The early manifestation of Yersinia colitis demonstrated by the double-contrast barium enema

A 19-year old female with a bloody, diarrheal illness of acute onset where Crohn's disease primarily was suspected is presented. The double - contrast barium enema revealed multiple, diffusely scattered aphthous erosions of the colonic mucosa: the rectum was scarcely affected. Biopsies taken by endoscopy demonstrated nonspecific inflammatory changes of the mucous membrane. However, routinely taken stool cultures revealed an infectious colitis due to Yersinia enterocolitica. Our case demonstrates the necessity to consider Yersinia enterocolitis in the radiographic differential diagnosis when the diagnosis of Crohn's disease or ulcerative colitis seems obvious.     

Hirschsprung disease: accuracy of the barium enema examination

To determine the relative accuracy of the various radiologic signs of Hirschsprung disease (HD), we retrospectively reviewed both radiographs obtained after a barium enema and the medical records of 62 children who had surgery to prove or exclude the diagnosis of HD. The visualization of a rectosigmoid transition zone was highly predictive of HD, but nonvisualization did not rule out HD. A false positive transition zone at the splenic flexure was seen in four neonates who had small left colon syndrome rather than HD. Retention of barium seen on radiographs obtained 24 hours after a barium enema was not a specific sign, but it was the only sign of HD in seven neonates, including two who had total colonic aganglionosis. Anal manipulation prior to the barium enema examination did not affect the diagnostic value of that procedure. We conclude that the single most reliable radiographic sign of HD is the presence of a rectosigmoid transition zone. Statistically, the use of three radiographic features combined (rectosigmoid transition zone, retention of barium, and stool mixed with barium) correlated better with the presence or absence of HD than did any of these features alone. A comparison of 24 and 48 hour postevacuation radiographs may help to differentiate HD from meconium plug syndrome.     

The radiologic picture of total colonic aganglionosis

The radiological findings pathognomonic of Hirschsprung's disease have been known for quite a long time. However, in addition to those diseases characterized by rectum or rectum-sigmoid aganglionosis (as in the classic form of Hirschsprung's disease), in pediatric pathology of surgical interest severe affections exist characterized by aganglionosis extending from the rectum to the entire colon, and exceptionally as far as the small bowel (ultra-long Hirschsprung's disease). The authors report on the results they obtained in radiological studies of 6 cases of total colonic aganglionosis by means of the current radiological procedures, i.e. plain abdominal films and barium enema. As for total colonic aganglionosis, no diagnostic radiological parameters have been assessed yet. The authors compare their results with those taken from international literature: microcolon with reflux into mega-ileum (2 out of 6 cases) appears to be the most suggestive X-ray finding for total colonic aganglionosis. Finally, the role is discussed of radiological studies in the diagnostic approach to total colonic aganglionosis. The authors conclude that, even though radiological investigations are indispensable, they are often not conclusive. Therefore, an accurate evaluation of the proximal extension of aganglionosis can be made only at surgery.     

Acute large-bowel pseudo-obstruction

The clinical and radiological features of acute large-bowel pseudo-obstruction occurring in 13 patients over a 7-year period are reviewed. Clinical features included atypical signs and symptoms of large-bowel obstruction and serious concomitant illness, including trauma in 10. The predominant radiological features were gross colonic dilatation, scant fluid levels, a gradual transition to collapsed bowel and a normal gas and faecal pattern in the rectum. Correct diagnosis was established by plain film and/or barium enema examination in the majority of cases (nine out of the 13). In the remaining four cases the diagnosis was made at laparotomy, although review of the radiographs suggested that the correct diagnosis could have been made pre-operatively in three. Instant barium enema is recommended in doubtful cases to rule out distal obstruction. Prompt recognition of the condition, with daily monitoring and conservative management, should eliminate unnecessary surgery and minimise the risk of caecal perforation.     

The left lateral view in the plain-film assessment of abdominal distension.

Since the left lateral position facilitates the entry of air into the rectosigmoid, it has been employed in the plain-film evaluation of patients with abdominal distension. The value of this view is illustrated by examples of patients with (a) colonic ileus due to imipramine hydrochloride (Tofranil) or chlorpromazine, (b) partial mechanical obstruction due to diverticulitis, (c) involvement of the rectum by Hirschsprung's disease, and (d) sequential evaluation of a patient with clindamycin colitis. This simple maneuver is recommended for (a) evaluation of patients with plain-film evidence of low colonic obstruction, (b) problems of differential diagnosis between bowel obstruction and ileus, and (c) evaluation of patients with conditions affecting the rectosigmoid.     

