Macari et al.

Gastrointestinal Imaging • Review

MDCT and CT
Enterography of the Small
Bowel

A Pattern Approach to the

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Abnormal Small Bowel:

Observations at MDCT and
CT Enterography
Michael Macari1 OBJECTIVE. Imaging of the vast array of pathologic processes occurring in the small
Alec J. Megibow bowel has been facilitated by recent advances, including the use of MDCT scanners that acquire
Emil J. Balthazar isotropic data and neutral oral contrast agents that improve small-bowel distention.
CONCLUSION. This review shows how a systematic pattern approach can be used to
Macari M, Megibow AJ, Balthazar EJ narrow the differential diagnosis when an abnormal small-bowel loop is detected on MDCT.

maging of pathologic processes identified in the small bowel at MDCT and

I occurring in the small bowel has

traditionally been performed with
barium small-bowel follow-through
CT enterography.

Keywords: CT, CT technique, inflammatory bowel disease,
small bowel
DOI:10.2214/AJR.06.0712
Received May 27, 2006; accepted after revision
October 11, 2006.
M. Macari and A. J. Megibow are consultants to E-Z-EM.
1All authors:
Department of Radiology, Division of
Abdominal Imaging, NYU Medical Center, 560 First Ave.,
Ste. HW 207, New York, NY 10016. Address
correspondence to M. Macari
(michael.macari@med.nyu.edu).
AJR 2007; 188:1344–1355
0361–803X/07/1885–1344
© American Roentgen Ray Society
examinations, single- or double-contrast intu-
bated enteroclysis, and CT [1]. Recent inno-
vations, including capsule endoscopy and
MRI, have emerged as alternative small-
bowel imaging techniques that can be per-
formed without ionizing radiation [2, 3].
Technical advances have improved the imag-
ing evaluation of the small bowel using CT [4,
5]. These advances include the use of MDCT
scanners that acquire isotropic data, oral con-
trast agents, and administration techniques that
improve small-bowel distention. These ad-
vances, coupled with imaging workstations that
allow multiplanar and 3D evaluation of these
isotropic data sets, have allowed improved de-
piction and characterization of small-bowel pa-
thology. The use of MDCT, neutral (attenuation
values between 10–30 H) oral contrast agents to
distend the small bowel, and multiplanar thin-
section data evaluation has come to be known as
CT enterography (Fig. 1).
Current indications for performing CT en-
terography include the evaluation of obscure
gastrointestinal bleeding, the presence and
activity of Crohn’s disease, and suspected
small-bowel neoplasia. Moreover, a vast ar-
ray of pathologic processes occurring in the
small bowel will be detected incidentally at
MDCT in patients with abdominal pain. The
differential diagnosis for these processes is
broad and can be confusing. The purpose of
this article is to show how a systematic pattern
approach can be used to narrow the differen-
tial diagnosis when an abnormal process is
Technique
Confident detection and optimal evaluation
of an abnormal segment or loop of small bowel
is achieved when the small bowel is well dis-
tended, IV contrast has been administered, and
thin-section (≤ 1-mm) CT is used. Tradition-
ally, positive contrast materials such as dilute
barium or water-soluble iodinated solutions
have been used to mark and sometimes distend
the small bowel at CT [1, 5]. These contrast
agents work well in delineating the small
bowel, the degree of distention being propor-
tionate to the amount of contrast material con-
sumed, the rate at which it is consumed, and
the time delay of the examination itself. When
the small bowel is distended with positive con-
trast material, wall thickness ranges from im-
perceptible to no greater than 2 mm [1]
(Fig. 2). However, unless care is taken in ad-
ministering these agents, any portion of the
bowel may be either underdistended or even
unfilled with contrast material, leading to a
possible false-positive diagnosis. In general,
adequate luminal distention is present if the di-
ameter of the small bowel is ≥ 2 cm.
When the small bowel is distended with
positive contrast material, the wall is thin and
may be imperceptible but should not measure
more that 1–2 mm [1]. Dilute barium and io-
dinated positive oral contrast agents are par-
ticularly well suited in evaluating thin pa-
tients without a lot of intraperitoneal adipose
tissues and in oncology patients, in whom im-
plants and lymph nodes will stand out from
the small bowel. A potential limitation of pos-

1344 AJR:188, May 2007

 MDCT and CT Enterography of the Small Bowel
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Fig. 1—30-year-old woman with normal CT findings at enterography. Coronal
reformatted image of small bowel using neutral oral and IV contrast agents shows
normal small bowel (arrows). Note wall of small bowel is thin, measuring 1–2 mm, and
shows uniform mural enhancement. Moreover, normal fold pattern of jejunum (many
folds) is distinguished from that of ileum (few folds).
Fig. 2—60-year-old man with excellent small-bowel distention on CT using positive
oral contrast material. Coronal reformatted image of small bowel shows normal small
bowel. Note wall of small bowel (arrows) is barely perceptible.

