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CLASSICAL SIGNS IN GASTROINTESTINAL
RADIOLOGY(PART 1 & 2)
Dr. Muhammad Bin Zulfiqar
PGR IV FCPS SHL/SIMS
Alnoor Diagnostic...
INTRODUCTION
 Radiologists have established many classic imaging signs for
visual manifestations of pathophysiologic proc...
INTRODUCTION
 This article organizes the gastrointestinal signs from proximal
to distal within the gastrointestinal tract.
BIRD’S BEAK SIGN
 The “bird’s beak” sign is a classic finding on esophagrams; it
describes a dilated proximal esophagus w...
 Radiograph of the distal esophagus after oral contrast
administration obtained in a patient with achalasia
demonstrates ...
ACHALASIA
 There are both primary and secondary forms of
achalasia.
 Primary achalasia, the more common etiology, is
idi...
ACHALASIA
 Proposed causes
1. Neuronal degeneration
2. Viral infection
3. Genetic inheritance
4. Autoimmune disease
ACHALASIA
 Secondary achalasia is much less common
 Caused by
1. Esophageal carcinoma
2. Chagas disease.
CORKSCREW SIGN
 The “corkscrew” sign is the visual manifestation of lumen-
obliterating, simultaneous, nonperistaltic con...
Esophagram in a patient with diffuse esophageal spasm demonstrates non-
peristaltic contractions within the esophagus resu...
DIFFUSE ESOPHAGEAL SPASM
 Characterized on manometry by periods of normal peristalsis
followed by simultaneous, repetitiv...
DOUBLE-BARREL ESOPHAGUS
 The term “double-barrel esophagus” classically refers to the
radiographic appearance of a dissec...
DOUBLE-BARREL ESOPHAGUS
 Intramural esophageal dissection is most commonly seen in
middle-aged or elderly women
 This en...
Esophagram demonstrates dissection of oral contrast between the
esophageal mucosa and submucosa producing a double-barrel ...
BULL’S EYE LESIONS
 Lesions within the stomach forming central collections of oral
contrast within ulcerated intramural m...
Radiograph from an upper gastrointestinal series of a patient with
metastatic melanoma demonstrates a bull’s eye lesion in...
RAM’S HORN
 The unusual shape of the stomach resembling the horn of the
ram is due to combination of gastric deformity ca...
Radiograph of the stomach following the oral administration of contrast in a
patient with HIV/AIDS demonstrates somewhat t...
LEATHER BOTTLE STOMACH
 The stiff, nondistensible wall gives the stomach a leather
bottle appearance, also known as linit...
LEATHER BOTTLE STOMACH
 Primary scirrhous adenocarcinoma of the stomach spreads
predominantly in the submucosa and muscul...
Radiograph of the stomach following oral barium administration
demonstrates a thickened, stiff wall of the stomach seconda...
WINDSOCK SIGN
 The windsock appearance is formed by passive elongation of
the intraluminal diverticulum due to continual ...
WINDSOCK SIGN
 Intraluminal duodenal diverticulum is a rare congenital cause
of duodenal obstruction
 These intraluminal...
Duodenal wind sock sign in a patient with duodenal diverticulum. Image
from an upper gastrointestinal series clearly demon...
DOUBLE BUBBLE SIGN
 The “double bubble” sign represents the appearance of 2 gas-
filled structures in the upper abdomen o...
DOUBLE BUBBLE SIGN
 The intrinsic causes include
1. Duodenal webs
2. Duodenal atresia
3. Duodenal stenosis
 The extrinsi...
DOUBLE BUBBLE SIGN
 Duodenal atresia is the causative entity most commonly linked
with a double bubble sign.
 Duodenal a...
Plain radiograph of the abdomen in a patient with duodenal atresia creates
a double bubble appearance of the stomach and d...
WHIRLPOOL SIGN
 The “whirlpool” sign is found on both cross-sectional imaging
as well as abdominal ultrasound in the pres...
WHIRLPOOL SIGN
 Embryological explanation
 Normally, the midgut undergoes a 270-degree counterclockwise
rotation during ...
 CT maximal intensity projection (MIP) demonstrates
the whirlpool appearance of the superior mesenteric
artery and vein w...
STRING OF PEARLS
 The “string of pearls” sign indicates the presence of a small-
bowel obstruction. This sign is also com...
