Non-Hodgkin lymphoma of the small intestine

The authors present a simplified radiographic classification of non-Hodgkin lymphoma involving the small intestine. The classification system is based on radiographic findings in 22 pathologically proved cases of lymphoma involving the small bowel and consists of three major forms: primary, lymphoma complicating celiac disease, and mesenteric nodal. In this series, small bowel lymphoma was evenly distributed in the jejunum and ileum. The most common radiographic patterns were circumferential lesion (seven cases), cavitary lesion (four cases), and mesenteric nodal disease invading the small bowel (seven cases). Obstructive symptoms were usually encountered with the mesenteric nodal form. Lymphoma complicating celiac disease was typified by multiple, thickened, nodular folds involving a segment of proximal small intestine.     

Primary lymphoma of the small intestine: clinico-radiological correlations

From 1987 to 1989, 7 patients were diagnosed as having a primary lymphoma of the small bowel. The patients, 5 men and 2 women aged 14-66 years (average: 45), were studied by means of small bowel enema and CT. Using small bowel enema, our findings were: masses related to a loop, stenosis, mucosal patterns with thick, irregular, and nodular folds, and bowel walls thickening. In nearly all cases CT showed not only small bowel lesions but also mesenteric lymphadenopathy. Five of seven patients had lymphomas, 1 had IP-SID lymphoma (immunoproliferative small intestinal disease related lymphoma), and 1 had IPSID associated with a late prelymphomatous stage. The diagnosis of IPSID is very important in patients with malabsorption syndrome, which may or may not be related to alpha heavy chain disease, because IPSID may evolve into lymphoma but its prelymphomatous stage can be treated and cured. We have therefore reported the different features seen with enteroclysis and CT, comparing the results obtained in the various forms of lymphoma of the small bowel. The importance is stressed of an accurate diagnosis of IPSID forms, however uncommon in our Country.     

Capsule enteroscopy and radiology of the small intestine

In a very few years, the video capsule for small bowel enteroscopy has gained widespread clinical acceptance. It is readily ingested, disposable, and allows for a complete, low-invasive endoscopic examination of the entire mucosa of the small bowel. It is a patient-friendly method and a first-line procedure in the difficult evaluation of obscure gastrointestinal bleeding. It has the highest proven figure of diagnostic sensitivity for detecting lesions of the mucosa, irrespective of aetiology. The limitations of capsule endoscopy include difficulty in localising mucosal lesions anatomically and its restricted use in patients with dysphagia, strictures or motor dysfunction. Strictures, transmural and extra-mural lesions in patients with small bowel Crohn’s disease are evaluated by MRI- enterography and CT-enterography.     

Multidetector CT of the small bowel: evaluation after oral hyperhydration with isotonic solution

PURPOSE: The aim of our study was to assess the diagnostic capabilities of multidetector CT in the evaluation of the small bowel in different pathological conditions, with the use of oral hyperhydration with isotonic solution. MATERIALS AND METHODS: The study retrospectively evaluated 106 patients who underwent multidetector CT of the small bowel. Four groups were considered on the basis of the clinical findings: group A (48 cases), with suspected or certain chronic inflammatory disease of the small bowel; group B (16 cases), with suspected neoplastic lesion of the small bowel; group C (17 cases), patients affected by malabsorption; group D (25 cases), others: 13 cases with non-specific abdominal pain, 4 cases with occult bleeding, 8 cases affected by fever of unknown origin. Thirteen patients had previously undergone surgical intestinal resection. In all cases the CT examination was performed after the oral administration of 2000 mL polyethylene glycol electrolyte balanced solution; before the scan, N-butyl scopolamine or glucagon were administered intravenously to obtain rapid inhibition of bowel peristalsis. All multidetector CT scans were acquired at baseline and 50 seconds after the I.V. administration of 110-130 ml high-concentration non-ionic iodinated contrast medium. The images were subsequently processed on a dedicated workstation (Advantage Windows 4.0, GE Medical Systems) to obtain multiplanar reconstruction (MPR). We considered the following CT findings: fold distribution, wall thickening and stratification and contrast enhancement, extraparietal involvement and abnormalities of the abdominal organs. The CT diagnoses were compared with the clinical and laboratory findings (86 cases) and with the results of barium follow-through (55 cases), ileo-colonoscopy (45 cases) or surgery (28 cases). RESULTS: CT examination allowed the correct diagnosis in 86/106 cases (89%); 20 patients were not included in the study because of a poor (11 cases) or absent (9 cases) small bowel loop distension. The final diagnoses in the 86 patients were: Crohn's disease of the small bowel (38 cases), Crohn's disease of the duodenum (1 case), granulomatous colitis (3 cases), malabsorption (8 cases), neoplastic lesion (4 cases), post-radiation conglomeration of ileal loops (1 case), intestinal lymphangiectasia (1 case), ulceration of the last ileal loop (1 case). In 29 cases no abnormalities of the small bowel were found. Spiral CT yielded 52 true positive cases, 5 false negative cases, 2 false positive cases, and 27 true negative RESULTS: The sensitivity of the technique was 91%, specificity 93% and diagnostic accuracy 92%. CONCLUSIONS: Multidetector CT of the small bowel performed after oral hyperhydration with isosmotic solution, proved to be an accurate and thorough technique. It can be considered a safe and effective alternative to conventional radiographic studies and to small bowel spiral CT enema in patients that refuse the nasojejunal balloon catheter or the administration of methylcellulose.     

