Small and Large Intestine Disease · Small and Large Intestine Disease: A Case Based Review _____...

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Small and Large Intestine Disease:

A Case Based Review

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Michael F. McNeeley, M.D.

Assistant Professor of Radiology, Body ImagingUniversity of Washington School of Medicine

Associate Program Director, Body Imaging FellowshipAssociate Program Director at UWMC, Radiology Residency

Co-Director, Image-Guided Body Procedures

Disclosure Statement

• The presenter has no relevant financial or nonfinancial relationships to disclose.

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Acknowledgements

• The presenter would like to thank the following gracious physicians for their generous case contributions:

– Charles Rohrmann, M.D.

– Joel Liechtenstein, M.D.

– Carlos Cuevas, M.D.

First Case:

Two patients with chronic systemic diseases; incidental AXR finding

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Patient A Patient B

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Patient A Patient B

What is the most likely explanation for this pattern of mucosal disease?

a) Hypoalbuminemiab) Lymphangiectasiac) Lymphomatous infiltrationd) Graft-vs-Host Diseasee) Systemic Hypotension

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ESLD

ESRD

• Congested lymphatics, interstitium• Hypoalbuminemia:

• ≤ 2 g/dL• ESLD• Nephrotic syndrome• Protein losing enteropathy

Small Bowel Edema

Gore and Levine. Textbook of Gastrointestinal Radiology, 4th edition., p 867

Patient C

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Lymphoma

Next Case:

18 year old male patient with right lower quadrant pain and diarrhea

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Patient D

Findings

• Mucosal edema, probable fat wrapping• Ulceration with nodular filling defects• Enterocolic fistulae

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What causes mucosal “cobblestoning” in Inflammatory Bowel Disease?

a) Premalignant polypsb) Aphthaec) Ulceration with islands of

edematous mucosad) Nodular lymphatic hyperplasia

• Seen in Crohn Disease and Ulcerative Colitis

• Intersecting ulcers interspersed with islands of swollen mucosa

• Connotes advanced disease

Mucosal Cobblestoning

McNeeley MF, Itani M, Rohrmann CA (2015) in Ficheraand Krane (eds.), Crohn’s Disease: Basic Principles.

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Patient E

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Other Patterns of Disease in IBD

Aphthae

• Early sign of inflammation• Focal erosions on hyperplastic follicles.• Tiny collection of contrast surrounded

by a radiolucent halo.

Patient F

Freeny PC, Stevenson GW. Margulis and Burhenne'sAlimentary Tract Radiology. 5th ed. St. Louis: Mosby;

1994. p. 564-600.

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Collar Button Ulcers

• Focal mucosal disruption• Broader submucosal damage• Intact muscularis forms the floor

Patient G

Patient G

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Patient H

Patient I

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Next Case:

History withheld

Patient J

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Patient J

In addition to colorectal cancer, patients with Familial Adenomatous Polyposis are at increased risk for…

a) Thyroid cancerb) Brain tumorsc) Ampullary carcinomad) Gastric cancere) All of the above.

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• Increased risk of GI malignancy• Untreated: 42 year life expectancy• Treated: still require lifelong

surveillance

Familial Adenomatous Polyposis

Patient K

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Next Case:

66 year old woman with acute-on-chronic abdominal pain

Patient L

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a) More common in womenb) Usually presents before 65 y.o.c) Portal venous gas is typicald) Results from an internal fistula

Which two of the following statements regarding gallstone

ileus are true?

• Rigler’s Triad:• Intestinal obstruction• Pneumobilia• Ectopic gallstone

• Usually presents after 65 years old• Strong female predominance• Not a true “ileus.”

Gallstone Ileus

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Patient M Patient N

Patient O

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Next Case:

20 year old patient with fever and abdominal pain

Patient S

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Patient S

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Grading Appendicitis

Raptopoulos, et al. February 2003 Radiology, 226,521-526.

0) No tomographic evidence for acute appendicitis.

1) Probable appendicitis, based on mild appendiceal enlargement.

2) Appendicitis.

3) Appendicitis and periappendicitis.

4) Appendicitis with rupture. Concern for gangrenous or hemorrhagic appendicitis.

5) Complicated appendicitis, with periappendiceal abscess or phlegmon.

• In one study which correlated the CT and surgical-pathologic grades for acute appendicitis, the weighted κ statistic was 0.75 (P < .001), which indicates substantial to almost perfect agreement. The Spearman rank correlation between the two series was 0.83 (P < .001).

Companion Cases

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Ruptured Appendicitis

Patient T

Appy w/ Periappendicitis

Patient U

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“What if you can’t find the appendix???”

The Non-Visualized Appendix

• Make doubly sure that you’re not missing it.– Retrocecal, up the lateral conal fascia to the liver?

– Draping over the right-sided iliac vessels?

• Look for secondary signs:– Appendicolith

– RLQ fat stranding or fluid

– Extraluminal gas

– Thickening of the terminal ileus or sigmoid

– Lymphadenopathy

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The Non-Visualized Appendix

• Differential Diagnosis (limited):

– Mesenteric lymphadenitis

– Gastroenteritis

– Diverticulitis

– Inflammatory Bowel Disease

– Enterocolitis

• If no secondary signs of appendicitis:

– Incidence of acute appendicitis is ~2%.

The Non-Visualized Appendix

Nikolaidis et al. AJR:183, 889-892, October 2004.

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The Non-Visualized Appendix

• One secondary sign: lymphadenopathy

– Can’t exclude appy, but consider mesenteric lymphadenitis

• Clustered (3+) nodes anterior to psoas. The largest usually are 5-15 mm in diameter.

Nikolaidis et al. AJR:183, 889-892, October 2004.

The Non-Visualized Appendix

• One secondary sign: thickening of ileum/sigmoid

– Can’t exclude appy, but consider enterocolitis or IBD.

Nikolaidis et al. AJR:183, 889-892, October 2004.

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Next Case:

74 y.o. male patient with worsening colicky pain, distention.

Patient P

• Onset: acute or inisidious• Usually presents after 60 y.o.

Preferred treatment:• Sigmoidoscopy +/- rectal

tube insertion.• ~Half recur

• Definitive treatment:• Resection w/ Hartmann

Sigmoid Volvulus

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