itive oral contrast agents in the evaluation of
the small bowel is that mucosal enhancement
may be obscured by the luminal contrast ma-
terial, and thus the pattern of enhancement,
which serves as a primary aid in the differen-
tial diagnosis of an abnormal small-bowel
segment, may be impaired (Fig. 3).
Neutral oral contrast agents allow full visu-
alization of the normal intestinal wall, thereby
allowing analysis of the degree and pattern of
small-bowel enhancement [5–12]. “Neutral
contrast” refers to agents that have an attenua-
tion value similar to that of water (10–30 H).
For neutral contrast agents to be effective, they
must be used with IV contrast material and the
small-bowel distention must be optimal.
Several neutral contrast agents have been
evaluated for small-bowel distention, includ-
ing water, water in combination with a bulk-
ing agent such as methylcellulose or locust
bean gum, polyethylene glycol solutions, and
a commercially available low-density barium
solution (VoLumen [low-Hounsfield-value
barium sulfate], E-Z-EM) [5, 6]. A limitation
of using water is that it is rapidly absorbed
across the small-intestinal mucosa, resulting
in suboptimal small-bowel distention. VoLu-
men and polyethylene glycol solutions are
less rapidly absorbed; studies have shown that
they are superior to both water and methylcel-
lulose in achieving small-bowel distention
[5–7, 12]. The initial studies evaluating the
potential use of CT enterography were per-
formed with positive oral contrast agents [8].
However, since that time, CT enterography in
most reports has been performed with a neu-
tral oral contrast agent [5–7, 9–12].
Peroral CT enterography differs from CT
enteroclysis in that the latter technique is per-
formed after placement of a nasojejunal tube
in conjunction with active small-bowel dis-
tention. CT enterography performed with
VoLumen is inferior to CT enteroclysis in
achieving small-bowel distention [9]. How-
ever, the noninvasive nature and speed of CT
enterography make it well suited as a first-line
technique for the evaluation of suspected
small-bowel disease [4, 5, 12].
Our specific protocol for performing CT
enterography requires that the patient fast for
at least 3 hours before the examination. This
will decrease the possibility of misinterpret-
ing a foreign body as a polyp or tumor. On ar-
rival at the imaging center, patients ingest two
450-mL bottles of VoLumen over a 30-minute
period. The first bottle is ingested 30 minutes
before the procedure, the second 20 minutes
before the procedure. Immediately before
changing for the examination, the patient con-
sumes 225 mL of water, and finally, on enter-
ing the scanning room, the patient drinks a fi-
nal 225 mL of water. The total volume of fluid
is therefore 1,350 mL. Water is adequate for
the final contrast agent because it is designed
primarily to distend the stomach and duode-
num. Other imaging centers deliver a similar
volume of contrast material over a 1-hour pe-
riod (450 mL 60 minutes and 40 minutes be-
fore scanning and 225 mL 20 and 10 minutes
before scanning) [12].
The optimal timing of the administration of
oral contrast material will continue to be in-
vestigated. It is likely easier for the patient to
ingest the oral volume over a longer period of
time. However, if ingested over too long a pe-
riod, the contrast material may be in the co-
lon. Whether the contrast material is adminis-
tered over 30 or 60 minutes, if insufficient
volume is ingested, suboptimal small-bowel
distention will limit the CT enterography ex-
amination. Therefore, the importance of the
oral contrast agent must be explained to the
patient. This is facilitated by having the CT
technologist or nurse instruct and monitor pa-
tients as they are ingesting the oral contrast
material. If patients are left on their own, sub-
optimal distention may result.

