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CT of Bowel Wall Thickening

Significance and Pitfalls of Interpretation

¹ Both authors: Department of Radiology, NYU Medical Center, Tisch Hospital, 560 First Ave., Ste. HW 207, New York, NY 10016.

View larger version (130K): [in a new window]   Fig. 1. —Normal enhancement and appearance of small bowel in 77-year-old woman. Axial CT scan obtained at level of kidneys with IV contrast material and water as oral contrast agent shows enhancement of normal bowel wall. Note thinly enhancing valvulae conniventes (arrow). This finding is often better seen when water alone is given as oral contrast agent. Enhancement may be obscured with positive contrast in lumen.

View larger version (186K): [in a new window]   Fig. 2A. —Perceived pitfall in interpretation of bowel wall thickening caused by mixing of water and oral contrast material in 47-year-old man with history of lymphoma. Axial CT scan through upper abdomen shows apparent homogeneous circumferential thickening of wall of jejunum loops (arrow), a finding suspicious for lymphoma.

View larger version (147K): [in a new window]   Fig. 2B. —Perceived pitfall in interpretation of bowel wall thickening caused by mixing of water and oral contrast material in 47-year-old man with history of lymphoma. Radiograph from upper gastrointestinal series performed 2 days after A shows normal small bowel (arrow).

View larger version (161K): [in a new window]   Fig. 3. —Normal colonic wall thickness in 81-year-old woman with breast cancer. Contrast-enhanced axial CT scan of cecum suggests bowel wall thickening with target appearance (arrow). However, ventral wall is thin, without target appearance (arrowhead). Occasionally, residual fluid in bowel can mimic submucosal edema and bowel wall thickening, as in this case. Identifying focal area of distention without adjacent fluid will clarify wall thickness.

View larger version (143K): [in a new window]   Fig. 4A. —"Target" sign detected only after IV contrast administration in 64-year-old man with pain and bloody diarrhea. CT scan obtained without IV contrast material shows moderate circumferential thickening of sigmoid colon (arrow). Attenuation of bowel wall is homogeneous. Without IV contrast material, further characterization is not possible.

View larger version (114K): [in a new window]   Fig. 4B. —"Target" sign detected only after IV contrast administration in 64-year-old man with pain and bloody diarrhea. Contrast-enhanced axial CT image obtained 48 hr after A at same level shows thickened sigmoid with target configuration (arrow). Findings suggest inflammation or ischemia. Endoscopy and biopsy confirmed ischemic colitis.

View larger version (158K): [in a new window]   Fig. 5. —Deposition of fat in submucosa producing "target" sign in 85-year-old man with history of chronic ulcerative colitis. Contrast-enhanced axial CT scan of rectum shows target configuration with central low attenuation in submucosa (arrow). Central low attenuation is same density (-80 H) as surrounding perirectal fat, indicating submucosal fat deposition. Patient was asymptomatic at time of examination.

View larger version (117K): [in a new window]   Fig. 6A. —Improved detection and evaluation of intramural air with wide window and low level settings in 34-year-old woman with AIDS and diarrhea. Contrast-enhanced axial CT scan (window width and level, 420 and 30 H) at level of cecum shows gas surrounding cecum (arrow).

View larger version (86K): [in a new window]   Fig. 6B. —Improved detection and evaluation of intramural air with wide window and low level settings in 34-year-old woman with AIDS and diarrhea. Same CT slice as A (window width and level, 1550 and -460 H, respectively) better shows that central low attenuation (gas) is in wall (arrow) of cecum, which is compatible with pneumatosis. Patient was treated with antibiotics, improved within a week, and did not require colectomy.

View larger version (165K): [in a new window]   Fig. 7. —Intramural hemorrhage in 64-year-old man with bowel wall thickening (homogeneous attenuation). Contrast-enhanced axial CT scan of abdomen shows segmental circumferential thickening with homogeneous attenuation of a loop of jejunum (arrow). Differential diagnosis includes hemorrhage, ischemia, and lymphoma. Because of history of anticoagulation therapy and abrupt onset, hemorrhage is most likely. Unenhanced study can better define high attenuation.

View larger version (159K): [in a new window]   Fig. 8A. —Ischemic bowel with mural thickening and target configuration of attenuation in 71-year-old woman. Contrast-enhanced axial CT scan at level of terminal ileum shows circumferential small-bowel wall thickening with target configuration (arrow).