Adult Hirschsprung's disease

Two cases of adult Hirschsprung's disease are reported along with a review of 47 cases reported in the literature. Chronic constipation is present in almost all cases. The barium enema examination may suggest the diagnosis if an area of smooth narrowing with proximal dilatation is seen (83%), but biopsy proof of absence of ganglion cells is necessary. Fourteen per cent of patients had a dilated colon without a narrowed segment. Anal manometry is helpful if it demonstrates absence of normal anorectal inhibitory reflex. Total colonic aganglionosis in the adult has been reported, but is exceptionally unusual. The diagnosis of adult Hirschsprung's disease should be suspected in patients with a history of chronic constipation and appropriate radiographic findings.     

Computed tomography study of the sigmoid colon: discriminating diagnostic criteria and interobserver correlations]

PURPOSE: To assess the value of pericolonic findings at CT in the evaluation of the sigmoid colon. MATERIALS AND METHODS: A total of 210 CT examinations were retrospectively reviewed by 3 blinded radiologists. Data was analyzed to determine the interobserver correlation and the value of pericolonic and colonic wall findings in diagnosis of sigmoid colon pathology. RESULTS: The interobserver correlation for pericolonic findings was equal to or superior to that for colonic wall findings. The presence of abnormal pericolonic fat was the most sensitive (88%) and specific (93%) sign to differentiate a diseased sigmoid colon from a normal one or from sigmoid diverticulosis. Wall-thickening was less sensitive (82%) and specific (76%). Findings suggesting malignancy over diverticulitis included acute zone of transition, focal fatty infiltration, and lymph nodes. Symmetrical and circumferential wall thickening, target-like enhancement, and local fatty proliferation were findings suggesting colitis over diverticulitis. Wall thickening more than 15 mm, involvement of 15 cm or less, asymmetrical involvement, acute zone of transition, and homogeneous or heterogeneous enhancement were findings suggesting malignancy over colitis. CONCLUSION: To render a diagnosis, the evaluation of the fat infiltration must prevail on the parietal thickening appreciation.     

Pathogenesis of massively bleeding colonic diverticulosis: new observations.

Colonic diverticulosis is a common cause of acute severe rectal hemorrhage. The precise site of bleeding, etiology, and pathogenesis have not been previously identified. Arteriographic, microangiographic, and detailed histologic observations in 10 cases of massively bleeding colonic diverticulosis demonstrated strikingly consistent changes related to the characteristic angioarchitecture of colonic diverticula. These changes included: (1) asymmetric rupture of the vas rectum toward the lumen of the diverticulum precisely at its dome or its antimesenteric margin; (2) conspicuous eccentric intimal thickening of the vas rectum, often with thinning of the media and duplication of the internal elastic lamina at and near the bleeding point; and (3) general absence of diverticulitis. Comparison with control colonic diverticula suggests that traumatic factors arising within the diverticular or colonic lumen induce asymmetric intimal proliferation and segmental weakening of the associated vas rectum, predisposing to rupture and massive bleeding.     

Mucosal detail at CT virtual reality: surface versus volume rendering

PURPOSE: To evaluate computed tomographic virtual reality with volumetric versus surface rendering. MATERIALS AND METHODS: Virtual reality images were reconstructed for 27 normal or pathologic colonic, gastric, or bronchial structures in four ways: the transition zone (a) reconstructed separately from the wall by using volume rendering; (b) with attenuation equal to air; (c) with attenuation equal to wall (soft tissue); (d) with attenuation halfway between air and wall. The four reconstructed images were randomized. Four experienced imagers blinded to the reconstruction graded them from best to worst with predetermined criteria. RESULTS: All readers rated images with the transition zone as a separate structure as overwhelmingly superior (P <.001): Nineteen cases had complete concurrence among all readers. The best of the surface-rendering reconstructions had the transition zone attenuation equal to the wall attenuation (P <.001). The third best reconstruction had the transition zone attenuation equal to the air attenuation, and the worst had the transition zone attenuation halfway between the air and wall attenuation. CONCLUSION: Virtual reality is best with volume rendering, with the transition zone (mucosa) between the wall and air reconstructed as a separate structure.     

Colonic transit studies with 99mTc-rhenium sulfide colloid in live rats. A preliminary study

Abnormal colonic motility is associated with clinical relevant conditions such as irritable bowel syndrome or constipation. Accurate assessment of colonic transit in an animal model would be useful in studying these conditions and screen potential drug candidates. The aim of this study was to assess if scintigraphic analyses could reliably evaluate total and segmental colonic transit as a measure of colonic motility of a non-absorbable radiotracer in rats. Normal Lewis rats (250-300 g) were given oral technetium-99m-rhenium sulfide colloid (15-20 MBq; 0.5 mL; n=4) followed by a rinse with water for injection (1.0 mL). Rats were fed and hydrated ad libitum. After 30 min, each rat was contained inside an 'imaging' tube then placed on a g-camera collimator. Whole body 5 min static images were acquired every 30 min up to 9 h, and then finally at 25 hours. Region of interest analyses were applied to the caecum/proximal colon, sigmoidal loop and distal colon/rectum. The tracer entered into the colon at approximately 4 hours, and the rats remained static to permit 'live' imaging. At 4 hours the % whole body activity was: 51% caecum/proximal colon, 39% sigmoidal loop, 6% distal colon/rectum; at 8 hours, 30% caecum/proximal colon, 13% sigmoidal loop, 7% distal colon/rectum. In the whole colon there was < or =1% of total activity present at 25 hours, and the half clearance time was determined as 4.0 hours. These results suggest this is a reliable technique of measuring regional colonic transit as a measure of colonic motility in normal rats. This methodology might be well suited to screen potential motility effects of drug candidates.     