AJR:188, May 2007 1345


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Fig. 3—47-year-old man with ileal Crohn’s disease.
A, Axial CT image with positive intraluminal oral contrast material shows loop of thickened ileum (arrow). However, pattern of enhancement is obscured by contrast material.
B, Axial CT image with neutral intraluminal oral contrast material shows same loop of ileum is thickened (arrow), but now pattern of enhancement is readily seen with mucosal
hyperenhancement indicative of active Crohn’s disease.
IV contrast enhancement is essential when
performing CT enterography. A 20-gauge
catheter is inserted into an arm vein, and 1.5
mL/kg of iodinated contrast material (Ul-
travist, 300 mg I/mL, [iopromide], Berlex
Laboratories) is injected at a rate of at least 4
mL/s. Without IV contrast material, the bowel
wall is not seen and intestinal marking is com-
promised. If there is a possibility of compro-
mised venous access or the patient cannot re-
ceive IV contrast material, we perform the
study with a positive contrast agent.
The optimal timing of data acquisition for
CT enterography is somewhat controversial.
We begin the acquisition 60 seconds after the
initiation of the bolus. Others have suggested
that an enterography phase (≈ 45 seconds af-
ter the injection), or even a dual-phase acqui-
sition, may be helpful in patients with obscure
gastrointestinal bleeding [10–12]. Glucagon
in a dose of 0.1 mg is administered IV and
given a few minutes before data acquisition to
diminish peristalsis.
MDCT enterography should be performed
on a 16-MDCT or higher scanner. These
scanners can acquire the submillimeter iso-
tropic data necessary for 3D displays in a
short enough time to minimize motion arti-
1346
Macari et al.
A B
facts. At our institution, we use either a
16 × 0.75 mm or 64 × 0.6 mm detector con-
figuration, depending on whether a 16- or 64-
MDCT scanner is used, reconstructing either
1- or 0.8-mm slices. From this data set, the
technologist will generate a set of axial 4-mm
sections and a set of 3-mm-thick coronal mul-
tiplanar reformatted images at 3-mm intervals
encompassing the entire bowel. These are
sent to the PACS for review.
In addition, the thin slices are sent to a
workstation, where they are available for the
radiologist to view the data in 3D volume-
rendering or maximum-intensity-projection
displays [12, 13]. Images are acquired at 120
kVp, 0.4-second gantry rotation, and 180 ef-
fective mAs. A dose modulator, available on
all MDCT scanners, which automatically
decreases the radiation exposure to thinner
areas of the patient, is used and can reduce
the dose up to 30%.
A Pattern Approach to the
Abnormal Small Bowel at MDCT
An abnormal small-bowel loop is present
when the wall thickness is ≥ 3 mm despite ad-
equate luminal distention [1]. When an abnor-
mal small-bowel loop is recognized, a pattern
approach can be used to narrow the differen-
tial diagnosis [1]. Seven criteria can be used
to aid in the evaluation of the abnormal small
bowel on contrast-enhanced MDCT, includ-
ing the pattern of enhancement, the length of
involvement, the degree of thickening,
whether the thickening is symmetric or asym-
metric, location of the lesion along the course
of the small bowel (proximal or distal), loca-
tion of the lesion in the wall of the small
bowel (mucosal, submucosal, or serosal),
and, finally, associated abnormalities in the
mesentery and vessels.
Mural Enhancement Pattern
The first criterion that should be assessed
when evaluating an abnormal loop of small
bowel is the mural enhancement pattern. Four
patterns may be present during contrast-en-
hanced CT. These include a double-halo or
target appearance, referred to as mural strati-
fication; homogeneous or hyperenhance-
ment; heterogeneous enhancement; and de-
creased or absent enhancement.
Target Appearance
If the abnormal segment of small bowel
displays a target appearance, a benign process
AJR:188, May 2007
 MDCT and CT Enterography of the Small Bowel

Fig. 4—35-year-old is present in the wall [14]. The target sign

woman with target results from mucosal and serosal enhance-
appearance in small
bowel due to lupus ment surrounding a prominent low-attenua-
vasculitis. Axial CT image tion submucosa (Fig. 4). Visualization of a
in this patient with target appearance is facilitated by having neu-
systemic lupus
erythematosus shows
tral contrast material in the small-bowel lu-
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marked mural thickening men (Fig. 3). The neutral contrast agent al-
(> 1 cm) (long arrow) and lows better depiction of the inner aspect of the
target appearance after wall of the small bowel. The target sign was
contrast administration.
Note edematous first described as a specific sign for Crohn’s
changes in right kidney disease [15], but it is now recognized that any
due to lupus nephritis nonneoplastic condition may lead to a target
(short arrow).
appearance in the small bowel. Common
causes include Crohn’s disease, infection, is-
chemia, radiation enteritis, angioedema, and
hemorrhage [1, 14, 16–20] (Figs. 4–6).
A relatively rare condition that generally
shows long segments or even diffuse small-
bowel involvement with a target appearance is
angioedema [16] (Fig. 7). Angioedema may
be congenital or acquired and is due to in-
creased capillary permeability in the mucosa
that results in submucosal edema. This condi-
tion may occur in the skin, airways, or intes-
tine and is usually self-limited and treated
conservatively. When it occurs in the small
bowel, the condition causes acute abdominal
pain. When angioedema is acquired, there is
often a recent history of the use of an angio-
tensin-converting enzyme inhibitor, which ap-
pears to be an inciting event [16]. The major
differential diagnosis of angioedema is is-
chemia and vasculitis [16–20]. If the diagnosis
of angioedema is considered at imaging, labo-
Fig. 5—45-year-old ratory testing can be helpful because the C1
woman with target esterase inhibitor level is low in this condition.
appearance in small In patients with small-bowel thickening due to
bowel due to acute
radiation enteritis. A vasculitis, there is a combination of edema and
A, Axial CT image in hemorrhage in the wall secondary to the vas-
patient, who has cervical culitis-induced ischemia [19, 20].
cancer and just finished
4-week course of
Submucosal hemorrhage has been classi-
radiation therapy. Note cally thought to cause homogeneous en-
moderate mural hancement of the bowel wall after IV con-
thickening (5–10 mm) trast administration [17]. However, after
(arrow) and target
appearance after administration of a rapid bolus of IV con-
contrast administration. trast material, the small bowel usually
B, Coronal reformatted shows a target appearance in the setting of
image shows segmental
involvement of abnormal
submucosal hemorrhage [17] (Fig. 8). The
loop in pelvis (long major differential diagnosis of small-bowel
arrow) and normal- submucosal hemorrhage is intestinal is-
appearing loop in chemia. Both conditions tend to occur in
abdomen (short arrow).
Inflammatory process elderly patients. Most patients with submu-
was localized to loops of cosal hemorrhage will present with acute
small bowel in pelvis abdominal pain and will be found to be at in-
within radiation field;
findings were attributed creased risk of bleeding, usually from anti-
to acute radiation coagulation with warfarin. Laboratory tests
enteritis. will show an elevated international normal-
B ized ratio level, usually greater than 4 [17].

