C ridereau zins thickening of bowel wall jfim hanoi 2015

Thickening of the bowel wall: how to manage?

(small bowel and colon)

Catherine Ridereau-Zins University Hospital of ANGERS - FRANCE

Hanoï November 2015

Thickening of the bowel wall: how to manage ?

? In a clinical context of intestinal disease

? Fortuitously discovered

? a perfect radiological analysis of: bowel wall peri enteric fat peritoneal cavity (fluid, vessels, other organs)

? a knowledge of the main etiologies:

Tumors (benign, malignant) Infection Inflammatory (IIBD, diverticulitis, post radiation)

Vascular (venous ischemia, hematomas, vascularitis)

Theoretically easy, with…

Theoretically easy, with…

? Clinical data

? the use of other imaging techniques: � specific CT: CT enterography water enema CT � US � MRI

Final diagnosis will be done by endoscopy, histology and bacteriology.

Bowel wall: � 5 mm (no distension) ≈ 2 mm (digestive repletion) � homogeneous uptake after injection � no individualisation of the layers on CT

Normal

Radiological analysis

CT enterography

Water enema CT

Pseudo thickening if: � contraction � poor filling of the lumen

Radiological analysis Normal

CT enterography

Water enema CT

Perienteric fat: homogeneous

Abdominal cavity: no fluid no ADP

Digestive lumen: without repletion ≤ 2.5 cm (small bowel) or 6 cm (colon)

Normal



is based on: è EXTENSION è type of ENHANCEMENT

Thickened bowel wall

FOCAL SEGMENTAL or DIFFUSE

Tumors (except lymphoma)

Inflammatory Infectious Vascular

Lymphoma

Thickened wall EXTENSION


homogeneous

target appearance (submucosal oedema)

heterogeneous

Radiological analysis Thickened wall ENHANCEMENT

Thickening Uptake Location Perienteric fat Lumen Fluid ADP

66 year old man; abdominal pain; rectal bleeding

Water enema CT

Thickening Focal, circumferential Uptake heterogeneous Location colon Perienteric fat Non infiltrated Lumen narrowed Fluid - ADP +

Endoscopy (histology)

WHAT TO DO ?


ADENOCARCINOMA

Water enema CT


45 year old woman; abdominal pain

Thickening Focal: exoluminal growth Uptake +/ - heterogeneous Location Small bowel Perienteric fat clean Lumen narrowed Fluid - ADP -

WHAT TO DO ?

GIST

Pathology: immune markers (CKIT,DOG) mitotic index



56 year old man; abdominal pain; flushes

ENDOCRINE TUMOR

Thickening Focal, small size Uptake intense Location Small bowel Perienteric fat normal Lumen +/- narrowed Fluid - ADP Satellite + mesenteric retraction

WHAT TO DO ?

56 year old man; abdominal pain; flushes

Look at the liver (mets)

Somatostatin receptor scinti (assess resectability)



CT enterography

Thickening Focal; multiple exophytic tumors Uptake homogeneous Location Small bowel Perienteric fat normal Lumen +/- narrowed Fluid - ADP +

PEUTZ JEGHERS syndrome

WHAT TO DO ?


CT enterography

Look at the lips Hamartomas

Histology is necessary.

Endocrine tumor

Ectopic pancreas

Neurofibroma

GIST

Adenoma

SMALL BOWELL TUMORS

ADK

Rare; look similar !


20 year old man, renal transplantation abdominal mass on the follow up US

Thickening Segmental, regular Uptake homogeneous Location Small bowel Perienteric fat clean Lumen Dilated Fluid - ADP +++

LYMPHOMA

WHAT TO DO ?

Biopsy (pathology needed for chemotherapy)

20 year old man, renal transplantation abdominal mass on the follow up US


25 year old woman; abdominal pain; diarrhea

Thickening segmental Uptake target appearance Location Small bowel Perienteric fat comb sign Lumen stenosis Fluid - ADP +

Endoscopy Histology (giant cell granuloma)

Crohn’s disease

WHAT TO DO ?


