Imaging of Small Bowel and Colon

Linda Pantongrag-Brown, MD King Chulalongkorn Memorial Hospital, Bangkok

Small Bowel Anatomy

Longest tubular organ in body, 18-22 feet Mesentery: 15 cm long between ligament of Treitz to IC junction Rule of 3s
Wall thickness < 3mm Diameter < 3 cm Air-fluid levels < 3

Normal Bowel Caliber

Mnemonic: 3-6-9-12
3 cm max size of small bowel 6 cm max size of transverse colon 9 cm max size of cecum 12 cm max size of cecum before it may burst

Case 1
A 58-year-old man presented with abdominal pain, nausea, vomiting.

Case 1
Rigler Triad
Partial small bowel obstruction Gas in biliary tree Ectopic calcified gallstone

Diagnosis: Gallstone Ileus

Case 2
A 63-year-old man presented with abdominal pain, nausea, vomiting.

Case 2
Stepladder pattern Multiple air-fluid levels (> 3 ), different height in the same loops Dilated small bowel lumen (> 3cm) with no air in the colon Diagnosis: Small bowel obstruction (CA cecum)

SBO Etiologies
Adhesion/Fibrosis Internal hernia Volvulus Intussusception GS ileus Abscess Neoplasm

Case 3
A 45-year-old man presented with abdominal pain and fever.

Case 3
Abscess at the RLQ causing partial SBO Possible etiologies
Ruptured appendicitis Ruptured diverticulitis SB infarction with perforation CA colon with perforation

Diagnosis: SB infarction with perforation

Case 4
A 26-year-old female presented with recurrent abdominal pain.

Case 4
Cluster of small bowel loops at the leftside abdomen with marked dilatation of the duodenum suggestive of left paraduodenal hernia (through fossa of Landzert)

Case 5
A 58-year-old female presented with abdominal pain.

Case 5
Relatively thickened, regular folds with minimal nodularity This pattern implies relatively even distribution of submucosal deposition. It is usually caused by edema or hemorrhage.

D/Dx: Regular, smooth thickened folds

Edema (Diffuse)
Hypoproteinemia (cirrhosis, NS, protein losing enteropathy) CHF Portal HT

Hemorrhage (Focal)
Anticoagulant therapy/coagulopathies Ischemia (SMA, SMV thrombosis; hypoperfusion) Vasculitis

Case 5
Thrombus within the SMV Diffusely thickened small bowel wall Dx: Ischemic bowel, SMV thrombosis

Case 6
A 58-year-old man presented with abdominal distension and pain.

Case 6
String of pearls appearance with relatively absence of air in colon, indicative of small bowel obstruction Site of obstruction is possibly proximal.

SBO Etiologies
Adhesion/Fibrosis Internal hernia Volvulus Intussusception GS ileus Abscess Neoplasm

Case 6
Coil-spring appearance, indicative of intussusception Dx: Lymphoma

Case 7
A 74 year-old man presented with abdominal pain and fever.

Case 7
Jejunal diverticula with inflammatory mass encasing the small bowel loops and extraluminal air bubbles Dx: Rupture jejunal diverticulitis

Case 8
A 59-year-old man, check up.

Case 8
A pedunculated polyp with lobulated contour at the descending colon Diagnosis: Tubulovillous adenoma

Colonic Polyp
Hyperplastic polyp
Sessile polyp < 5 mm

Adenomatous polyp
Tubular adenoma Tubulovillous adenoma Villous adenoma

Adenoma Size & Incidence of Malignancy

< 5 mm, 0.5% 5-9 mm, 1% 10-20 mm, 5-10% > 20 mm, 10-50% All polyps > 10 mm should be removed Time for adenoma-carcinoma sequence 10-15 years

Case 9
A 56-year-old man presented with constipation.

Case 8
Circumferential mass at rectum with a small processional node Dx: CA rectum, Modified Dukes C
T3 (servos) N1 (1-3 regional l.n.) M0 (No distant met)

CA Colon: preop staging by CT

(Balthazar, AJR 1988) CT vs Modified Dukes Stage A (limit to colonic wall): 57% Stage B (extend to serosa/pericolic fat): 17% Stage C (involve regional nodes): 68% Stage D (involve adjacent organs, peritoneal seedings, liver met): 81% with 100% positive predictive value.

CA Colon: preop staging by CT

(Balthazar, AJR 1988) CT is inaccurate in Dukes A, B, C staging, and do not effect surgical treatment. CT is sensitive with high +ve predictive value in Dukes D

Should pre-op CT staging be performed?

Yes. Because its high sensitivity and high +ve predictive value in detecting advanced lesions, which may lead to changes in surgical planning (limited resection instead of extensive curative procedure), or preoperative management.

Case 10
A 60-year-old man presented with melon.

CT Coronagraph

Case 10
Intriguingly lobulated mass with relatively thin wall Dx: CA rectum, Modified Dukes A
T2 (muscular propia) N0 M0

2 cm polyp

Case 11
A 46-year-old man presented with abdominal pain and distension.

Case 11
Distended cecum rotates into the LUQ Dx: Cecal volvulus

Case 12
A 55-year-old man presented with fever and abdominal pain.

Case 12
Extraluminal air bubbles at LLQ with evidence of sigmoid diverticulosis Dx: Ruptured sigmoid diverticulitis

Case 13
A 45-year-old man presented with fever and abdominal pain.

Case 13
Dilated appendix with air bubbles dissecting in its wall and rupture into the peritoneal cavity Dx: Rupture acute appendicitis

Case 14
A 45-year-old man presented with abdominal distension.

Case 14
Omental cake Implantation with mass effect over the liver and splenic surfaces (scalloping sign) Ascites Rim calcified cyst at the RLQ Dx: Pseudomyxoma peritonei, from ruptured mucocele

D/Dx omental cake

Peritoneal carcinomatosis TB peritonitis Pseudomyxoma peritonei
Rupture mucocele Mucinous adenoCA metastasis

Peritoneal mesothelioma Lymphoma

Case 15
A 57-year-old presented with acute abdominal pain and diarrhea.

Case 15
Diffuse thickening of sigmoid colon D/Dx:
Infectious colitis Ischemic colitis Pseudomembranous colitis Inflammatory bowel (UC, Crohns)

Case 15
Dx: Ischemic colitis

Conclusion
Normal anatomy SBO
Gallstone ileus CA cecum Abscess (SB infarction with perforation) Intusussception (lymphoma)

Internal hernia
Left paraduodenal hernia

SB ischemia (SMV thrombosis) Rupture jejunal diverticulitis

Conclusion
Colonic polyp Carcinoma (T3N1, T2N0) Cecal volvulus Ruptured diverticulitis Ruptured appendicitis Pseudomyxoma peritonei (ruptured mucocele) Ischemic colitis