CT of the small intestine

CT of the small intestine continues to be a diagnostic challenge. Three protocols have turned out to be useful. The frequently used general protocol is highly suitable for most indications that require an overview of the small intestine and in cases where no specific queries regarding the small intestine have to be answered. A dedicated protocol with opacification of the small intestine by means of a probe appears to be useful in patients with a suspected tumour or to exclude a tumour as well as in cases of inflammatory bowel disease. Filling of the bowel ensures optimal distention and, in combination with intravenous contrast medium administration, allows differentiation of tumours from inflammatory lesions. In cases of suspected intestinal ischaemia, angiographic techniques should be used. State-of-the-art techniques such as bolus tracking and acquisition of a dynamic scan for determination of individual circulation time facilitate optimal arterial opacification of the intestinal wall. The results obtained in our patients suggest that the use of multislice CT in combination with optimal opacification improves sensitivity. Further studies have to show whether the improved diagnostic options also translate into an improved clinical outcome or survival rate.     

Malignant stromal tumors of the small intestine: report of 9 cases

PURPOSE: Analysis of imaging features of malignant stromal tumors of the small bowel and review of literature. MATERIAL AND METHODS: 9 cases of malignant stromal tumor of the small bowel with histological proof were imaged at US (8 cases), small bowel series (9 cases) and CT scan (3 cases). RESULTS: There were 6 cases of leiomyosarcoma and 3 cases of malignant schwannoma. Tumors involved the jejunum in 3 patients, the ileum in 4 patients, and the duodenum in 2 patients. The main clinical presentation was an abdominal mass (8 cases), which appeared heterogeneous and hypoechoic with eccentric lumen at US confirming its GI origin (7 cases). Small bowel series showed a bulky cavitary mass opacified via a thin fistula (7 cases), an ileo-ileal intussusception (1 case) and enlarged duodenal lumen (1 case). CT performed in 3 cases showed an intraperitoneal mass with soft-tissue density. A communication with the GI tract was noted in 1 case, and in another case, it showed an intestinal intussusception. US guided biopsy performed in 3 cases provided diagnosis in 2 cases (malignant schwannoma, leiomyosarcoma). Tumor growth was exophytic in 8 cases and dumbbell-shaped in 1 case. CONCLUSION: The imaging features of malignant stromal tumors of the small bowel are similar. It varies with the type of tumor growth and its size. The diagnosis may be suggested based on imaging features.     

Crohn disease of the small bowel: spiral CT evaluation after oral hyperhydration with isotonic solution

PURPOSE: Our aim was to evaluate the accuracy of spiral CT study of small-bowel Crohn disease with use of oral hyperhydration with isoosmotic solution. METHOD: We prospectively analyzed 33 consecutive patients and 10 control subjects with spiral CT after oral administration of 2,000 ml of polyethylene glycol electrolyte-balanced solution. The CT diagnoses were compared with the results of conventional radiologic oral barium examination (33 cases), ileum colonoscopy (8 cases), and surgery (4 cases). RESULTS: The final diagnoses were Crohn disease (14 cases), no small-bowel disease (16 cases), cancer of ileocecal valve (1 case), carcinosis of mesenteric root (1 case), and intestinal lymphangiectasia (1 case). In the control group, no abnormalities of the small bowel were found. The sensitivity of spiral CT was 85.7%, specificity 100%, positive predictive value 100%, negative predictive value 90%, and diagnostic accuracy 93.9%. CONCLUSION: Our method allowed adequate distension of the small bowel for spiral CT studies, thus resulting in a safe and effective alternative to small-bowel spiral CT enema, which can be used in patients that refuse the nasojejunal balloon catheter.     