Acute colonic pseudo-obstruction complicating chemotherapy in paediatric oncohaematological patients: clinical and imaging features

Objective

Although acute colonic pseudo-obstruction (ACPO) complicating chemotherapy is still a controversial entity, it is one with which radiologists should be familiar. We describe the imaging features of ACPO in children following chemotherapy for treatment of a haematological malignancy.

Methods

We retrospectively reviewed the imaging features of eight children (age 3–14 years) with chemotherapy-related ACPO, all of whom had undergone plain radiography and CT examinations. The diagnosis of ACPO was based on both clinical features and imaging findings.

Results

Abnormalities noted on plain radiography included faecal gaseous distension of the transverse colon (4/8), faecal gaseous distension of the ascending colon (3/8), gaseous distended transverse colon (3/8) and gaseous small bowel loops (6/8). As seen on CT scans, findings of faecal fluid distended the ascending and transverse colon (5/8), faecal gas distended the transverse and ascending colon (3/8), and small bowel dilatation (5/8) and pneumatosis intestinalis (2/8) were noted. Seven of the eight patients had colonic dilatation from the caecum to the transverse colon with the transition zone near the splenic flexure.

Conclusion

In children presenting with abdominal pain and constipation following chemotherapy, imaging features of progressive colonic dilatation seen on radiography and dilatation from the caecum to the transverse colon with the transition zone near the splenic flexure, as noted on CT, are suggestive of ACPO. CT is more successful than plain radiography for evaluating this finding, particularly in colonic segments filled primarily with fluid, but CT should not be necessary for making the diagnosis as plain radiographs and clinical evaluation should be adequate.Acute colonic pseudo-obstruction (ACPO) is a disorder of gastrointestinal motility characterised by marked dilatation of the colon in the absence of mechanical obstruction and with combined clinical symptoms and signs. It is thought to be caused by an autonomic imbalance such as excessive sympathetic stimulation of the colon combined with suppressed parasympathetic activity [1-3]. ACPO of the colon is often mistaken, both clinically and radiologically, for other abnormal conditions such as mechanical obstruction and paralytic ileus.ACPO is very rarely seen in children. Although the CT findings have already been reported in an adult series [4], there have only been a few paediatric literature reports on ACPO. Our study is unique in that ACPO was diagnosed in a homogeneous group of children with underlying haematological malignancies and occurred following chemotherapy.     

Radiologic features of multinodular lymphoma of the colon

The colon is frequently involved in patients with systemic malignant lymphoma and may be the site of initial clinical presentation. Multiple nodules are one of the manifestations of colonic lymphoma. In an effort to determine the most useful and characteristic features, the radiographic findings in 23 patients with multinodular colonic lymphoma were reviewed. The most characteristic radiographic features were identified: (1) variably sized, smooth, sessile nodules with an average diameter of 7 mm; (2) a cecal mass larger than 3 cm; (3) distortion of the haustra ; (4) incomplete evacuation of barium; and (5) involvement of the stomach, small bowel, or spleen. Less common were irregular, pedunculated, or filiform nodules and occasional umbilication . The differential diagnosis includes gastrointestinal polyposis, benign lymphoid hyperplasia, and inflammatory bowel disease. The radiologist may be the first to suggest the correct diagnosis when lymphoma patients present with multiple colonic nodules.     

全结肠无神经节细胞症X线诊断(附13例报告)

目的：探讨全结肠无神经节细胞症的X线表现,及其X线诊断方法。方法：回顾性分析经手术病理证实的全结肠无神经节细胞症13例,均作腹部平片和钡剂灌肠检查。结果：腹部平片显示普遍性小肠胀气13例,出现液平9例,无1例结肠或直肠充气,钡灌肠（13例）显示结肠细小10例,3例结肠近似正常,有1例表现结肠缩短,1例合并多处穿孔,6例排钡延。结论：钡肠检查仍是目前X线诊断全结肠无神经节细胞症的主要方法。     

Acute colonic disease: how to image in emergency

The diseases affecting the large intestine represent a diagnostic problem in adult patients with acute abdomen, especially when clinical symptoms are not specific. The role of the diagnostic imaging is to help clinicians and surgeons in differential diagnosis for an efficient early and prompt therapy to perform. This review article summarizes the imaging spectrum of findings of colonic acute disease, from mechanical obstruction to inflammatory diseases and perforation, offering keys to problem solving in doubtful cases as well as discussing regarding the more indicated imaging method to use in emergency, particularly MDCT.     