STRING OF PEARLS
 The observed rows of gas bubbles represent gas trapped
between the valvulae conniventes of the nondepen...
String of pearls sign in a patient with small-bowel obstruction (SBO).
Left lateral decubitus radiograph of the abdomen de...
STACK OF COINS
 The “stack of coins” sign typically indicates the presence of a
small-bowel hematoma
 This sign is seen ...
STACK OF COINS
 Over-anticoagulation with warfarin is the most common
cause of spontaneous intramural small-bowel hematom...
Plain radiograph of the abdomen following the oral administration of
barium to a patient with a small bowel hematoma demon...
STRING SIGN
 The string sign represents the marked narrowing of the
terminal ileum lumen secondary to symmetric, transmur...
STRING SIGN
 In the setting of Crohn’s disease, the terminal ileum often
becomes markedly stenotic secondary to bowel-wal...
A thin line of barium is seen in the terminal ileum (long arrows), which
resembles a frayed cotton string (the gastrointes...
RIBBON SIGN
 Fluoroscopic examinations performed with high-density oral
contrast material in patients with GVHD of the GI...
RIBBON SIGN
 The ribbon bowel appearance can also occur with
multiple other clinical settings, such as
1. Infection
2. Ir...
Plain radiograph of a small bowel follow through in a patient with
graft versus host disease illustrates marked luminal na...
THANK YOU
COMB SIGN
 The “comb sign” is seen in the presence of Crohn’s
disease.
 This sign is observed on contrast-enhanced CT or...
COMB SIGN
 The vasa recta of the small bowel seen in Crohn’s disease
become tortuous and enlarged.
 They appear as promi...
Contrast-enhanced
CT image in a
patient with
Crohn’s disease
demonstrating
engorged vasa
recta secondary to
hyperemia of t...
TARGET SIGN
 The target sign is classically seen in patients with
Crohn’s disease.
 This pattern of bowel wall enhanceme...
TARGET SIGN
 It represents an enhancement pattern of the bowel
wall seen in various disease processes on contrast-
enhanc...
TARGET SIGN
 The higher-attenuation inner and outer layers
represent the mucosa and muscularis propria,
respectively.
 T...
Contrast-enhanced CT
image of the small
bowel in a patient with
Crohn’s disease reveals
rings of high attenuation
represen...
COILED SPRING SIGN
 The “coiled spring” sign can be seen anywhere in
the bowel where an intussusception has occurred.
 T...
COILED SPRING SIGN
 Classically, this sign describes the appearance of
the cecum in the presence of appendiceal
intussusc...
Plain radiograph of the abdomen following the administration
of contrast through a feeding tube in a patient who is status...
ARROWHEAD SIGN
 This perceived arrowhead shape is secondary to
focal, symmetric thickening of the cecal wall
secondary to...
ARROWHEAD SIGN
 The arrowhead sign, which is obtained after the
administration of oral and/or rectal contrast
material, i...
Contrast-enhanced CT image in a patient with right lower-
quadrant pain demonstrates arrowhead-shaped
inflammatory changes...
THUMBPRINT SIGN
 This sign is seen in roughly 75% of cases of
transient, nongangrenous ischemic colitis
 Other condition...
THUMBPRINT SIGN
 This sign describes smooth, rounded impressions
causing filling defects classically seen in barium
studi...
Plain radiograph of the abdomen in a patient with ischemic colitis
demonstrates thickening of the haustra secondary to ede...
COBBLESTONE SIGN
 The “cobblestone sign” is classically seen within the
small and large bowel on fluoroscopic studies in ...
Radiograph of a small bowel follow-through in a patient with Crohn’s
disease demonstrates scattered islands of normal inte...
BOWLER HAT SIGN
 The “bowler-hat sign” represents the appearance of
a sessile colonic polyp on a double contrast barium
e...
BOWLER HAT SIGN
 The bowler-hat sign is formed by a ring of barium
adjacent to the base of the polyp surrounding a
domed ...
Magnified view of the sigmoid colon demonstrates " the
bowler hat sign" of the mid-sigmoid sessile polyp seen
obliquely (a...
MEXICAN HAT SIGN
 Pedunculated colonic polyps form the “Mexican hat
sign”
 The Mexican hat sign is formed by the appeara...
Radiograph of an upper gastrointestinal series demonstrates a
pedunculated gastric polyp demonstrating a close resemblance...
