Small Bowel

SMALL BOWEL Normal Small Bowel

Non-infiltrated (Stack of Coins)

Dilatation

Submucosal Infiltration • Edema • Inflammatory exudates • Blood • Lymph tissue • Tumor Two patterns • depends upon the amount of submucosal infiltration o small amount = “stack of coins”  little separation of the normal folds o large amount = “picket fence”  greater separation of the normal folds Stack of Coins

Dilution

No Dilution

Sprue

Scleroderma

Infiltrated (Picket Fence) +/- Dilated

Whipple’s Disease (nodularity)

Non-dilated

Amyloid Edema Ischemia Hemorrhage Radiation Lymphoma

Sprue

• • •

Picket Fence

Celiac disease of the children Non-tropical sprue o Improve on gluten free diet Tropical sprue o Improves with antibiotic and folic acid

X-ray Findings • Hallmark features o Dilatation o Dilution- jejunum

• •

Segmentation – masses of barium separated from the adjacent clumps Fragmentation – exaggerated example of irregular stippling of residual barium in the proximal bowel

X-ray Features • Intusussception • Increase risk of carcinoma and lymphoma • Moulage sign o caused by dilated loops with effaced folds o Looking like tube into which wax has been poured

Scleroderma • • • X-Ray • • • • •

Dilatation + Dilution

Affects: esophagus, small bowel and colon Atrophy of the muscular layer and replacement of fibrous tissue Associated with malabsorption features Entire small bowel is usually dilated “hide-bound appearance” Close approximation of the valvulae Does not have increase secretions May be associated with pneumatosis intestinalis

“Hide-Bound appearance”

Intusussception

Scleroderma

Moulage Sign

Whipple’s Disease • •

•

Very rare disease Glycoprotein in lamina propria of small bowel o Sudan-negative o PAS-negative o Gram (+) rods are also present Clinically

o Abdominal pain, diarrhea, weight •

•

loss Treated with long term antibiotics

X-ray Features • Hallmarks o Nodules o Picket fence(markedly thickened mucosal wall) • Small bowel may or may not be dilated • Affects jejunum mostly

X-ray findings o Changes are present throughout the small bowel o Loops are separated due to edema of walls o Folds are quite thick (picket fence)

Ishemic Bowel Disease • •

Thickening of the wall due to edema and hemorrhage Localized perforation can produce: air in bowel wall and air in portal venous system.

X-ray Findings • Spasm and irritability • Narrowed lumen

• •

Thickened folds – “thumb printing” Healing may result in stricture formation

Ischemic Bowel Disease Amyloidosis • • • •

RARe GI involvement is common Associated with malabsorption Radiologic features o Picket fence – markedly thickening of the valvulae o No dilation or dilution o Affects the entire small bowel

Intramural Bleeding

• • •

Hypoproteinemia • •

Resulting from liver or kidney disease Usually asymptomatic from intestinal edema

Suggestive if there is a duodenal obstruction secondary to trauma Localized lesion occur with trauma Diffuse lesion seen with anticoagulants

Radiation Enteritis •

Mucosa is most sensitive to radiation

• •

Changes similar to ischemia

•

•

Radiation changes are actually secondary to arteritis with occlusion of small bowels Localized to the area of radiation portal Especially in the pelvis of female e patients with endometrial carcinoma

Lymphoma •

Most commonly involve the terminal ileum

•

Bowel mall is markedly thickened and mucosa is infiltrated (picket fence) “thumb-printing” may be seen Loops are widely separated Single or multiple mass –producing mass effect are confined ulceration with perforation Produces “aneurismal dilatation” of bowel

• • •

• •

Aneurysmal Dilatation of Bowel

Giardiasis • •

Giardia lamblia o Flagellated protozoan o Small bowel Signs and symptoms: o Diarrhea o Malabsorption

X-ray Findings • Usually limited to the duodenum and jejunum • Thickened folds • Marked spasm and irritability • Increase secretions