Diffuse SmallBowel Disease

©  William Herring, MD, FACR

Normal Small Bowel

“Feathery-appearance” ofjejunum

Smoothappearanceof ileum

Submucosal Infiltration

What can infiltrate

Edema

Inflammatory exudate

Blood

Lymph tissue

Tumor

Two Patterns

Depends upon amount of submucosalinfiltration

Small amount = “stack-of-coins”

Little separation of the normal folds

Large amount = “picket fence”

Greater separation of normal folds

Stack-of-coins

Picket fence

Non-infiltrated (Stack-of-coins)

Dilatation

Infiltrated (Picket fence)

 +/- Dilated

Non-dilated

Dilution

No dilution

SprueSprue

SprueSprue

SclerodermaScleroderma

SclerodermaScleroderma

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

AmyloidAmyloid

EdemaEdema

IschemiaIschemia

HemorrhageHemorrhage

RadiationRadiation

LymphomaLymphoma

Non-infiltrated (Stack-of-coins)

Dilatation

Dilution

SprueSprue

SprueSprue

Sprue

3 diseases

Celiac Disease of Children

Nontropical sprue

Tropical Sprue

Celiac disease and Nontropical sprueimprove on gluten-free diet

Tropical sprue improves with antibioticsand folic acid

SprueX-ray Findings

Hallmark features are

Dilatation

Dilution, especially in jeunum

Segmentation

Masses of barium separated from adjacentclumps

Not commonly seen with newer bariummixtures

SprueX-ray Findings

Fragmentation

Exaggerated example of  irregular stipplingof residual barium in proximal bowel(normal)

Intussusception

Frequently seen

Usually not obstructive

SprueX-ray Findings

Increased risk of carcinoma andlymphoma

 Moulage sign

Caused by dilated loop with effaced foldslooking like tube into which wax has beenpoured

SprueDilatation + Dilution

SprueIntussusception

Moulage

Sprue

Non-infiltrated (Stack-of-coins)

Dilatation

Dilution

No dilution

SprueSprue

SprueSprue

SclerodermaScleroderma

SclerodermaScleroderma

Scleroderma

Affects

Esophagus

Small bowel

Colon

Spares stomach

 Atrophy of muscular layers andreplacement with fibrous tissue

 Associated with malabsorption

Whole small bowel is usually dilated

Close approximation of valvulae (hide-bound appearance)

Does not have increased secretions asdoes sprue

May be associated with pneumatosisintestinales

SclerodermaX-ray Findings

SclerodermaDilatation + “Hide bound” appearance

Scleroderma

Sprue

Scleroderma

Scleroderma

Non-infiltrated (Stack-of-coins)

Dilatation

Infiltrated (Picket fence)

 +/- Dilated

Dilution

No dilution

SprueSprue

SprueSprue

SclerodermaScleroderma

SclerodermaScleroderma

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

Whipple’s Disease

Very rare

Glycoprotein in lamina propia of smallbowel

Sudan-negative

PAS-positive

Gram-positive rods also present

Whipple’s Disease

Clinically

Arthralgia

Abdominal pain

Diarrhea

Weight loss

Treated with long term antibiotics-penicillin

 Hallmarks of the disease are

Nodules

Markedly thickened bowel wall (picket-fence)

 Small bowel may or may not be dilated

 Affects jejunum mostly

Whipple’s DiseaseX-ray Findings

Whipple’s Disease

Whipple’s Disease

Non-infiltrated (Stack-of-coins)

Dilatation

Infiltrated (Picket fence)

 +/- Dilated

Non-dilated

Dilution

No dilution

SprueSprue

SprueSprue

SclerodermaScleroderma

SclerodermaScleroderma

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

AmyloidAmyloid

Amyloidosis

Amyloidosis is rare

GI involvement is common

Associated with malabsorption

 Marked thickening of the valvulae(picket-fence)

 No dilatation or dilution

 Affects entire small bowel

AmyloidosisX-ray Findings

Amyloidosis

Amyloidosis

Non-infiltrated (Stack-of-coins)

Dilatation

Infiltrated (Picket fence)

 +/- Dilated

Non-dilated

Dilution

No dilution

SprueSprue

SprueSprue

SclerodermaScleroderma

SclerodermaScleroderma

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

AmyloidAmyloid

EdemaEdema

Hypoproteinemia

Hypoalbuminemia resulting from liveror kidney disease lower than 1.5 gramsper cent