AJR:188, May 2007 1347

 Macari et al.

Fig. 6—80-year-old man shown that this may be a normal variant and
with target appearance may not necessarily be associated with
in small bowel due to
superior mesenteric chronic bowel inflammation [22]. In a study
artery (SMA) embolus. of 100 patients undergoing unenhanced CT to
A, Axial CT image in evaluate for kidney stones, 21 patients were
patient who has atrial
fibrillation and abdominal
shown to have submucosal adipose tissue in
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pain shows mild to the bowel, and in 4% it was in the terminal il-
moderate mural eum. These patients had no history of chronic
thickening (≈ 5 mm) (long bowel inflammation. Therefore, if this find-
arrows) and target
appearance diffusely ing is seen at CT, correlation with the clinical
throughout small bowel history is essential.
and ascending colon When a target sign is visualized on CT, the
(short arrow).
B, Axial CT image shows differential diagnosis can be narrowed by
filling defect (long arrow) observing the degree of thickening, the
in SMA and wedge- length of the abnormal segment, associated
shaped perfusion defect
imaging abnormalities, and the clinical his-
(short arrow) in left A
kidney. Findings are tory. Only a few conditions generally cause
consistent with intestinal marked thickening of the small bowel with a
ischemia due to embolus. target appearance. These include vasculitis,
C, Intraoperative image
shows diffuse infarction Crohn’s disease, venous thrombosis with as-
of small bowel and sociated bowel edema or ischemia, and in-
cecum (arrows). Patient tramural hemorrhage. Associated findings
subsequently died.
that suggest Crohn’s disease include fibro-
fatty proliferation, hyperemia of the vasa
recta (the comb sign), sinus and fistula for-
mation, and abscess. The small-bowel me-
senteric arteries and veins should always be
evaluated when an abnormal small bowel is
seen. The vasculature should be assessed for
both caliber (hypovolemia) and occlusion
(embolus or thrombus). Finally, the location
of the abnormality should be determined.
B Clustered loops in the pelvis or elsewhere
suggest the possibility of radiation enteritis.

Occasionally, adipose tissue will be depos-
ited in the submucosa of the small intestine,
resulting in a target appearance. Recognition
of the fat attenuation in the submucosa will al-
C
low differentiation from edema. Submucosal
fat deposition in the wall of the small bowel
has been associated with chronic bowel in-
flammation [1, 21]. However, one study has
Homogeneous Enhancement
When an abnormally thickened loop of
small bowel enhances homogeneously after
contrast administration, it is important to as-
sess whether the enhancement is moderate or
marked. Although quantitative measures of
determining the degree of enhancement have
been developed, qualitative assessment has
been shown to be as good a predictor, or even
a better predictor, of hyperenhancement [4].
When assessing the degree of enhancement of
a thickened segment, comparison of the seg-
ment with other small-bowel loops is neces-
sary. In addition, the timing and adequacy of
the bolus of IV contrast material that was ad-
ministered need to be assessed.
If the enhancement is mild and the attenu-
ation is similar to muscle, one should con-
sider chronic inflammatory conditions, such
as chronic Crohn’s disease, ischemia, or radi-
ation [1, 14]. The milder homogeneous en-
hancement in these cases is likely related to
the development of fibrosis. Lymphoma and

