C ridereau zins thickening of bowel wall jfim hanoi 2015
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C ridereau zins thickening of bowel wall jfim hanoi 2015
- 1. Thickening of the bowel wall: how to manage? (small bowel and colon) Catherine Ridereau-Zins University Hospital of ANGERS - FRANCE Hanoï November 2015
- 2. Thickening of the bowel wall: how to manage ? ? In a clinical context of intestinal disease ? Fortuitously discovered
- 3. ? 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…
- 4. Theoretically easy, with… ? Clinical data ? the use of other imaging techniques: Ÿ specific CT: CT enterography water enema CT Ÿ US Ÿ MRI Final diagnosis will be done by endoscopy, histology and bacteriology.
- 5. Bowel wall: Ÿ 5 mm (no distension) ≈ 2 mm (digestive repletion) Ÿ homogeneous uptake after injection Ÿ no individualisation of the layers on CT NormalRadiological analysis CT enterography Water enema CT
- 6. Pseudo thickening if: Ÿ contraction Ÿ poor filling of the lumen Radiological analysis Normal CT enterography Water enema CT
- 7. Perienteric fat: homogeneous Abdominal cavity: no fluid no ADP Digestive lumen: without repletion ≤ 2.5 cm (small bowel) or 6 cm (colon) NormalRadiological analysis
- 8. Radiological analysis is based on: è EXTENSION è type of ENHANCEMENT Thickened bowel wall
- 9. FOCAL SEGMENTAL or DIFFUSE Tumors (except lymphoma) Inflammatory Infectious Vascular Lymphoma Thickened wall EXTENSIONRadiological analysis
- 10. homogeneous target appearance (submucosal oedema) heterogeneous Radiological analysis Thickened wall ENHANCEMENT
- 11. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 66 year old man; abdominal pain; rectal bleeding Water enema CT
- 12. 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
- 13. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 45 year old woman; abdominal pain
- 14. 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
- 15. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 56 year old man; abdominal pain; flushes
- 16. 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)
- 17. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 30 year old woman; abdominal pain CT enterography
- 18. 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
- 19. Histology is necessary. Endocrine tumor Ectopic pancreas NeurofibromaGISTAdenoma SMALL BOWELL TUMORS ADK Rare; look similar !
- 20. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 20 year old man, renal transplantation abdominal mass on the follow up US
- 21. 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
- 22. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 25 year old woman; abdominal pain; diarrhea
- 23. 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
- 24. 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 +
- 25. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 64 year old man; abdominal pain; defense of left lower quadrant
- 26. 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
- 27. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 33 year old man; abdominal pain; diarrhea; fever
- 28. 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)
- 29. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 40 year old man, abdominal pain, rectal bleeding, defense of right lower quadrant
- 30. 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
- 31. 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
- 32. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 35 year old man, abdominal pain, diarrhea
- 33. 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
- 34. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 50 year old man; left lower quadrant abdominal pain
- 35. 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
- 36. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 70 year old man; malaise; rectal bleeding; abdominal pain
- 37. 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
- 38. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 78 year old man; abdominal pain; hematuria ; no fever
- 39. 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
- 40. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 54 year old man; abdominal pain; rectal bleeding
- 41. 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)
- 42. Thickening Uptake Location Perienteric fat Lumen Fluid ADP 45 year old man, abdominal pain, defense of right lower quadrant
- 43. 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)
- 44. KEY POINTS ✔ A perfect radiological analysis: focal / segmental or diffuse thickening enhancement ✔ Clinical context Thickening of the bowell wall: how to manage ? cảm ơn bạn