Usually asymptomatic from intestinaledema itself

Changes are present throughout smallbowel

Loops are separated due to edema ofwalls

Folds are quite thick (picket-fence)

HypoproteinemiaX-ray Findings

Hypoproteinemia

Non-infiltrated (Stack-of-coins)

Dilatation

Infiltrated (Picket fence)

 +/- Dilated

Non-dilated

Dilution

No dilution

SprueSprue

SprueSprue

SclerodermaScleroderma

SclerodermaScleroderma

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

AmyloidAmyloid

EdemaEdema

IschemiaIschemia

Ischemic Bowel Disease

Thickening of the wall due to

 Edema

 Hemorrhage

Localized perforations can produce

 Air in bowel wall

 Air in portal venous system

Spasm and irritability early replaced byatonic bowel later

Lumen narrowed

Folds are thickened, sometimes producing“thumb-printing”

Healing may result in stricture formation

Ischemic Bowel DiseaseX-ray Findings

Ischemic Ileum

Non-infiltrated (Stack-of-coins)

Dilatation

Infiltrated (Picket fence)

 +/- Dilated

Non-dilated

Dilution

No dilution

SprueSprue

SprueSprue

SclerodermaScleroderma

SclerodermaScleroderma

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

AmyloidAmyloid

EdemaEdema

IschemiaIschemia

HemorrhageHemorrhage

Intramural Bleeding

Suggested if there is duodenal obstructionfollowing trauma

Localized lesions occur with trauma

Diffuse lesions seen with anticoagulants

 Uniform, regular, thickening of folds

 Separation of the loops

 Mass effect

 No spasm

Intramural BleedingX-ray Findings

Hemorrhage into wall

Intramural hematoma

Resolved in 3 weeks

Non-infiltrated (Stack-of-coins)

Dilatation

Infiltrated (Picket fence)

 +/- Dilated

Non-dilated

Dilution

No dilution

SprueSprue

SprueSprue

SclerodermaScleroderma

SclerodermaScleroderma

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

AmyloidAmyloid

EdemaEdema

IschemiaIschemia

HemorrhageHemorrhage

RadiationRadiation

Radiation Enteritis

Changes identical to ischemia

Radiation changes are actually 2° to arteritiswith occlusion of small vessels

Localized to area of radiation portal

Especially pelvis in female 2° endometrialcarcinoma treatment

Radiation Enteritis

Previous adhesions from surgery mayanchor small bowel in pelvic portal andpredispose to XRT changes

Mucosa is most sensitive to radiation

Localized thickening of the folds

2° edema and hemorrhage

May result in strictures later in course

Radiation EnteritisX-ray Findings

Radiation Enteritis

Radiation Enteritis

Non-infiltrated (Stack-of-coins)

Dilatation

Infiltrated (Picket fence)

 +/- Dilated

Non-dilated

Dilution

No dilution

SprueSprue

SprueSprue

SclerodermaScleroderma

SclerodermaScleroderma

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

Whipple’s Disease(nodularity)Whipple’s Disease(nodularity)

AmyloidAmyloid

EdemaEdema

IschemiaIschemia

HemorrhageHemorrhage

RadiationRadiation

LymphomaLymphoma

Lymphoma

Most commonly involves terminal ileum

Most commonly diffuse histiocytic type

Bowel wall becomes markedlythickened and submucosa infiltrated(picket-fence)

“Thumb-printing“ may be seen

Lymphoma

Loops are widely separated

May be mass effect

Single or multiple masses

Another form

Large confined ulceration with perforation

Produces “aneurysmal dilatation” of  bowel

Lymphosarcoma

Lymphosarcoma

“Aneurysmaldilatation” ofsmall bowel

Lymphosarcoma

Giardiasis

Giardia lamblia

Flagellated protozoan

Normal parasite of small bowel

Clinically

Diarrhea

Malabsorption

Treated with metronidazole (Flagyl)

Giardiasis

Some patients with Giardiasis haveassociated hypogammaglobulinemiaand nodular lymphoid hyperplasia

GiardiasisX-ray Findings

Usually limited to duodenum andjejunum

Thickening of folds

Marked spasm and irritability of bowel

Increased secretions common

Giardiasis

Take Home

Two patterns of infiltration

Remember the algorithm

Sprue features dilatation and dilution

Scleroderma has hide-bound appearance

Whipple’s features nodularity

Take Home

Radiation = hemorrhage = ischemia

Radiation occurs in a portal

Lymphoma may have aneurysmaldilatation

Most of these diseases look alike

End