1348 AJR:188, May 2007

 MDCT and CT Enterography of the Small Bowel

Fig. 7—31-year-old man with segmental thickening of terminal ileum due to allergic
angioedema.
A, Axial CT image in patient with acute abdominal pain shows multiple loops of
moderately thickened (6 mm) small bowel (arrows). Determining whether
enhancement pattern shows target appearance is difficult due to positive
intraluminal contrast material. However, subtle increase is seen in attenuation of
serosal layer of small bowel.
B, Coronal reformatted image better shows segmental area (30 cm) of thickening of
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terminal and distal ileum (arrows). Pattern of thickening suggests a submucosal

process. In light of submucosal appearance, differential diagnosis includes
vasculitis, angioedema, and infection.
C, Small-bowel series in same patient performed 24 hours later confirms submucosal
disease with preservation of mucosa (arrow). Stool cultures were negative for
pathogens, as were laboratory tests for vasculitis. Fecal material did show many
Charcot-Leyden crystals, suggesting allergic edema. Patient improved over several days.

B C

Fig. 8—76-year-old man with acute abdominal pain. Axial CT image shows marked
thickening (11 mm) of short segment (15 cm) of ileum (arrows) and target appearance
of wall. Patient was receiving warfarin with an international normalized ratio of 7.
Findings are consistent with acute submucosal hemorrhage.

AJR:188, May 2007 1349

 Macari et al.

Heterogeneous Enhancement
Heterogeneous enhancement is typical of
small-bowel neoplasms. Although any small-
bowel tumor may appear this way, heteroge-
neous enhancement is most frequent with ade-
nocarcinoma and malignant gastrointestinal
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stromal tumors (GISTs). The enhancement pat-

tern of a GIST is related to its size; small tumors
tend to be well circumscribed and to enhance
homogeneously, and large tumors tend to have
more irregular morphology, ulcerate, and en-
hance heterogeneously after contrast adminis-
tration [24, 25]. Metastasis and endometriotic
implants to the serosal surface of the bowel may
show heterogeneous or homogeneous enhance-
ment. Rarely, lymphoma will appear heteroge-
A
neous in its enhancement pattern.

Diminished Enhancement
The normal small bowel enhances after ad-
ministration of IV contrast material (Fig. 1).
Decreased or diminished enhancement may
be difficult to appreciate when the bowel is
filled with a positive contrast agent; however,
when the bowel is filled with a neutral con-
trast agent and displayed in 3D, regional dif-
ferences in mural enhancement become ap-
parent. In the correct clinical situation,
decreased enhancement is pathognomonic for
intestinal ischemia [17, 18, 26]. When evalu-
ating the small bowel for intestinal ischemia,
it is important to compare the loops that show
apparent decreased enhancement with the
more normally enhancing loops (Fig. 10).
B The several causes of small-bowel ischemia
C
include strangulation due to a closed-loop ob-
Fig. 9—79-year-old man with segmental thickening of jejunum due to lymphoma. struction, low-flow states from cardiac arrhyth-
A, Axial CT image in patient with abdominal pain shows moderate thickening (9 mm) of loop of jejunum (arrow) and
adjacent abscess (arrowhead). mias, sepsis or shock, embolus or thrombosis of
B, Coronal reformatted CT image better shows segmental (15-cm) area of homogeneous thickening (long arrows). the superior mesenteric artery (SMA), and supe-
Note enlarged lymph node in adjacent mesentery (short arrow). Differential diagnosis includes Crohn’s disease rior mesenteric vein (SMV) thrombosis. In the
and lymphoma.
C, Surgical specimen reveals segmental primary small-bowel lymphoma (arrows). setting of intestinal ischemia, the small bowel
will initially show mild thickening and often a
target appearance due to edema and intramural
bleeding [1, 17] (Fig. 6). As the process
occasionally intramural hemorrhage can enhanced. If the small bowel is not well progresses to infarction, the bowel becomes thin
cause marked thickening and homogeneous distended, the wall may appear falsely and shows diminished enhancement; finally,
enhancement of the small bowel [17, 23] thick and show homogeneous enhance- when mucosal integrity is breached, pneumato-
(Fig. 9). Occasionally, Crohn’s disease will ment. This typically occurs in the jejunum. sis and perforation may occur [17, 18].
show homogeneous hyperenhancement of the In these cases, it is important to evaluate When small-bowel ischemia is suspected,
wall [4, 10]. Homogeneous hyperenhance- the perienteric mesentery for the presence the vessel caliber, presence of atheroscle-
ment in the setting of Crohn’s disease implies or absence of inflammatory changes and rotic plaque, thrombus, and embolus in the
active disease [4]. As depicted on MDCT en- vessels that should be normal as opposed to mesenteric vasculature should be carefully
terography, attenuation of the enhanced wall hyperemic. Visualization of small bubbles evaluated. At our institution, we perform a
exceeding 109 H in a loop of bowel affected of gas trapped between the valvulae con- dual-phase acquisition for patients sus-
by Crohn’s disease has a high degree of cor- niventes will help to confirm that the small- pected of having mesenteric ischemia: an
relation with disease activity [4]. bowel wall is not thickened. Finally, if arterial phase at about 30 seconds evaluat-
Again, visual assessment is usually suf- there is still concern, a small-bowel series ing the patency of the mesenteric arterial
ficient to determine if a segment is hyper- can be obtained. supply, followed by a mural phase at ap-

