal dilation (black arrow) results.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15A —Coronal MRI small-bowel follow-through images of 85-year-old woman with high-grade B-cell non-Hodgkin's lymphoma of duodenum. (Reprinted with permission from Lohan DG, Alhajeri AN, Cronin CG, Roche CJ, Murphy JM. MR enterography of small-bowel lymphoma: potential for suggestion of histologic subtype and the presence of underlying celiac disease. AJR 2008; 190:287–293 [14]) Duodenal mural thickening, aneurismal dilation (white arrows), and stranding of mesenteric fat planes (black arrow, A) were found at MRI small-bowel follow-through. Because of aneurysm dilation, lymphoma was thought to be more likely than adenocarcinoma.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15B —Coronal MRI small-bowel follow-through images of 85-year-old woman with high-grade B-cell non-Hodgkin's lymphoma of duodenum. (Reprinted with permission from Lohan DG, Alhajeri AN, Cronin CG, Roche CJ, Murphy JM. MR enterography of small-bowel lymphoma: potential for suggestion of histologic subtype and the presence of underlying celiac disease. AJR 2008; 190:287–293 [14]) Duodenal mural thickening, aneurismal dilation (white arrows), and stranding of mesenteric fat planes (black arrow, A) were found at MRI small-bowel follow-through. Because of aneurysm dilation, lymphoma was thought to be more likely than adenocarcinoma.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16A —35-year-old man with stage IV non-Hodgkin's lymphoma. Axial (A) and coronal (B) MRI small-bowel follow-through shows large mesenteric mass compressing duodenum posteroinferiorly. In duodenum, folds are thickened, nodular, and irregular because of lymphomatous involvement (arrows).

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16B —35-year-old man with stage IV non-Hodgkin's lymphoma. Axial (A) and coronal (B) MRI small-bowel follow-through shows large mesenteric mass compressing duodenum posteroinferiorly. In duodenum, folds are thickened, nodular, and irregular because of lymphomatous involvement (arrows).

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17 —Coronal MRI small-bowel follow-through true fast imaging with steady-state precession (true FISP) in 61-year-old man with carcinoid tumor. MR small-bowel follow-through shows irregular thickening of duodenal wall and folds (arrows) that were confirmed at histology to contain tumor.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18A —MRI small-bowel follow-through in 35-year-old man with biopsy-proven melanoma metastatic to small bowel. On axial (A) and coronal (B) images, eccentric mural soft-tissue mass (arrows) results in considerable luminal distention, having appearance typical of melanoma metastases.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18B —MRI small-bowel follow-through in 35-year-old man with biopsy-proven melanoma metastatic to small bowel. On axial (A) and coronal (B) images, eccentric mural soft-tissue mass (arrows) results in considerable luminal distention, having appearance typical of melanoma metastases.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 19A —57-year-old man with metastatic abdominal neuroendocrine tumor. Coronal (A) and axial (B) images from MRI small-bowel follow-through show large left upper quadrant metastases (black arrows, A). One of these metastases (white arrows) is invading posterior aspect of fourth part of duodenum.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 19B —57-year-old man with metastatic abdominal neuroendocrine tumor. Coronal (A) and axial (B) images from MRI small-bowel follow-through show large left upper quadrant metastases (black arrows, A). One of these metastases (white arrows) is invading posterior aspect of fourth part of duodenum.

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