GI Barium Cases 26-50

Case directory 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

Case 26

Duodenal hematoma Diffuse thickening of the duodenal folds DDX: Case directory Duodenal hematoma Diffuse thickening of the duodenal folds DDX: Lymphoma

Case 27

Gastric bezoar Complication of subtotal gastrectomy and vagotomy Case directory Gastric bezoar Complication of subtotal gastrectomy and vagotomy Poorly chewed fibrous foods, lack of gastric peristalsis, absence of hydrochloric acid

Case 28

Gastric carcinoma Sharply circumscribed constricting lesion (arrows) in proximal body Mucosa is irregular and there are shoulders at the lesion's margins Segment involved by the tumor is rigid and non-distensible

Gastric (ulcerative) carcinoma Ulcerated lesion in the body of the stomach with irregularly thickened folds around it Ulcer crater (black) is rectangular in shape Surface pattern of the adjacent mucosa (white) is nodular Nodules are of different sizes and more irregular than the usual areae gastricae pattern

Gastric carcinoma Diagnosis: gastric carcinoma, linitus plastica Body and antrum of the stomach are narrowed, rigid No peristalsis was seen

Gastric carcinoma Diagnosis: ulcerating carcinoma of cardia, with extension into lower esophagus Irregular shaped ulcer crater (arrows) in gastric cardia Folds radiating towards the ulcer crater are of uneven thickness, and most do not reach the crater edge Distal esophagus is narrowed, secondary to proximal extension of the tumor (arrowhead)

Gastric carcinoma Mass in the cardia with thickened folds (arrows) Case directory Gastric carcinoma Mass in the cardia with thickened folds (arrows) Normal cardiac rosette is obliterated Mucosa is coarsely nodular in some areas

Case 29

Gastrointestinal stromal tumor Case findings: Well- circumscribed, smooth-surfaced 3 cm mass in gastric antrum Barium-filled ulcer crater is centrally located

Ectopic pancreatic rest Single, smooth-surfaced, relatively flat, polypoid lesion (arrow) on the greater curvature of the distal gastric antrum

Gastrointestinal stromal tumor Case directory Gastrointestinal stromal tumor Large smooth broad-based polypoid lesion (arrows) along distal lesser curvature Lesion has abrupt margins (arrowheads) with the luminal contour  submucosal mass Large, solitary submucosal masses of the stomach  MC GIST and lymphoma (about 50% are ulcerated) DDX: lymphoma

Case 30

Gastric lymphoma Loss of the normal gastric rugal pattern, with multiple, large ulcers (large arrows) Stomach is diffusely narrowed, which is the result of diffuse infiltration by lymphomatous tissue Well demarcated line (small arrows) in fundus, suggesting that the barium is being displaced by a mass effect exerted by the tumor

Case directory Gastric lymphoma MC NHL of B-cell origin, arising in the mucosa-associated lymphoid tissue of the stomach (MALT) Associated H pylori gastritis Features: MC appearance an infiltrating lesion May be focal or diffuse, nodular or smooth thickening of the rugal folds Gastric wall may either be rigid mimicking scirrhous carcinoma or be pliable due to the soft nature of the lymphomatous infiltrate Multiple ulcers are often present Ulcerated submucosal mass Ulcerating mass with a nodular surface

Case 31

Carcinoid Smooth-surfaced, broad-based, sessile polypoid lesion (arrows) in the ileum Wall opposite the tumor is mildly in-bowed (arrowhead)

Carcinoid DDX sessile polypoid lesion in ileum: Gastrointestinal stromal tumor (GIST) Lipoma: soft and change size or shape DDX ileal submucosal lesion: Metastasis Disseminated lymphoma Kaposi's sarcoma Carcinoid tumor

Carcinoid Polypoid lesion in the terminal ileum (black arrowhead), carcinoid lesion Ileal diverticula (white arrowheads) and the smooth-surfaced submucosal mass (black arrows) at the entrance of the appendix into the cecum (mucinous cystadenoma of the appendix)

Carcinoid (annular) Mucosal folds are shown to be preserved (arrow) Case directory Carcinoid (annular) Mucosal folds are shown to be preserved (arrow)