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 MDCT and CT Enterography of the Small Bowel
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A B
Fig. 10—76-year-old man with diminished enhancement of multiple loops of small bowel. Fig. 11—49-year-old man with target appearance in
A, Coronal reformatted CT image in patient with closed-loop small-bowel obstruction due to transmesenteric segmental distribution due to acute Crohn’s disease.
hernia shows cluster of small-bowel loops with diminished enhancement (short arrows) when compared with Coronal reformatted CT image shows moderate mural
loops that are not in closed loop (long arrows). thickening (5–10 mm) with target appearance in
B, Surgical resection shows infarcted small bowel (arrow). ulcerated segment of terminal ileum (long arrows).
Additional findings supporting diagnosis of Crohn’s
disease include fibrofatty proliferation and prominent
vasa recta (short arrow).

Fig. 12—77-year-old man with focal thickening of

jejunum due to diverticulitis.
A, Coronal CT enterography image in patient with
abdominal pain shows focal (2 cm) area of jejunal
thickening centered on small out-pouching (arrow)
with adjacent perienteric fat stranding. Note adjacent
mesenteric abscess (arrowheads). Differential
diagnosis includes foreign body perforation,
perforated neoplasm, and diverticulitis.
B, Coronal CT enterography image in same patient
several centimeters caudal to A clearly shows a
proximal jejunal diverticulum (arrow). Note normal
small bowel (arrowheads). Surgery confirmed
perforated diverticulitis (arrow).
A B

proximately 60–65 seconds that captures
the maximally enhanced intestinal wall.
Neutral contrast-enhanced MDCT is ideal
for these patients. If the patient is too ill to
drink, our ability to detect subtle changes of
mural ischemia may be limited.
Length of Involvement
The second criterion used to evaluate an ab-
normal small-bowel loop is the length of involve-
ment. Determination of the length of involvement
is particularly facilitated by using coronal multi-
planar reformatted and 3D volume-rendered im-
ages obtained with MDCT [13] (Figs. 5, 7, 9, and
11). Pathologic conditions tend to cause focal in-
volvement (≤ 5 cm), segmental involvement
(6–40 cm), or diffuse involvement (> 40 cm). Al-
though these lengths are somewhat arbitrary, they
aid in narrowing the differential diagnosis [1].