COLLAR BUTTON SIGN
 “Collar button ulcers” are manifestations of
inflammatory processes within the bowel.
 These deep ul...
COLLAR BUTTON SIGN
 The collar button appearance is formed by mucosal
ulceration with associated undermining of the
ulcer...
Radiograph from a single contrast barium enema in a patient with active
ulcerative colitis shows a deep ulcer within the d...
APPLE CORE SIGN
 The apple core sign is classically seen in cases of colon
carcinoma
 This appearance is most commonly l...
APPLE CORE SIGN
 The differential diagnosis of a lesion with an apple
core appearance is
1. Focal diverticulitis
2. Ische...
APPLE CORE SIGN
 The apple core appearance is the visual manifestation of
an annular lesion of the bowel with irregular o...
Fluoroscopic image from a double contrast barium enema in
a patient with changing bowel habits reveals an annular
lesion w...
ACCORDION SIGN
 The “accordion sign” describes the appearance of
colonic wall thickening in the setting of colitis
 The ...
ACCORDION SIGN
 This sign describes the appearance of alternating,
edematous haustral folds that are due to transmural
ed...
White oval highlights markedly thickened bowel wall with
oral contrast trapped between haustral folds in a patient
with kn...
LEAD PIPE SIGN
 The lead pipe appearance of the colon is classically
seen with chronic, smoldering ulcerative colitis.
 ...
LEAD PIPE SIGN
 The lead pipe appearance likely represents the
visual manifestation of multiple pathophysiological
proces...
Radiograph from a double contrast barium enema in a
patient with chronic, smoldering ulcerative colitis
demonstrates an ah...
REFERENCES
1. Abbas MA, Collins JM, Olden KW. Spontaneous intramural small-bowel
hematoma: Imaging findings and outcome. A...
Radiology ----Classical Signs in GIT Dr. Muhammad Bin Zulfiqar
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Radiology ----Classical Signs in GIT Dr. Muhammad Bin Zulfiqar

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Radiology ----Classical Signs in GIT Dr. Muhammad Bin Zulfiqar.
It is very difficult to learn much in the sea of radiology.
This presentation is the way to memorize classical signs in radiology.

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Radiology ----Classical Signs in GIT Dr. Muhammad Bin Zulfiqar

  1. 1. CLASSICAL SIGNS IN GASTROINTESTINAL RADIOLOGY(PART 1 & 2) Dr. Muhammad Bin Zulfiqar PGR IV FCPS SHL/SIMS Alnoor Diagnostic Centre
  2. 2. INTRODUCTION  Radiologists have established many classic imaging signs for visual manifestations of pathophysiologic processes.  The use of familiar objects to describe visual findings enables radiologists both to arrive at a correct diagnosis and to effectively convey such diagnostic findings to clinicians  The goal of this article is to review an array of classic signs associated with gastrointestinal tract pathologies whose imaging manifestations resemble everyday objects e.g. The “football” and “cobblestone” signs.
  3. 3. INTRODUCTION  This article organizes the gastrointestinal signs from proximal to distal within the gastrointestinal tract.
  4. 4. BIRD’S BEAK SIGN  The “bird’s beak” sign is a classic finding on esophagrams; it describes a dilated proximal esophagus with a smooth- tapered, distal esophagus at the level of the esophageal hiatus in the setting of achalasia.  Achalasia is further characterized by esophageal aperistalsis and failure of the lower esophageal sphincter to relax
  5. 5.  Radiograph of the distal esophagus after oral contrast administration obtained in a patient with achalasia demonstrates marked proximal esophageal dilatation with tapering of the distal esophagus resembling a bird’s beak. Note the debris in the dilated proximal esophagus.
  6. 6. ACHALASIA  There are both primary and secondary forms of achalasia.  Primary achalasia, the more common etiology, is idiopathic  The lack of lower esophageal sphincter relaxation is likely due to a loss of inhibitory neurons in the esophageal myenteric plexus
  7. 7. ACHALASIA  Proposed causes 1. Neuronal degeneration 2. Viral infection 3. Genetic inheritance 4. Autoimmune disease
  8. 8. ACHALASIA  Secondary achalasia is much less common  Caused by 1. Esophageal carcinoma 2. Chagas disease.