Bowel perforation in Hirschsprung's disease

A review of the medical records of 45 infants less than 1 year old with Hirschsprung's disease identified two (4.4%) who presented with bowel perforation. A literature survey was done to evaluate the relationship between bowel perforation of the bowel early in the course of Hirschsprung's disease indicates that: the infant under 4 months old is at the greatest risk; the majority of cases (62%) were associated with long-segment or total colonic Hirschsprung's disease; the most common sites of perforation were the proximal colon (68%) and appendix (17%); in cases with a short or intermediate length of aganglionic bowel, the perforation was proximal to or at the site of transition, but in 84% of infants with total colonic aganglionosis the perforation was situated in aganglionic bowel. Hirschsprung's disease should be a prime differential consideration in a young infant with penumoperitoneum caused by distal bowel perforation.     

Optimum overhead views in double-contrast barium-enema examinations

On 100 consecutive double-contrast barium-enema examinations demonstrating a benign or malignant mass in the colon, 10 overhead views were analyzed to determine the smallest number of projections that would permit an accurate diagnosis. The combination of six overhead views (anteroposterior, posteroanterior, angled view of the rectosigmoid, lateral view of the rectum, right and left decubitus) and fluoroscopic spot films of the cecum, transverse colon, and flexures was sufficient to demonstrate all colonic masses. In no instance was a lesion seen only on overhead views performed with the patient in an oblique position. Elimination of the four oblique views from the routine double-contrast barium-enema examination can result in substantial savings in cost and radiation exposure without adversely affecting diagnostic accuracy.     

Imaging features of a cecal lipoma as a lead point for colo-colonic intussusception

Intussusception is a rare occurrence in the adult population with most of the cases seen during the childhood period. Compared with the pediatric intussusceptions, there is more often an underlying cause in adults. Lipoma as a lead point for colonic intussusception is rare. Ultrasound may be helpful in the diagnosis, but computed tomography is more reliably used for differential diagnosis. An adult patient with colo-colonic intussusception diganosed with ultrasound and confirmed with computed tomography is presented.     

Dynamic aspects of colonic Crohn's disease.

Changing patterns of the lesions in colonic Crohn's disease were studied in 86 patients who underwent multiple consequetive roentgen examinations. Local progression of lesions was seen in 56 out of 86 patients; rapid local advancement from mild to severe lesions was not uncommon. Temporary regression of lesions was only seen in 7%; definitive permanent healing on conservative treatment was not observed. Preoperative extension of lesions was seen in 29%, with ultimate involvement of the rectum in 7% and development of anal fistulae in 17%. Clinical implications of the findings are briefly discussed.     

Endometriosis: unusual cause of colonic obstruction

In the differential diagnosis of colonic obstruction, the endometriosis is an uncommon disease, rarely reported. The endometriosis of the bowel should be suspected on young women with a history of colonic symptoms and gynecologic complaints. The preoperative diagnosis is difficult, based on the clinical history, the imaging modalities and the endoscopic explorations.     

CT imaging of colitis

Computed tomography (CT) is widely used to assess patients with nonspecific abdominal pain or who are suspected of having colitis. The authors recommend multidetector CT with oral, rectal, and intravenous contrast material and thin sections, which can accurately demonstrate inflammatory changes in the colonic wall and help assess the extent of disease. In most cases, the final diagnosis of the type of colitis is based on clinical and laboratory data and colonoscopic and biopsy findings, but specific CT features help narrow the differential diagnosis. Ulcerative colitis is distinguished from granulomatous colitis (Crohn disease) in terms of location of involvement, extent and appearance of colonic wall thickening, and type of complications. Ulcerative colitis and Crohn disease (granulomatous colitis) are rarely associated with ascites, which is often seen in infectious, ischemic, and pseudomembranous colitis. Pseudomembranous colitis also demonstrates marked wall thickening and, occasionally, skip areas but is associated with broad-spectrum antibiotic treatment or chemotherapy. Neutropenic colitis is characterized by right-sided colonic and ileal involvement, whereas ischemic colitis is characterized by vascular distribution pattern and history. Diverticulitis is a focal asymmetric process with fascial thickening and inflamed diverticula. Dilatation of a thick-walled appendix with increased enhancement and adjacent stranding suggests appendicitis, but inflammatory changes may extend to the cecum and terminal ileum. Epiploic appendagitis is a focal rim-enhancing area next to the colon, usually without any substantial colonic wall thickening.