AJR:188, May 2007 1351


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Fig. 13—62-year-old woman with diffuse small-bowel thickening due to encasement
and obstruction of superior mesenteric vein (SMV) by neuroendocrine tumor.
Coronal reformatted CT image shows encasement of SMV by neoplasm
(arrowheads) and mild diffuse edema throughout small bowel (arrows).
Focal Involvement
Conditions that cause focal small-bowel ab-
normalities include neoplasms, endometriosis,
small-bowel diverticulitis, foreign-body perfo-
rations, small-bowel ulcers from the use of
nonsteroidal antiinflammatory drugs, and, oc-
casionally, granulomatous processes such as
tuberculosis and Crohn’s disease [24, 25,
27–29] (Fig. 12). Focal tumors of the small
bowel are usually due to metastasis, adenocar-
cinoma, and GIST. GIST tumors tend to be
round and more eccentric or exophytic than
circumferential lesions such as adenocarci-
noma [24]. Foreign-body perforations are of-
ten due to fish bones that appear as thin, linear,
hyperdense structures in the small bowel. The
affected segment will appear as a short length
of mural thickening, often with mural stratifi-
cation. Increased density in the perienteric fat
reflects the mesenteric reaction to the perfora-
tion. Intraperitoneal gas may be present.
Segmental Involvement
Conditions that typically result in segmental
involvement of the affected small bowel in-
clude intramural hemorrhage, Crohn’s disease,
lymphoma, infectious enteritis, and, occasion-
ally, intestinal ischemia, particularly when the
cause is SMA embolus or SMV thrombosis
[17, 18, 23, 30, 31]. Secondary signs will often
be present in patients with Crohn’s disease, in-
cluding skip areas, fibrofatty proliferation, fis-
tulas, prominent vasa recta, and, occasionally,
abscess formation [14]. Vasculitis and an-
gioedema may result in a segmental or diffuse
1352
Macari et al.
Fig. 14—50-year-old man with abdominal pain. Axial CT image shows short segment
(15 cm) of marked (25 mm) mural thickening in distal ileum (arrows) with
homogeneous enhancement. Small-bowel lymphoma was confirmed at surgery.
distribution of abnormality [16, 19]. These
conditions classically show a target sign with
small-bowel edema. When the segmental dis-
tribution is localized in a particular region of
the peritoneal cavity in a patient with a prior
malignancy, a history of radiation therapy
should be sought. The effects of radiation may
be acute or may manifest many years after
therapy [32]. Although lymphoma may have
numerous morphologic manifestations, it
tends to cause segmental involvement in the
small bowel. As opposed to the nonneoplastic
conditions listed previously, lymphoma most
frequently results in homogeneous enhance-
ment in the affected segment [23].
Diffuse Involvement
Diffuse involvement of the small bowel is
seen in benign conditions. Conditions that
may cause diffuse thickening include hypo-
albuminemia, low-flow intestinal ischemia
and proximal SMA embolus, vasculitis, an-
gioedema, graft-versus-host disease, and in-
fectious enteritis [17–19, 33, 34] (Figs. 6 and
13). Patients with hypoalbuminemia will typ-
ically show edematous changes in the subcu-
taneous tissues, peritoneum, and retroperito-
neum. When diffuse small-bowel thickening
is present, the SMA should be carefully in-
spected for filling defects and caliber. In low-
flow states, the caliber of the SMA is usually
quite small. In patients with acute hypo-
volemia or shock, a typical appearance of the
small bowel known as “shock bowel” may be
seen. In these patients, mild to moderate dif-
fuse small-bowel thickening and marked hy-
perenhancement of the mucosa are seen [35].
The findings in these patients appear to be re-
lated to reversible ischemia [35]. Other typi-
cal CT findings in these patients include hy-
perenhancing adrenal glands and a slitlike
inferior vena cava due to the hypovolemia.
Degree of Thickening
The degree of thickening is the third major
criterion used to evaluate an abnormal small
bowel. When the normal small bowel is dis-
tended, the wall measures no greater than 2
mm. If the small bowel is not distended, an ac-
curate assessment of the degree of wall thicken-
ing is often impossible. Mural thickening can
be stratified into three categories: mild (3–4
mm), moderate (5–9 mm), and marked (≥ 10
mm). Although conditions that cause mild,
moderate, and marked thickening overlap,
these categories do help in narrowing the differ-
ential diagnosis of the abnormal small bowel.
Mild Thickening
Mild thickening of the small bowel is seen
in hypoalbuminemia, infectious enteritis, and
occasionally in patients with ischemia due to
lack of arterial inflow or mild Crohn’s disease
[17, 18, 36–38] (Fig. 6). Patients with intesti-
nal ischemia related to mesenteric venous
thrombosis typically have moderate to
marked thickening of the small bowel [18,
30]. Most other common abnormalities af-
fecting the small bowel cause moderate to
marked thickening.
AJR:188, May 2007
 MDCT and CT Enterography of the Small Bowel
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A B
Moderate Thickening
Moderate thickening of the small bowel is
seen in patients with Crohn’s disease, intestinal
ischemia, intramural hemorrhage, angio-
edema, and vasculitis [14, 16–19] (Fig. 7).
Some neoplastic processes such as low-T-stage
adenocarcinoma and some lymphomas can
also show moderate thickening [23] (Fig. 9).
Marked Thickening
Conditions that cause marked thickening
(≥ 10 mm) of the small bowel include lym-
phoma and other neoplasms, vasculitis,
Crohn’s disease, and intramural hemorrhage
(Fig. 14). Infectious bacterial and viral colitis
may result in marked thickening of the colon
[39]. However, it is unusual for infectious en-
teritis to show marked mural thickening. Is-
chemia of the small bowel causes mild to
moderate thickening unless due to venous oc-
clusion [17, 30]. Crohn’s disease may result
in mild, moderate, or marked thickening of
the small bowel [14]. Finally, most cases of
small-bowel wall thickening measuring > 20
mm are due to neoplasms and, occasionally,
to intramural hemorrhage.
Symmetric Versus
Asymmetric Thickening
Most conditions that cause symmetric
thickening along the circumference of the
small bowel are benign. Crohn’s disease and
other granulomatous conditions such as tu-
berculosis may occasionally cause asymmet-
ric thickening [14, 29]. Asymmetric thicken-
ing along the circumference of the wall of the
AJR:188, May 2007
small bowel is usually seen with neoplasms
[40]. Lymphoma in the small bowel may
show symmetric thickening [23, 40].
Location Along the Course of the
Small Bowel (Proximal or Distal)
In general, the location along the length of the
small bowel cannot be used to reliably differen-
tiate abnormal conditions. Adenocarcinoma of
the small bowel tends to occur proximally
(duodenum and jejunum), whereas lymphoma
and carcinoid tumors are more frequent in the il-
eum [40]. Although Crohn’s disease has a pre-
dilection for the terminal ileum, it may affect
any segment of the gastrointestinal tract [41].
Celiac disease tends to affect the proximal small
bowel, where a paucity of small-bowel folds
may be detected at MDCT [41, 42].
Location in the Wall of the Small Bowel
(Mucosal, Submucosal, or Serosal)
The determination of whether a process af-
fects primarily the mucosa, the submucosa, or
the serosal surface of the small bowel is an im-
portant criterion in determining the cause of the
disorder. Although the fine mucosal detail of a
small-bowel series or the actual visualization of
the mucosal surface on endoscopy is superior to
that on MDCT, the location can often be in-
ferred by typical MDCT signs (Fig. 15).
Mucosal Disease
The inner surface of the small bowel is the
mucosa, which should have a smooth appear-
ance. Diseases that affect and disrupt the small-
bowel mucosa and can be seen on MDCT in-
Fig. 15—Differentiating mucosal from submucosal
disease.
A, Coronal reformatted image of terminal ileum in 27-
year-old man with surgically proven perforated
appendicitis shows moderate to marked thickening of
terminal ileum (arrow). Mucosa is smooth, and at
surgery secondary edema of terminal ileum was
present due to perforated appendix and abscess
(arrowhead).
B, Coronal reformatted image of terminal ileum in 34-
year-old man with endoscopically proven Crohn’s
disease shows moderated to marked thickening and
irregularity of terminal ileum mucosa (arrow)
consistent with multiple ulcerations. Note adjacent
abscess (arrowhead).
clude neoplasms and certain inflammatory pro-
cesses such as Crohn’s disease and tuberculosis
(Fig. 11). Other infectious processes and intes-
tinal ischemia may affect the small-bowel mu-
cosa; however, these processes generally can-
not be seen to disrupt the mucosa on CT.
Submucosal Disease
Submucosal deposition of edema or blood
will cause a target sign that can be visualized
on MDCT when a rapid bolus of IV contrast
agent is administered. Submucosal disease is
seen in intramural hemorrhage, vasculitis, is-
chemia, angioedema, and hypoalbuminemia
(Figs. 4, 5, 7, and 8). The appearance of the
bowel wall on MDCT will show a smooth in-
ner surface or straightened thick parallel folds
that have been called a “stacked-coin” or
“picket fence” appearance on barium studies.
Serosal Disease
On barium examinations, serosal disease is
recognized as tethering or spiculation of the
folds [43, 44]. This same pattern may be seen
on CT and, in addition, the cause of the sero-
sal disease can often be determined (Fig. 16).
Conditions that cause serosal disease include
metastases, carcinoid tumors, endometriosis,
and other inflammatory conditions in the
peritoneal cavity.
Associated Abnormalities in the
Mesentery and Vessels
As has been discussed throughout this arti-
cle, the mesenteric vasculature; the size, loca-
tion, and attenuation of lymph nodes; and the
1353

