LearningRadiology - Diffuse Small Bowel Disease

Diffuse Small Bowel Disease

Sprue

• 3 diseases: Celiac Disease of Children, Nontropical sprue and Tropical Sprue

• Celiac disease and Nontropical sprue improve on gluten-free diet

• Tropical sprue improves with antibiotics and folic acid

X-ray

• The hallmark features are: dilatation and dilution, especially in jejunum

• Segmentation of the barium column occurs because it moves more slowly through areas of excessive fluid and separates from the rest of the column-not commonly seen with newer barium mixtures

• Fragmentation is an exaggerated example of the irregular stippling of residual barium in the proximal bowel (which is normal)

• Intussusception is not uncommon but is usually not obstructive; sprue has increased risk of ca and lymphoma

• Moulage sign is caused by dilated loop with effaced folds looking like tube into which wax has been poured

Scleroderma

• Affects esophagus, small bowel and colon, sparing the stomach

• Atrophy of the muscular layers and replacement with fibrous tissue

• Associated with malabsorption

X-ray

• Whole small bowel is usually dilated with close approximation of the valvulae (hide-bound appearance) (stack-of-coins)

• Does not have increased secretions as does sprue

• May be associated with pneumatosis intestinales

Whipple’s Disease

• Glycoprotein in the lamina propia of the small bowel is Sudan-negative, PAS-positive

• Clinically: arthralgia, abdominal pain, diarrhea and weight loss

• Treated with long term antibiotics-penicillin

• Very rare

X-ray

• The hallmarks of the disease are nodules and a markedly thickened bowel wall (picket-fence)

• Small bowel may or may not be dilated

• Affects jejunum mostly

Amyloidosis

• GI involvement is common

• Associated with malabsorption

X-ray

• Marked thickening of the valvulae (picket-fence)

• No dilatation or dilution

• Affects entire small bowel

Hypoproteinemia

• Hypoalbuminemia resulting from liver or kidney disease lower than 1.5 grams per cent

• Usually asymptomatic from intestinal edema itself

X-ray

• Changes are present throughout small bowel

• Loops are separated due to edema of walls

• Folds are quite thick (picket-fence)

Giardiasis

• Giardia lamblia is a flagellated protozoan, a normal parasite of the small bowel

• Clinically: diarrhea and malabsorption

• Treated with metronidazole (Flagyl)

• Some patients have hypogammaglobulinemia and nodular lymphoid hyperplasia associated with giardiasis

X-ray

• Usually limited to duodenum and jejunum

• Thickening of the folds

• Marked spasm and irritability of the bowel

• Increased secretions is common

Ischemic Bowel Disease

• Thickening of the wall due to edema and hemorrhage

• Localized perforations can produce air in the bowel wall or in portal venous system

X-ray

• Spasm and irritability early is replaced by an atonic bowel later

• Lumen is narrowed

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

• Healing may result in stricture formation

Intramural Bleeding

• Suggested if there is duodenal obstruction following trauma

• Localized lesions occur with trauma

• Diffuse lesions are seen with anticoagulants

X-ray

• Uniform, regular, thickening of the folds

• Separation of the loops

• Mass effect

• No spasm

Radiation Enteritis

• Changes are identical to ischemia since radiation changes are actually secondary to an arteritis with occlusion of small vessels

• Localized to area of radiation portal, especially pelvis in female 2° endometrial carcinoma treatment

• Previous adhesions from surgery may anchor small bowel in pelvic portal and predispose to XRT changes

• Mucosa is most sensitive to radiation

X-ray

• Localized thickening of the folds 2° edema and hemorrhage

• May result in strictures later in course

Lymphoma

• Most commonly involves terminal ileum

• Bowel wall becomes markedly thickened and submucosa infiltrated (picket-fence)

• “Thumb-printing“ may be seen

• Loops are widely separated and there may be mass effect

• Another form may have a large ulceration which is confined and produces so called “aneurysmal dilatation” of the bowel

WH/93