View larger version (153K): [in a new window]   Fig. 8B. —Ischemic bowel with mural thickening and target configuration of attenuation in 71-year-old woman. Contrast-enhanced axial CT scan at level of superior mesenteric artery shows intraluminal filling defect (arrow) consistent with mural thrombus. Thrombus was confirmed at follow-up angiography.

View larger version (147K): [in a new window]   Fig. 9. —Closed-loop small-bowel obstruction with ischemic bowel in 83-year-old woman. Contrast-enhanced axial CT image at level of pelvis shows typical configuration of closed-loop obstruction with dilated small-bowel loops in radial distribution, minimal to no mural thickening, and homogeneous attenuation (open arrows). Note loops in closed-loop obstruction do not enhance to same degree as loops not in closed loop (solid arrow), suggesting ischemia. Ischemic bowel with infarction was present at subsequent surgery.

View larger version (104K): [in a new window]   Fig. 10. —Well-differentiated adenocarcinoma in 26-year-old man with bowel obstruction. Contrast-enhanced axial CT scan at level of cecum shows homogeneous attenuation (enhancement) of circumferentially thickened cecum (straight arrows). Small amount of fluid is seen in lumen (arrowhead). Note multiple obstructed loops of small bowel with air—fluid levels (curved arrow). Surgery revealed well-differentiated adenocarcinoma of cecum.

View larger version (147K): [in a new window]   Fig. 11. —Lymphoma of small bowel in 30-year-old man. Contrast-enhanced axial CT image of mid abdomen shows homogeneous attenuation (enhancement) of markedly thickened small bowel (arrows). Thickening involves a short segment of small bowel. Despite small-bowel thickening, mild dilatation of lumen is seen. Findings are strongly suggestive of small-bowel lymphoma. Note retroperitoneal lymphadenopathy (arrowhead). Biopsy revealed non-Hodgkin's lymphoma.

View larger version (142K): [in a new window]   Fig. 12. —"Target" sign in 35-year-old woman with history of ulcerative colitis. Contrast-enhanced axial CT image of rectum shows mild wall thickening with classic target appearance and inner enhancement of mucosa (short white arrow) and outer enhancement of muscular layer (long white arrow) surrounding low-attenuation edematous submucosa (black arrow).

View larger version (127K): [in a new window]   Fig. 13. —"Target" sign in 37-year-old man with history of acute Crohn's disease. Contrast-enhanced axial CT image shows marked circumferential thickening of terminal ileum. Target appearance is present, with enhancement of mucosa (short arrow) and outer enhancement of muscular layer (long arrow) surrounding low-attenuation edematous submucosa (arrowhead).

View larger version (119K): [in a new window]   Fig. 14. —"Target" sign in 37-year-old woman with history of lupus erythematosus. Contrast-enhanced axial CT image at level of mid abdomen shows diffuse marked circumferential thickening of colon. Target appearance is present, with enhancement of mucosa (short white arrow) and outer enhancement of muscular layer and serosa (long white arrow) surrounding low-attenuation edematous submucosa. Small amount of ascites is present (arrowhead).

View larger version (159K): [in a new window]   Fig. 15. —Intraluminal air mimicking pneumatosis in 58-year-old man. Unenhanced axial CT scan at level of stomach shows gas (arrow) between wall of stomach and residual gastric fluid mimicking pneumatosis. Note pneumobilia (arrowhead) from previous procedure.

View larger version (179K): [in a new window]   Fig. 16. —Heterogeneous low-attenuation enhancement in mucinous adenocarcinoma with irregular circumferential bowel wall thickening in 64-year-old man with abdominal pain. Contrast-enhanced axial CT image of splenic flexure shows irregular wall thickening (arrows) with heterogeneous areas of low attenuation in colon wall (arrowhead). Large mucinous adenocarcinoma was found at surgery.

View larger version (115K): [in a new window]   Fig. 17. —Diffuse marked colonic thickening with target appearance in pseudomembranous colitis in 18-year-old woman with diarrhea. Contrast-enhanced axial CT image of mid abdomen shows diffuse marked circumferential wall thickening of cecum and descending colon with target appearance (arrows). Findings are consistent with inflammatory colitis; stool was positive for Clostridium difficile cytotoxin.