  9. 9. CORKSCREW SIGN  The “corkscrew” sign is the visual manifestation of lumen- obliterating, simultaneous, nonperistaltic contractions within the esophagus  These abnormal contractions of varying amplitude occur in diffuse esophageal spasm, a rare esophageal motility disorder
  10. 10. Esophagram in a patient with diffuse esophageal spasm demonstrates non- peristaltic contractions within the esophagus resulting in a corkscrew appearance
  11. 11. DIFFUSE ESOPHAGEAL SPASM  Characterized on manometry by periods of normal peristalsis followed by simultaneous, repetitive, ineffective contractions.  These abnormal contractions segment the normal esophageal lumen, mimicking a corkscrew on barium studies of the esophagus
  12. 12. DOUBLE-BARREL ESOPHAGUS  The term “double-barrel esophagus” classically refers to the radiographic appearance of a dissection between the esophageal mucosa and submucosa without perforation.  The double-barrel radiographic appearance of the esophagus is due to the visualization of a barium-filled, intramural dissecting channel separated from the true esophageal lumen by a lucent line known as the mucosal stripe.
  13. 13. DOUBLE-BARREL ESOPHAGUS  Intramural esophageal dissection is most commonly seen in middle-aged or elderly women  This entity can occur in the setting of a 1. Coagulopathy, 2. Emetogenic injury, 3. Trauma, 4. Instrumentation, 5. Ingestion of foreign bodies 6. Intramural esophageal abscess, 7. Intraluminal diverticulum 8. Esophageal duplication
  14. 14. Esophagram demonstrates dissection of oral contrast between the esophageal mucosa and submucosa producing a double-barrel appearance
  15. 15. BULL’S EYE LESIONS  Lesions within the stomach forming central collections of oral contrast within ulcerated intramural masses can produce a target or bull’s eye appearance on upper gastrointestinal barium examinations  Differential diagnosis is broad and includes 1. Gastric metastatic lesions from melanoma and lymphoma 2. Kaposi’s sarcoma 3. Carcinoid tumors 4. Gastric lipomas may also ulcerate and produce a bull’s eye appearance
  16. 16. Radiograph from an upper gastrointestinal series of a patient with metastatic melanoma demonstrates a bull’s eye lesion in the body of the stomach
  17. 17. RAM’S HORN  The unusual shape of the stomach resembling the horn of the ram is due to combination of gastric deformity causing a tubular shape, conical narrowing, and limited distensibility of the stomach.  Crohn’s disease is notable for this appearance  Crohn’s disease affects the stomach and duodenum in 0.5% to 4.0% of patients  The antrum is the gastric region most frequently involved
  18. 18. Radiograph of the stomach following the oral administration of contrast in a patient with HIV/AIDS demonstrates somewhat tubular, conical shape of the distal stomach resembling a ram’s horn
  19. 19. LEATHER BOTTLE STOMACH  The stiff, nondistensible wall gives the stomach a leather bottle appearance, also known as linitis plastica  Differential diagnoses for the appearance of a leather bottle stomach include 1. Primary scirrhous adenocarcinoma of the stomach 2. Scirrhous metastases from lung, breast, colon 3. Pancreatic carcinomas 4. Lymphoma 5. Crohn’s disease 6. Sarcoidosis 7. Syphilis.
  20. 20. LEATHER BOTTLE STOMACH  Primary scirrhous adenocarcinoma of the stomach spreads predominantly in the submucosa and muscularis propria  Scirrhous tumors constitute 5% to 15% of all gastric carcinomas  Scirrhous adenocarcinoma is thought to arise near the pylorus and spread proximally diffusely involving the entire stomach
  21. 21. Radiograph of the stomach following oral barium administration demonstrates a thickened, stiff wall of the stomach secondary to syphilis creating a leather water bottle-like appearance
  22. 22. WINDSOCK SIGN  The windsock appearance is formed by passive elongation of the intraluminal diverticulum due to continual peristalsis of the duodenum.  The windsock appearance is most commonly located in the second portion of the duodenum and consists of the barium- filled diverticulum that lies entirely within the duodenum  Appearance most commonly caused by Intraluminal Duodenal Diverticulum
  23. 23. WINDSOCK SIGN  Intraluminal duodenal diverticulum is a rare congenital cause of duodenal obstruction  These intraluminal diverticula are believed to arise from an improper luminal recanalization of the foregut in the 7th week of embryogenesis.  A residual tissue diaphragm may span the entire circumference of the duodenum and only allow passage of enteric contents through fenestrations
  24. 24. Duodenal wind sock sign in a patient with duodenal diverticulum. Image from an upper gastrointestinal series clearly demonstrates an intraluminal duodenal diverticulum (arrows) surrounded by a narrow radiolucent line (arrowheads). The diverticulum, arising in the second portion of the duodenum and extending to the third portion, was confirmed at surgery.
