SMALL BOWEL

Normal Small Bowel

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

Picket Fence

Sprue 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 Dilatationo 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

Non-infiltrated (Stack of Coins)

Dilatation

DilutionNo Dilution

SprueScleroderma

Infiltrated (Picket Fence)

+/- DilatedNon-dilated

Whipple’s Disease(nodularity)

AmyloidEdema

IschemiaHemorrhage

RadiationLymphoma

Increase risk of carcinoma and lymphoma Moulage sign

o caused by dilated loops with effaced foldso Looking like tube into which wax has been

poured

Dilatation + Dilution

Intusussception

Moulage Sign

Scleroderma Affects: esophagus, small bowel and colon

Atrophy of the muscular layer and replacement of fibrous tissue

Associated with malabsorption

X-Ray 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”

Scleroderma

Whipple’s Disease Very rare disease Glycoprotein in lamina propria of small bowel

o Sudan-negativeo PAS-negativeo Gram (+) rods are also present

Clinicallyo Abdominal pain, diarrhea, weight loss

Treated with long term antibiotics

X-ray Features Hallmarks

o Noduleso Picket fence(markedly thickened mucosal

wall) Small bowel may or may not be dilated Affects jejunum mostly

Amyloidosis RARe GI involvement is common Associated with malabsorption Radiologic features

o Picket fence – markedly thickening of the valvulae

o No dilation or dilutiono Affects the entire small bowel

Hypoproteinemia Resulting from liver or kidney disease Usually asymptomatic from intestinal edema X-ray findings

o Changes are present throughout the small bowel

o Loops are separated due to edema of wallso 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

Intramural Bleeding 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 protozoano 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