Assessment of small bowel Crohn disease: noninvasive peroral CT enterography compared with other imaging methods and endoscopy--feasibility study

A feasibility study was conducted to evaluate two biphasic computed tomographic (CT) enterography protocols, a noninvasive CT technique with water administered perorally and CT enteroclysis with methylcellulose administered through a nasojejunal tube, in 23 patients known or suspected to have Crohn disease. Results were compared with the results of fluoroscopic small bowel examination and terminal ileoscopy for the detection of active Crohn disease in the terminal ileum. Luminal distention did not differ significantly between the two CT protocols. Arterial phase imaging was noncontributory in 22 of 23 cases. The noninvasive peroral water CT enterography protocol had similar accuracy (12 of 15 cases, 80%) for enabling the detection of active Crohn disease in comparison with CT enteroclysis with nasojejunal tube (seven of eight, 88%) and fluoroscopic small bowel examination (17 of 23, 74%). No fistulas were missed with use of either CT technique. The authors conclude that noninvasive peroral portal venous phase CT enterography with use of water is an accurate and feasible technique for detecting active small bowel inflammation in patients with Crohn disease.     

Barium examinations of the small intestine and the colon in inflammatory bowel disease

PURPOSE: This article gives an overview of the possibilities of conventional radiography in the diagnosis of inflammatory bowel disease of the small intestine and colon. MATERIAL AND METHODS: For more than 25 years we examine the small bowel employing enteroclysis with barium and methylcellulose and the colon with the usual double-contrast method. In the last 152 months 1560 small bowel enemas were performed. In the last 40 months 410 examinations of the colon were performed. RESULTS: There is a thirty percent decrease in enteroclysis examinations within the past 5 years,however, the rate of examinations with positive results increased from 46 to 57%.The proportion of the inflammatory small intestinal diseases (not only Crohn's disease) remained constant with 18%.Concerning the examinations of the colon for inflammatory disease we confirmed the diagnosis in seven cases.The radiation exposure for the enteroclysis in inflammatory diseases was 7 mSv, for colon examinations 14 mSv. CONCLUSION: Barium examinations, especially of the stomach and colon are decreasing in frequency.Therefore the art of performance and interpretation might get lost.Enteroclysis, however, is still the method of reference for the other imaging methods.The advantages compared to the other imaging methods are the excellent presentation of the details of the mucosal surface and the observation of functional disorders.     

Double-contrast study of the small intestine using enteroclysis. Considerations on the results in 250 patients

The value of double contrast small bowel enema via duodenal intubation using barium sulphate and methylcellulose as contrast media was assessed in 250 patients. In cases of small bowel obstruction it represented the first-line investigation after a plain abdominal film. It was performed electively in patients of painful bowel syndrome, in cases of malabsorption, in cases of endoscopically or radiologically diagnosed colitis and in patients with Crohn's disease. On the basis of our results we believe double contrast small bowel enema to be the most reliable investigation in the localization and identification of small bowel lesions.     

Experience with double-contrast examination of the small intestine

Experiences and results of 600 small bowel examinations in double-contrast technique are reported. Pathologic lesions were found in 40%. The double-contrast technique has proved to be an efficient method in detecting small bowel pathology. Its specific value lies in precise delineation of pattern, extent and intensity of disease.     

Crohn's disease of the small intestine

The small bowel remains the most frequent site of inflammation in Crohn's disease, involving 75 to 85 per cent of all patients. In spite of the advent of newer imaging modalities and the increasing sophistication of endoscopy, barium studies remain the primary method of diagnosis and evaluation of small bowel Crohn's disease. It is important not only to detect the presence of disease, but also to give a correct anatomic distribution as well as identify possible complications.     

Lymphoma of the small intestine: radiological appearances

The radiological features of small intestinal lymphoma are described in 11 patients examined using the small bowel enema technique. The signs include luminal narrowing with mucosal destruction and occasionally shouldering of the margins and stricture formation, broad based ulceration, cavitation, non-specific thickening of the valvulae conniventes, discrete intraluminal filling defects, and a mass. In one patient, small nodules were scattered throughout the small intestine. Aneurysmal dilatation of a segment of intestine was seen in one case and an extraluminal mesenteric mass in another. A combination of different signs was a frequent finding and multiple intestinal lesions were present in four cases. Predisposing factors were present in five cases including coeliac disease, chronic lymphatic leukaemia, immunoproliferative small intestinal (alpha-chain) disease and previous extraintestinal lymphoma. In another patient there was evidence of extraintestinal lymphoma at the time of presentation.     