  25. 25. DOUBLE BUBBLE SIGN  The “double bubble” sign represents the appearance of 2 gas- filled structures in the upper abdomen of newborns and infants on plain films of the abdomen  The left-sided, proximal bubble is the distended gas and fluid- filled stomach.  The second, right-sided, more distal bubble is the distended duodenum.  The double bubble sign indicates the presence of duodenal obstruction that can be caused by a number of intrinsic or extrinsic etiologies
  26. 26. DOUBLE BUBBLE SIGN  The intrinsic causes include 1. Duodenal webs 2. Duodenal atresia 3. Duodenal stenosis  The extrinsic etiologies include 1. Preduodenal portal vein 2. Malrotation of the gut with a midgut volvulus 3. Ladd bands 4. Annular pancreas
  27. 27. DOUBLE BUBBLE SIGN  Duodenal atresia is the causative entity most commonly linked with a double bubble sign.  Duodenal atresia is found in 1 in 10,000 newborns and is typically associated with other congenital anomalies  30% of children with duodenal atresia have Down’s syndrome
  28. 28. Plain radiograph of the abdomen in a patient with duodenal atresia creates a double bubble appearance of the stomach and duodenum
  29. 29. WHIRLPOOL SIGN  The “whirlpool” sign is found on both cross-sectional imaging as well as abdominal ultrasound in the presence of midgut volvulus  The whirlpool appearance represents the swirling pattern of the gut and the superior mesenteric vein as they wrap around the superior mesenteric artery (SMA) in a clockwise rotation  It is the clockwise rotation of the bowel loops that result in the whirlpool sign on cross-sectional imaging
  30. 30. WHIRLPOOL SIGN  Embryological explanation  Normally, the midgut undergoes a 270-degree counterclockwise rotation during embryologic development.  Malrotation of the midgut represents a spectrum of developmental anomalies that result in either an insufficient or total lack of counterclockwise rotation of the midgut around the axis of the SMA.  These anomalies all lead to a shortened mesenteric base.  The shortened mesentery predisposes to volvulus that may result in bowel obstruction.  Midgut volvulus is the most common complication of malrotation of the small bowel in adults.
  31. 31.  CT maximal intensity projection (MIP) demonstrates the whirlpool appearance of the superior mesenteric artery and vein wrapping around one another in a patient with mid-gut volvulus.
  32. 32. STRING OF PEARLS  The “string of pearls” sign indicates the presence of a small- bowel obstruction. This sign is also commonly referred to as the “string of beads” sign.  It represents a row of small gas bubbles oriented in a relatively linear fashion within the abdomen on plain films
  33. 33. STRING OF PEARLS  The observed rows of gas bubbles represent gas trapped between the valvulae conniventes of the nondependent wall of small bowel.  These loops of small bowel are dilated and filled with fluid in the setting of a small-bowel obstruction, thus the meniscal effect of the surrounding fluid gives these pockets of gas a rounded or ovoid appearance.
  34. 34. String of pearls sign in a patient with small-bowel obstruction (SBO). Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows), which represents air trapped between the valvulae conniventes.
  35. 35. STACK OF COINS  The “stack of coins” sign typically indicates the presence of a small-bowel hematoma  This sign is seen on plain films or MDCT images and represents adjacent, thickened folds with sharp demarcation and crowding of the valvulae conniventes
  36. 36. STACK OF COINS  Over-anticoagulation with warfarin is the most common cause of spontaneous intramural small-bowel hematoma  Other Causes include 1. Idiopathic thrombocytopenic purpura 2. Leukemia 3. Pancreatitis 4. Pancreatic cancer 5. Hemophilia 6. Lymphoma 7. Myeloma 8. Chemotherapy 9. Vasculidites
  37. 37. Plain radiograph of the abdomen following the oral administration of barium to a patient with a small bowel hematoma demonstrates a stack of coins sign.