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Fig. 16—55-year-old woman with serosal disease due to carcinoid tumor.
A, Coronal reformatted CT image shows tethering of multiple loops of small bowel (arrows) toward partially calcified mass in mesentery (arrowhead).
B, Spot compression view from small-bowel series shows tethering and spiculation of folds (arrows) along mesenteric surface of bowel. Carcinoid tumor was removed at
surgery. Tumor incites desmoplastic reaction, resulting in appearance of small-bowel serosa.
status of the mesentery serve as important
clues in the differential diagnosis of an abnor-
mal bowel. Low-attenuation lymph nodes
suggest tuberculosis; soft-tissue-attenuation
lymph nodes suggest lymphoma, Crohn’s dis-
ease, or mesenteric adenitis. The SMA and
SMV must always be assessed when an ab-
normal small-bowel loop is present.
Conclusion
The differential diagnosis of the abnormal
small bowel is extensive, including variants and
pitfalls, inflammatory conditions, and neo-
plasms. Optimal evaluation of an abnormal
small-bowel loop is facilitated when the small
bowel is well distended, IV contrast material
has been administered, and thin-section CT is
used. CT enterography should be used when a
clinical concern exists for small-bowel disease.
When an abnormal small-bowel loop is recog-
nized, a pattern approach as discussed herein
can be used to narrow the differential diagnosis.
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