View larger version (133K): [in a new window]   Fig. 18. —"Accordion" sign in 44-year-old man with diarrhea and Clostridium difficile colitis. Contrast-enhanced axial CT image of mid abdomen shows marked thickening of haustra (arrowheads). Barium (arrow) trapped between thickened haustra mimic appearance of accordion.

View larger version (152K): [in a new window]   Fig. 19. —Exophytic intestinal mass in 84-year-old man with bowel obstruction. Contrast enhanced axial CT image shows large bulky exophytic mass extending from jejunum with heterogeneous attenuation (white arrows). Small bubble of gas is present in mass (black arrow), suggesting fistula in bowel. Surgery revealed malignant gastrointestinal stromal tumor.

View larger version (140K): [in a new window]   Fig. 20A. —CT scans of focal asymmetric thickening in 59-year-old man show importance of rectal distention. Axial scan at level of rectum shows lack of distention (arrow), which limits the examination.

View larger version (134K): [in a new window]   Fig. 20B. —CT scans of focal asymmetric thickening in 59-year-old man show importance of rectal distention. Axial scan at same level as A performed after administration of rectal air shows focal asymmetrically thickened ulcerated mass (arrow) on nondependent wall of rectum. Biopsy revealed rectal adenocarcinoma.

View larger version (121K): [in a new window]   Fig. 21. —Diffuse mild colonic wall thickening in 35-year-old woman. Contrast-enhanced axial CT image shows mild circumferential wall thickening of ascending and descending colons (arrows). Diffuse mild colitis suggests infection or ulcerative colitis. Endoscopy revealed ulcerative colitis.

View larger version (146K): [in a new window]   Fig. 22A. —42-year-old woman with low-attenuation caseating lymph nodes in intestinal tuberculosis. Contrast-enhanced axial CT image of cecum shows irregular focal thickening (arrow) with associated small regional lymph nodes (arrowhead). Findings mimic cecal carcinoma.

View larger version (149K): [in a new window]   Fig. 22B. —42-year-old woman with low-attenuation caseating lymph nodes in intestinal tuberculosis. Contrast-enhanced axial CT image 1 cm cephalad to A shows larger lymph node with central low attenuation (arrow). Endoscopy and biopsy revealed cecal tuberculosis.

View larger version (152K): [in a new window]   Fig. 23A. —Benign versus malignant colonic lesion: importance of lymphadenopathy. Contrast-enhanced axial CT scan of descending colon in 43-year-old man shows mild bowel wall thickening (straight arrow) with fluid in adjacent paracolic gutter (arrowhead). Small diverticulum is present (curved arrow). Findings are consistent with mild focal diverticulitis, which resolved after antibiotic therapy.

View larger version (169K): [in a new window]   Fig. 23B. —Benign versus malignant colonic lesion: importance of lymphadenopathy. 66-year-old man with left-sided abdominal pain. Contrast-enhanced axial CT image at level of descending colon shows mild thickening (long arrow) with fluid and stranding in adjacent paracolic gutter (arrowhead). In addition, cluster of small lymph nodes is seen in adjacent pericolonic fat (short arrow). This finding (lymphadenopathy) is more commonly present in focal adenocarcinoma than in diverticulitis. Surgery revealed adenocarcinoma, and seven of nine lymph nodes tested positive for lymphadenopathy.

View larger version (110K): [in a new window]   Fig. 24. —Mesenteric mass with calcification and adjacent desmoplastic reaction in 80-year-old woman with abdominal pain. Contrast-enhanced axial CT image of abdomen shows soft-tissue mass with small calcifications (black arrow) in mesentery (straight white arrow). Note desmoplastic response with stranding of adjacent fat and associated bowel wall thickening (curved arrow). Surgery revealed carcinoid tumor.

View larger version (128K): [in a new window]   Fig. 25. —Abscess in Crohn's disease in 21-year-old man. Contrast-enhanced axial CT image of pelvis shows segmental distal ileal thickening with "target" sign (white arrow) and abscess in right iliopsoas muscle (black arrow).

View larger version (138K): [in a new window]   Fig. 26. —Colonic edema in cirrhosis in 50-year-old man. Contrast-enhanced axial CT image of right colon shows mild circumferential wall thickening in right colon and target appearance consistent with edema (arrow). Patient did not have pain or diarrhea. CT of liver (not shown) showed findings consistent with cirrhosis.

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