  38. 38. STRING SIGN  The string sign represents the marked narrowing of the terminal ileum lumen secondary to symmetric, transmural granulomatous inflammation and subsequent fibrotic thickening of the bowel wall  Bowel-wall thickening is the most common manifestation of Crohn’s disease on MDCT scans, occurring in up to 82% of patients
  39. 39. STRING SIGN  In the setting of Crohn’s disease, the terminal ileum often becomes markedly stenotic secondary to bowel-wall inflammation and fibrosis.  This results in the lumen of this portion of the small bowel resembling a piece of string on plain radiographs after ingestion of high-density oral contrast material
  40. 40. A thin line of barium is seen in the terminal ileum (long arrows), which resembles a frayed cotton string (the gastrointestinal string sign). Small mesenteric border ulceration is seen (small arrow).
  41. 41. RIBBON SIGN  Fluoroscopic examinations performed with high-density oral contrast material in patients with GVHD of the GI tract may demonstrate marked fold thickening, luminal narrowing, separation of folds, and ultimately complete effacement of the valvulae conniventes. The latter causes the so-called “ribbon sign”  Donor lymphoid cells damage host tissues in graft-versus-host disease (GVHD).  The organs most commonly affected by GVHD include the gastrointestinal tract, liver, and skin.  Marked bowel-wall thickening can occur both in the small and large bowel GVHD: Graft versus host disease
  42. 42. RIBBON SIGN  The ribbon bowel appearance can also occur with multiple other clinical settings, such as 1. Infection 2. Irradiation 3. Allergy 4. Ischemia 5. Ingestion of corrosives or medications 6. Amyloid 7. Mastocytosis 8. Lymphoma 9. Crohn disease 10. Celiac disease
  43. 43. Plain radiograph of a small bowel follow through in a patient with graft versus host disease illustrates marked luminal narrowing and effacement of the valvulae conniventes producing a ribbon like appearance of the small bowel
  44. 44. THANK YOU
  45. 45. COMB SIGN  The “comb sign” is seen in the presence of Crohn’s disease.  This sign is observed on contrast-enhanced CT or magnetic resonance imaging (MRI) scans.  The teeth of the comb in this instance represent engorged small arteries, the vasa recta, perfusing the small bowel
  46. 46. COMB SIGN  The vasa recta of the small bowel seen in Crohn’s disease become tortuous and enlarged.  They appear as prominent opacities on the mesenteric side of the small bowel.  These small arteries become engorged due to increased blood flow to the inflamed small bowel and are accentuated due to the fibrofatty proliferation in the mesentery.
  47. 47. Contrast-enhanced CT image in a patient with Crohn’s disease demonstrating engorged vasa recta secondary to hyperemia of the bowel producing the comb sign.
  48. 48. TARGET SIGN  The target sign is classically seen in patients with Crohn’s disease.  This pattern of bowel wall enhancement has been observed in patients with 1. Radiation enteritis 2. GVHD 3. Ischemic bowel 4. Intramural hemorrhage 5. Vasculitides such as Henoch-Schonlein purpura, and 6. Pseudomembranous colitis
  49. 49. TARGET SIGN  It represents an enhancement pattern of the bowel wall seen in various disease processes on contrast- enhanced CT or MRI scans.  This appearance is formed when a thickened bowel wall demonstrates alternating degrees of attenuation, with an inner and outer layer of higher attenuation and a middle layer of lower attenuation
  50. 50. TARGET SIGN  The higher-attenuation inner and outer layers represent the mucosa and muscularis propria, respectively.  The high attenuation of these layers is believed to be secondary to contrast enhancement from inflammation.  The lower attenuation middle layer is thought to be due to submucosal bowel wall edema.
  51. 51. Contrast-enhanced CT image of the small bowel in a patient with Crohn’s disease reveals rings of high attenuation representing the hyperemic mucosa and muscularis propria of the small bowel. The hypodense ring represents the edematous submucosa. This enhancement pattern creates the target sign.