Ileal carcinoid tumors. Value of small intestine transit

The authors describe two personnel observations of ileal carcinoid tumors, demonstrated by double contrast small bowel examination. Confirmation came from operation and histology. Small bowel examination can demonstrate limited carcinoid tumors giving no angiographic traduction.     

Secondary non-Hodgkin's lymphoma of the small intestine. Double-contrast radiological study using oral enema

The small bowel double contrast enema was performed in 44 patients with diffuse non-Hodgkin lymphoma. "Secondary" involvement of small bowel is detected in 14 subjects (31.8%), but radiographic features are not specific for the disease. Really, lymphoma and regional enteritis may demonstrate strikingly similar patterns. The signs we have considered are: intraluminal involvement, with narrowing or dilated segments; diffuse or localized polypoid lesions; large extraluminal masses. The roentgenographic pattern of the mucosal folds consists of thick, straight or tortuous folds, with "cogwheel" appearance and moderate dilatation of the lumen.     

两种肠道准备方法在多层螺旋CT小肠造影中的效果对比

目的在小肠造影CT检查中,探讨2种口服对比剂对小肠充盈扩张效果和CT采集时间的影响。方法本文分析了以2.5%等渗甘露醇溶液为对比剂49例和以非离子型碘剂稀释液为对比剂57例,用药量为1 500～2 000 mL,分别在30 min、45 min和60 min 3个时间点,应用螺旋CT并综合三维重建技术采集小肠造影数据,根据对比剂到达回盲部来评价小肠充盈效果。结果口服等渗甘露醇溶液的49例观测结果为：肠管充盈扩张较好,CT值改变不大,对比剂前端到达回盲部时间相对提前;口服非离子型碘剂稀释液的57例观测结果为：肠管对比清晰,CT值改变较大。结论小肠完全充盈的时间和效果,与应用对比剂类型有关,同时对比剂的量及服用的持续程度对小肠的充盈扩张非常重要。     

Leiomyoma of the small intestine

Diagnosis and surgical treatment of a leiomyoma of the small bowel are described. The special findings in this case are the unusual location of this tumors and the fact that histological examination revealed a benign process, although the tumor had a diameter of more than 16 cm.     

Cavitating metastases of the small intestine.

Ten patients with small intestinal excavating metastatic lesions are described. Cavitation of a mass is a generally unrecognized appearance of metastatic disease to the small intestine and should be considered in the differential diagnosis of small bowel excavation.     

Segmental ischemic lesions of the mesenteric small intestine

Segmental ischemic disease consists of segmental infarctions and ischemic stenoses. Vasculitis (LES, polyarteritis nodosa, Sch?nlein-Henoch syndrome), thrombosis, arteriosclerotic changes, mechanical obstructions (adhesions, hernia, volvulus, traumas), hemorrhagic disorders are the most common causes of these intestinal lesions. The authors report their experience achieved during three years on 428 small bowel examinations; among these, 197 were double contrast enemas. Ten patients showed roentgenographic features referred to vascular diseases: 1 LES, 1 Sch?nlein-Henoch syndrome, 3 polyarteritis nodosa, 5 spontaneous hemorrhagic disorders or due to treatment with anticoagulants. The authors, after a review of the radiological findings, emphasize the high sensitivity and low specificity of double contrast small bowel enema. Furthermore they underline the usefulness of this method in demonstrating and monitoring intestinal pathologic changes.     

Morpho-functional evaluation of the small intestine patients with Crohn disease. Enema of the small intestine versus post-heparin plasma diamine oxidase

Our study was directed not only towards the diagnosis of small bowel Crohn's disease, but especially to a quantitative analysis, for a correct therapeutical approach. This experimental trial is based on the relationship between radiological evidence, measured during small bowel enema, and the seriousness of the morphological and functional damage to the intestinal mucosal membrane, evaluated with a post-heparin diamine-oxidase activity test. With this method we studied 35 selected patients; 16 of them were affected by the disease with an exclusive localization in the small bowel and 5 have been considered separately, because 3 patients had already been operated and the other 2 showed different localizations. In our results, the two parameters were not constantly related to each other. In other words the enema's morphological data sometimes do not accord with the mucosal membrane integrity index expressed by the enzyme. Anyway the importance of this study is the attempt of making an objective comparison between an anatomic situation and its functional consequence. These aspects have a great significance in Crohn's disease.