Case 32

Crohn’s Ulcer (black arrowheads) on the mesenteric border of the distal ileum Radiolucent collar of edema (arrows) parallels the barium-filled groove Aphthoid ulcers (white arrowheads)

Crohn’s More extensive along the mesenteric side of the small intestine, and extends along vessels and lymphatics entering the small bowel mesentery Linear mesenteric border ulcer: Associated with fibrosis and shortening of mesenteric side Whenever flattening of a mesenteric border is seen in a Crohn's, suspect mesenteric border ulceration Look on antimesenteric side for sacculations

Crohn’s Mesenteric border ulcer (arrowhead)  folds radiate toward the ulcer Opposite wall (antimesenteric border) is mildly sacculated (arrows), which is the result of the folds radiating toward the ulcer, and is associated shortening of the mesenteric border

Case directory Crohn’s With progressive luminal narrowing and fibrosis of the wall, some of the antimesenteric sacculations survive as diverticula-like outpouchings (arrows)

Case 33

Crohn’s DDX of small bowel stricture: Ischemia: MC solitary, smooth surfaced narrowing, with gradually tapering margins Radiation: smooth, thick folds perpendicular to the longitudinal axis If very long-standing, radiation strictures may be smooth circumferential tubular narrowing Neoplasm: annular constricting tumors (primary or metastatic) are sharply demarcated with shoulder formation Ulcerative colitis: rare, chronic stage of UC with short annular constrictions separating dilated segments are present

Case directory Crohn’s Stricture of the terminal ileum (string sign)

Case 34

Crohn’s Ileosigmoid fistula due to terminal ileal Crohn's disease Case directory Crohn’s Ileosigmoid fistula due to terminal ileal Crohn's disease BE: shows reflux of barium into the TI, and a strictured TI

Case 35

Small bowel ischemia Intramural hemorrhage: identical on SBFT  submucosal edema or blood causes thumbprinting, with thickened but straight folds Barium trapped between the thick folds produces interspace spikes CT target sign = barium thumbprinting Etiology of intramural hemorrhage/ischemia: Low flow states Emboli or atherosclerosis Vasculitis: SLE, RA, Behçet's, HSP Bleeding from hemophilia, ITP, anticoagulation, or intrinsic coagulopathies Radiation enteropathy

Case directory Small bowel ischemia

Case 36

Primary small bowel lymphoma Grow first by submucosal infiltration longitudinally resulting in thickened valvulae conniventes Then extends through the thickness of the wall with effacement of valvulae conniventes Lumen can be mildly narrowed by submucosal lymphoma, but obstruction is uncommon If the smooth muscle of the wall is destroyed, the lumen can expand (aneurysmal dilatation)

Primary small bowel lymphoma Features: MC type is infiltrative 2nd MC type is cavitary (ulcerating) DDX: Malignant GIST Metastatic melanoma Rarely primary adenocarcinoma

Primary small bowel lymphoma May infiltrate short segment of small bowel Segment of annular narrowing (arrowhead) of the distal jejunum Borders are abrupt (arrows), but not shelf-like Normal folds are absent NOTE: lack of obstruction and relative mild luminal narrowing favor primary lymphoma a over primary adenocarcinoma

Primary small bowel lymphoma Case directory Primary small bowel lymphoma Large cavity (white arrows) extends into the small bowel mesentery Surface of cavity is nodular Folds of the SB are thick (black arrows) Large tumor nodules (arrowheads) are seen on the mesenteric border

Case 37

Meckel’s diverticulum Case findings: Smooth-contoured saccular outpouching from the antimesenteric wall of a RLQ ileal loop No folds are seen in the outpouching Occurs at obliterated omphalomesenteric duct Contains all layers of the bowel wall Ectopic gastric mucosa may be present (hemorrhage) Pertechnetate scan

Meckel’s diverticulum Case directory Meckel’s diverticulum Junction of the diverticulum with the antimesenteric border of the distal ileum is a narrow neck (arrows)

Case 38

Scleroderma Dilated duodenum and jejunum Despite the massive dilatation, there are 7-8 folds per inch in the first jejunal loop

Scleroderma Hidebound bowel: crowding of small bowel folds despite luminal dilatation Asymmetric scarring leads to sacculation of the wall opposite the scarring (MC seen in colon)