MRI: mapping stenoses abces, fistula inflammatory activity (DW)

Crohn’s disease


WHAT TO DO ?

Thickening segmental Uptake target appearance Location Small bowel Perienteric fat comb sign Lumen stenosis Fluid - ADP +


64 year old man; abdominal pain; defense of left lower quadrant

WHAT TO DO ?

Thickening Segmental; diverticula Uptake homogeneous Location Left colon Perienteric fat infiltrated Lumen Narrowed (muscularis hypertrophy)

Fluid + ADP +/-

Diverticulitis

Look at the IMV

64 year old man; abdominal pain; defense of left lower quadrant


33 year old man; abdominal pain; diarrhea; fever

Antibiotics TT ?

Thickening Diffuse Uptake Target :“accordion sign” Location Colon Perienteric fat infiltrated Lumen +/ - narrowed Fluid ++ ADP +/-

33 year old man; abdominal pain; diarrhea; fever

Infectious colitis

WHAT TO DO ?

Endoscopy Coproculture

Pseudo membranous colitis (C. Difficile)


40 year old man, abdominal pain, rectal bleeding, defense of right lower quadrant

Thickening diffuse Uptake target Location R colon Perienteric fat infiltrated Lumen narrowed Fluid + ADP +


Infectious colitis ?

WHAT TO DO ?

No antibiotics TT Coloscopy 48 h before

Thickening diffuse Uptake target Location R colon Perienteric fat infiltrated Lumen collapsed Fluid + ADP +


Toxic colitis due to glutheraldehyde (endoscope cleaner)

WHAT TO DO ?

No antibiotics TT Coloscopy 48 h before

D7


35 year old man, abdominal pain, diarrhea

Bone Marrow Transplantation for leukemia

Thickeninf Diffuse Uptake target appearance Location All small bowel + colon Perienteric fat infiltrated Lumen collapsed Fluid ++ ADP ++

Clinical context?

35 year old man, abdominal pain, diarrhea

GVH ileocolitis


50 year old man; left lower quadrant abdominal pain

Thickening Diffuse Uptake Target Location Small bowell Perienteric fat infiltrated Lumen collapsed Fluid + ADP -

WHAT TO DO ?

Look at the vessels: portal vein thrombosis Pancretitis 2 M before

50 year old man; left lower quadrant abdominal pain

Venous ischaemia


70 year old man; malaise; rectal bleeding; abdominal pain

Thickening Diffuse Uptake Target appearance Location L colonic angle è recto-sigmoid Perienteric fat infiltrated Lumen dilated Fluid + ADP -

70 year old man; malaise; rectal bleeding; abdominal pain

WHAT TO DO ?

Look at the vessels

Arterial ischemia with reperfusion


78 year old man; abdominal pain; hematuria ; no fever

78 year old man; abdominal pain; hematuria ; no fever

WHAT TO DO ?

Thickening segmental Uptake target Location Small bowell Perienteric fat infiltrated Lumen collapsed Fluid + ADP -

anticoagulant treatment (atrial fibrillation)

Look well the non-injected CT: spontaneous hyperdensity

Mural hematomas

Ulcerative Colitis


WHAT TO DO ?

Thickening Diffuse, continuous Uptake homogeneous Location Rectum , sigmoid, left colon Perienteric fat Clean; hypertrophy mesorectum Lumen narrowed Fluid - ADP -

US: layers differentiation

Endoscopy (histology)


45 year old man, abdominal pain, defense of right lower quadrant

Leukemia: immuno-suppression; chemotherapy.

Thickening Segmental Uptake heterogeneous Location Caecum + late small bowel loop Perienteric fat infiltrated Lumen collapsed Fluid +++ ADP ++

Clinical context?

45 year old man, abdominal pain, defense of right lower quadrant

Typhlitis (neutropenic colitis)

KEY POINTS

✔ A perfect radiological analysis: focal / segmental or diffuse thickening enhancement

✔  Clinical context

Thickening of the bowell wall: how to manage ?

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C ridereau zins thickening of bowel wall jfim hanoi 2015

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