  52. 52. COILED SPRING SIGN  The “coiled spring” sign can be seen anywhere in the bowel where an intussusception has occurred.  These ring shadows represent contrast reflux within the lumen between the walls of the intussusceptum and intussuscipiens
  53. 53. COILED SPRING SIGN  Classically, this sign describes the appearance of the cecum in the presence of appendiceal intussusception, a rare entity.  It is thought that the coiled-spring appearance results from intussusception of the cecal tip with the invaginated appendix acting as the lead point for variable amounts of cecocecal or cecocolic intussusception
  54. 54. Plain radiograph of the abdomen following the administration of contrast through a feeding tube in a patient who is status postgastric bypass demonstrates a coiled-spring appearance of the small bowel secondary to intussusception
  55. 55. ARROWHEAD SIGN  This perceived arrowhead shape is secondary to focal, symmetric thickening of the cecal wall secondary to spreading inflammation from appendicitis  The cecal wall thickening causes funneling of oral or rectal contrast material within the upper cecum, which points to the obstructed appendiceal orifice
  56. 56. ARROWHEAD SIGN  The arrowhead sign, which is obtained after the administration of oral and/or rectal contrast material, is seen on computed tomographic (CT) images as an arrowhead-shaped collection of contrast medium localized to the upper part of the cecum near the orifice of the appendix
  57. 57. Contrast-enhanced CT image in a patient with right lower- quadrant pain demonstrates arrowhead-shaped inflammatory changes of the cecal base secondary to acute appendicitis. Note the thickened appendix.
  58. 58. THUMBPRINT SIGN  This sign is seen in roughly 75% of cases of transient, nongangrenous ischemic colitis  Other conditions that may also produce the thumbprint sign include 1. Pseudomembranous colitis 2. Ulcerative colitis 3. Lymphoma 4. Leukemia 5. Coagulopathies
  59. 59. THUMBPRINT SIGN  This sign describes smooth, rounded impressions causing filling defects classically seen in barium studies of ischemic colitis.  These nodular densities represent edema and hemorrhage into the wall of the colon most commonly secondary to ischemia
  60. 60. Plain radiograph of the abdomen in a patient with ischemic colitis demonstrates thickening of the haustra secondary to edema and hemorrhage resulting in the appearance of multiple thumbprints in the wall of the colon
  61. 61. COBBLESTONE SIGN  The “cobblestone sign” is classically seen within the small and large bowel on fluoroscopic studies in the presence of active Crohn’s disease  The cobblestone appearance of the bowel wall is due to a combination of extensive, broad, linear transverse and longitudinal ulcerations within an inflamed mucosal surface. Only scattered islands of normal mucosa remain in this setting
  62. 62. Radiograph of a small bowel follow-through in a patient with Crohn’s disease demonstrates scattered islands of normal intestinal mucosa adjacent to multiple ulcerations resulting in the cobblestone appearance of the distal ileum
  63. 63. BOWLER HAT SIGN  The “bowler-hat sign” represents the appearance of a sessile colonic polyp on a double contrast barium enema  A colonic diverticulum can partially fill with barium and also produce a bowler hat appearance
  64. 64. BOWLER HAT SIGN  The bowler-hat sign is formed by a ring of barium adjacent to the base of the polyp surrounding a domed layer of barium coating the surface of the polyp  The orientation of the dome of the bowler hat sign can help differentiate a polyp from a diverticulum.  An intraluminal polyp will result in a bowler-hat sign with its dome pointed inward toward the lumen, while a diverticulum will produce a bowler hat sign pointed outward
  65. 65. Magnified view of the sigmoid colon demonstrates " the bowler hat sign" of the mid-sigmoid sessile polyp seen obliquely (arrowhead) and diverticula en face (arrow).
  66. 66. MEXICAN HAT SIGN  Pedunculated colonic polyps form the “Mexican hat sign”  The Mexican hat sign is formed by the appearance of 2 concentric rings  The outer ring represents the “en face” visualization of barium coating the surface of the head of a pedunculated polyp, while  The inner ring represents a meniscus of barium surrounding the stalk of the polyp visualized through the head
  67. 67. Radiograph of an upper gastrointestinal series demonstrates a pedunculated gastric polyp demonstrating a close resemblance to a Mexican hat.
  68. 68. COLLAR BUTTON SIGN  “Collar button ulcers” are manifestations of inflammatory processes within the bowel.  These deep ulcerations are classically seen in the colon associated with active ulcerative colitis  However they have also been observed in the setting of other inflammatory bowel processes, such as 1. Crohn’s disease 2. Ischemic colitis 3. Shigellosis
  69. 69. COLLAR BUTTON SIGN  The collar button appearance is formed by mucosal ulceration with associated undermining of the ulcer’s edge by lateral submucosal extension  Vertical penetration into the bowel wall is limited due to the resistance of the underlying muscularis mucosa, thus resulting in the discoid collar button appearance of these ulcers
  70. 70. Radiograph from a single contrast barium enema in a patient with active ulcerative colitis shows a deep ulcer within the descending colon that demonstrates a collar button appearance
  71. 71. APPLE CORE SIGN  The apple core sign is classically seen in cases of colon carcinoma  This appearance is most commonly located in the sigmoid colon as well as in the ascending, transverse, and descending colon.  The apple core sign is not seen in the larger-caliber cecum.