Scleroderma Although the number of folds/inch remains is normal (5-6/inch), there are too many folds for the massive luminal dilatation

Scleroderma Lumen is dilated Case directory Scleroderma Lumen is dilated Folds radiate toward the mesenteric border (arrows) due to asymmetric scarring Antimesenteric border shows broad-based sacculations (arrowheads) Classic appearance: Luminal dilatation Tethered, crowded folds Broad based sacculations opposite these folds

Case 39

Familial adenomatous polyposis Case directory Familial adenomatous polyposis Hamartomatous polyps: Cowden (multiple hamartoma syndrome): associated with breast and thyroid cancer Peutz-Jeghers Multiple hamartomas  MC stomach Mucocutaneous hyperpigmentation Adenomatous polyps: Familial polyposis coli Turcot: associated with brain tumors (GBM, medulloblastoma) Gardner’s syndrome: colonic polyps, osteomas (frontal sinus, mandible), ST tumors (desmoid tumors, epidermoid inclusion cysts, fibroma, lipoma, leiomyoma) Juvenile polyps: Juvenile polyposis coli Cronkite-Canada: inflammatory juvenile polyps

Case 40

Ulcerative colitis Early ulcerative colitis: Colonic mucosa replaced by a diffusely granular appearance Corresponds to edema and hyperemia, and may precede actual ulceration

Ulcerative colitis Rectum shows diffuse narrowing Case directory Ulcerative colitis Rectum shows diffuse narrowing Widened presacral space

Case 41

Crohn’s Case findings: DDX terminal ileum fold thickening: Case directory Crohn’s Case findings: Distal ileum fold thickening and cobble-stoning Mild transient spasm of this portion of bowel indicating acute inflammation at this site No skip lesions, obstructions, leaks, or masses DDX terminal ileum fold thickening: Crohn's disease Yersinia infection Mycobacterium tuberculosis ileitis Adjacent appendiceal abscess

Case 42

Mucinous cystadenoma of appendix Case directory Mucinous cystadenoma of appendix Case findings: BE: Smooth, sharply outlined, broad based extramucosal mass impressing the apex of the cecum CT: Sharply defined round mass in RLQ Central part has low attenuation Wall of the lesion is thickened Peripheral calcification

Case 43

Crohn’s Case findings (SBFT): Early findings: Late findings: 20cm segment of the terminal ileum is narrowed and non-distensible Within the right mid abdomen, there is a shorter, approximately 10cm segment of similar narrowing Early findings: Aphthoid ulcer: shallow pinpoint mucosal erosions surrounded by an edematous mound Late findings: Cobblestone pattern: ulcerations grow and fuse together, forming linear confluent deep ulcerations separated by edematous mucosa

Crohn’s Thickened and distorted folds Case directory Crohn’s Thickened and distorted folds String sign: progressive narrowing of the lumen (MC in terminal ileum) Rigid, featureless bowel, strictures and obstruction, and foreshortening of bowel Asymmetric involvement of bowel wall both longitudinally and circumferentially  lesions MC on mesenteric side of intestine Sinus tract and fistula formation, originating in deep ulcers or fissures Creeping fat: inflamed mesenteric fat (stranding) accumulate on serosal surfaces

Case 44

Cecal bascule Case findings: DDX: cecal volvulus BE: CT: Contrast flowed to the level of what initially appeared to represent the cecum However, the hugely distended loop of bowel located in the pelvis and extending into the mid-abdomen did not fill with contrast No “birds beak” sign was demonstrated CT: Markedly distended bowel loop in the pelvis DDX: cecal volvulus

Cecal bascule Case directory Form of volvulus in which the cecum folds anteromedially in front of the ascending colon, producing a flap-valve occlusion at the site of flexion Torsion in the transverse plane Cecum usually falls into the pelvis, resting centrally Birds beak sign: not present with bascule because there is no true twist Axial torsion: classic cecal volvulus Rotation occurs in the longitudinal plane Cecum turns upward and usually lies in an ectopic location (MC LUQ) Classic “kidney-bean” appearance Bascules represent up to 1/3rd of cecal volvuli Two forms of cecal volvuli have similar presentations and treatments

Case 45