c ridereau zins thickening of bowel wall jfim hanoi 2015
TRANSCRIPT
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Thickening of the bowel wall: how to manage?
(small bowel and colon)
Catherine Ridereau-Zins University Hospital of ANGERS - FRANCE
Hanoï November 2015
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Thickening of the bowel wall: how to manage ?
? In a clinical context of intestinal disease
? Fortuitously discovered
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? 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…
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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.
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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
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Pseudo thickening if: � contraction � poor filling of the lumen
Radiological analysis Normal
CT enterography
Water enema CT
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Perienteric fat: homogeneous
Abdominal cavity: no fluid no ADP
Digestive lumen: without repletion ≤ 2.5 cm (small bowel) or 6 cm (colon)
Normal
Radiological analysis
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Radiological analysis
is based on: è EXTENSION è type of ENHANCEMENT
Thickened bowel wall
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FOCAL SEGMENTAL or DIFFUSE
Tumors (except lymphoma)
Inflammatory Infectious Vascular
Lymphoma
Thickened wall EXTENSION
Radiological analysis
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homogeneous
target appearance (submucosal oedema)
heterogeneous
Radiological analysis Thickened wall ENHANCEMENT
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
66 year old man; abdominal pain; rectal bleeding
Water enema CT
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Thickening Focal, circumferential Uptake heterogeneous Location colon Perienteric fat Non infiltrated Lumen narrowed Fluid - ADP +
Endoscopy (histology)
WHAT TO DO ?
66 year old man; abdominal pain; rectal bleeding
ADENOCARCINOMA
Water enema CT
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
45 year old woman; abdominal pain
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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
45 year old woman; abdominal pain
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
56 year old man; abdominal pain; flushes
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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)
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
30 year old woman; abdominal pain
CT enterography
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Thickening Focal; multiple exophytic tumors Uptake homogeneous Location Small bowel Perienteric fat normal Lumen +/- narrowed Fluid - ADP +
PEUTZ JEGHERS syndrome
WHAT TO DO ?
30 year old woman; abdominal pain
CT enterography
Look at the lips Hamartomas
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Histology is necessary.
Endocrine tumor
Ectopic pancreas
Neurofibroma
GIST
Adenoma
SMALL BOWELL TUMORS
ADK
Rare; look similar !
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
20 year old man, renal transplantation abdominal mass on the follow up US
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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
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
25 year old woman; abdominal pain; diarrhea
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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 ?
25 year old woman; abdominal pain; diarrhea
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MRI: mapping stenoses abces, fistula inflammatory activity (DW)
Crohn’s disease
25 year old woman; abdominal pain; diarrhea
WHAT TO DO ?
Thickening segmental Uptake target appearance Location Small bowel Perienteric fat comb sign Lumen stenosis Fluid - ADP +
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
64 year old man; abdominal pain; defense of left lower quadrant
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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
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
33 year old man; abdominal pain; diarrhea; fever
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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)
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
40 year old man, abdominal pain, rectal bleeding, defense of right lower quadrant
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Thickening diffuse Uptake target Location R colon Perienteric fat infiltrated Lumen narrowed Fluid + ADP +
40 year old man, abdominal pain, rectal bleeding, defense of right lower quadrant
Infectious colitis ?
WHAT TO DO ?
No antibiotics TT Coloscopy 48 h before
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Thickening diffuse Uptake target Location R colon Perienteric fat infiltrated Lumen collapsed Fluid + ADP +
40 year old man, abdominal pain, rectal bleeding, defense of right lower quadrant
Toxic colitis due to glutheraldehyde (endoscope cleaner)
WHAT TO DO ?
No antibiotics TT Coloscopy 48 h before
D7
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
35 year old man, abdominal pain, diarrhea
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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
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
50 year old man; left lower quadrant abdominal pain
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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
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
70 year old man; malaise; rectal bleeding; abdominal pain
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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
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
78 year old man; abdominal pain; hematuria ; no fever
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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
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
54 year old man; abdominal pain; rectal bleeding
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Ulcerative Colitis
54 year old man; abdominal pain; rectal bleeding
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)
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Thickening Uptake Location Perienteric fat Lumen Fluid ADP
45 year old man, abdominal pain, defense of right lower quadrant
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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)
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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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