Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

powerstage
09.07.2019 Views

PART III SECTION 9 Bowel Bowel Wall Thickening 1000

Bowel Wall Thickening Differential Diagnoses: Bowel DIFFERENTIAL DIAGNOSIS Common • Inflammatory Bowel Disease (IBD) ○ Crohn Disease ○ Ulcerative Colitis • Bowel Neoplasms ○ Adenocarcinoma ○ Lymphoma ○ Carcinoid ○ Gastrointestinal Stromal Tumors • Diverticulosis/Diverticulitis • Intussusception • Intestinal Ischemia ○ Primary – Acute Arterial Ischemia – Acute Venous Ischemia ○ Secondary – Secondary to Closed Loop Obstruction ○ Ischemic Colitis • Acute Infective Enteritis/Colitis • Reactive Thickening Adjacent to Inflammatory Process ○ Appendicitis, Cholecystitis • Chronic Edema ○ Portal Hypertension ○ Hypoproteinemia • Acute Edema ○ Prestenotic in Acute Bowel Obstruction Less Common • Tuberculosis • Clostridium Difficile Colitis • Mural Hemorrhage • Deep Infiltrative Endometriosis • Post-Radiation Enteritis • Excess Fat Deposition in Bowel Wall • Cystic Fibrosis Rare but Important • Vasculitis ○ Systemic Lupus Erythematosus • Graft-vs.-Host Reaction • Intestinal Amyloidosis • Systemic Mastocytosis ○ Inflammatory Bowel Disease (Mimic) • Behçet Disease ○ Crohn Colitis (Mimic) • Intestinal Lymphangiectasia ESSENTIAL INFORMATION Key Differential Diagnosis Issues • Clinical presentation is important ○ Overlapping findings from different causes • Identify site of involvement ○ Stomach, small bowel, or large bowel • When there is thickening, map bowel upstream and downstream • Comment on ○ Diffuse or focal thickening ○ When diffuse, length involved, and degree of thickening ○ Mural flow and surrounding vascularity with color flow and power Doppler • Assess for preservation/absence of mural stratification • Assess and comment on the perienteric/pericolonic fat • Observe and comment on peristalsis • Comment on presence of peritoneal free fluid • Contrast-enhanced US useful is assessing activity of IBD, inflammatory thickening, and bowel wall ischemia Helpful Clues for Common Diagnoses • Crohn Disease ○ Transmural inflammatory process ○ Most commonly occurs in terminal ileum ○ Usually noncompressible, rigid, and fixed ○ Wall thickening is symmetrical and circumferential – May be continuous or skipped ○ Hypertrophy of the mesenteric fat ○ Echogenic tissue "creeping fat" extending to antimesenteric surface of bowel ○ Mural stratification gut signature is usually preserved – Prominent widened echogenic submucosal layer is seen due to fibrofatty proliferation – In some, there is loss of gut signature, which is more common in active disease ○ Associated luminal narrowing – Inflammatory or fibrotic ○ Power Doppler useful in showing mural increased vascularity and engorged vasa recta: Comb sign ○ Bowel fistulation and abscess formation from deep penetrating ulcers can be detected ○ Involved segment shows aperistalsis or moderately reduced peristalsis • Ulcerative Colitis ○ Mucosal inflammatory process – Thickening is mild with loss of haustra coli – Mural stratification is preserved ○ Continuous involvement of colon ○ Suspect toxic megacolon when – Wall thickness reduced, gaseous distension, ascites • Adenocarcinoma ○ Segmental annular lesion – Affects short segment – May be associated with bowel obstruction ○ Focal mass ± ulceration ○ Loss of mural stratification ○ Extra mural tumor infiltration may be visible • Lymphoma ○ Most commonly occurs in stomach, small intestine, colon, and esophagus in decreasing order of frequency ○ Loss of gut signature ○ Morphology – Segmental circumferential, focal mass, or multifocal bowel wall involvement – Extramural spread into mesentery ○ Dilatation of bowel lumen may be seen – Rarely results in bowel obstruction ○ ± hepatosplenomegaly, lymph node enlargement • Carcinoid ○ Most common small bowel tumor 1000

PART III<br />

SECTION 9<br />

Bowel<br />

Bowel Wall Thickening 1000

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