  72. 72. APPLE CORE SIGN  The differential diagnosis of a lesion with an apple core appearance is 1. Focal diverticulitis 2. Ischemic colitis 3. Ulcerative colitis 4. Endometriosis 5. Amebiasis 6. Serosal metastatic implants 7. Infectious colitis
  73. 73. APPLE CORE SIGN  The apple core appearance is the visual manifestation of an annular lesion of the bowel with irregular overhanging edges and shouldered margins
  74. 74. Fluoroscopic image from a double contrast barium enema in a patient with changing bowel habits reveals an annular lesion with overhanging edges within the colon closely resembling an apple core.
  75. 75. ACCORDION SIGN  The “accordion sign” describes the appearance of colonic wall thickening in the setting of colitis  The accordion sign has also been observed with 1. colonic edema secondary to cirrhosis 2. Crohn’s disease 3. Ischemic colitis 4. Lupus vasculitis 5. Infectious colitis.
  76. 76. ACCORDION SIGN  This sign describes the appearance of alternating, edematous haustral folds that are due to transmural edema and are separated by transverse mucosal clefts filled with oral contrast .  Oral contrast is trapped between thickened, edematous colonic folds and pseudomembranes in the setting of C. difficile-induced pseudomembranous colitis
  77. 77. White oval highlights markedly thickened bowel wall with oral contrast trapped between haustral folds in a patient with known C difficle colitis. This is the "accordion sign."
  78. 78. LEAD PIPE SIGN  The lead pipe appearance of the colon is classically seen with chronic, smoldering ulcerative colitis.  The differential diagnosis for a lead pipe appearance of the colon includes 1. Crohn’s disease 2. Tuberculosis 3. Amebiasis
  79. 79. LEAD PIPE SIGN  The lead pipe appearance likely represents the visual manifestation of multiple pathophysiological processes  There is increased regeneration of the colonic mucosa in ulcerative colitis.  This mucosal regeneration may lead to hypertrophy of the muscularis mucosae.  Contraction of this hypertrophic muscle layer gives the colon the lead pipe-like narrowed, ahaustral, and foreshortened appearance
  80. 80. Radiograph from a double contrast barium enema in a patient with chronic, smoldering ulcerative colitis demonstrates an ahaustral, pipe-like appearance of the colon
  81. 81. REFERENCES 1. Abbas MA, Collins JM, Olden KW. Spontaneous intramural small-bowel hematoma: Imaging findings and outcome. Am J Gastroenterol.2002;179:1389- 1394. 2. Nelson SW. Some interesting and unusual manifestations of Crohn’s disease (“regional enteritis”) of the stomach, duodenum, and small intestine. Am J Roentgenol Radium Ther Nucl Med. 1969;107: 86-101. 3. Cotran RS, Kumar V, Robbins SL. Diseases of Immunity. In Schoen, FJ, ed. Robbins Pathologic Basis of Disease. 5th ed. Philadelphia, Pa:W.B. Saunders; 1994:801-804. 4. Goldberg HI, Gore RM, Margulis AR, et al. Computed tomography in the evaluation of Crohn disease. Am J Gastroenterol. 1983;140:277-282. 5. Jones B, Kramer SS, Sara R, et al. Gastrointestinal inflammation after bone marrow transplantation: Graft-versus-host disease or opportunistic infection? Am J Gastroenterol. 1988;150:277-281. 6. Jones B, Wall S. Gastrointestinal disease in the immunocompromised host. Radiol Clin North Am. 1992;30:555-577. 7. Kalantari BN, Mortele KJ, Cantisani V, et al. CT features with pathologic correlation of acute gastrointestinal graft-versus-host disease after bone marrow transplantation in adults. Am J Gastroenterol. 2003;181:1621-1625. 8. Gramm HF, Vincent ME, Braver JM. Differential diagnosis of tubular small bowel. Curr Imaging

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