Case presentation..

A 71 year old woman presented from surgery OPD with chief complaints of: Pain in abdomen and constipation since 6 months. USG abdomen: Gut wall thickening in hepatic flexure region. CECT abdomen was requested.

Impression
Ca transverse colon with pericolic lymphadenopathy.

Bowel wall thickening

Careful analysis of 4 CT features of the thickened bowel wall usually permits reliable differentiation: 1) bowel-wall attenuation and enhancement, 2) degree of wall thickening, 3) length of involvement, and 4) morphology.

Length of involvement
Pathology that affects >20 cm of bowel suggests a benign process. Wall thickening that involves <5 cm of bowel suggests malignancy. Pathology affecting between 5 and 20 cm is nonspecific, as many malignant (eg, non-Hodgkins lymphoma [NHL]) and benign (eg, granulomatous disease and bowel hemorrhage) processes cause segmental bowel involvement.

Bowel-wall morphology
Wall thickening that is homogeneous, symmetric, smooth, and tapered suggests a benign etiology. Wall thickening that is irregular, asymmetric, eccentric, and abrupt suggests malignancy.

Homogeneous Attenuation
The differential diagnosis of a thickened bowel wall that shows homogenous attenuation on CT includes Neoplasm Submucosal hemorrhage or hematoma Infarcted bowel Chronic Crohns disease Radiation injury Pseudothickening related to incomplete distention and residual fluid.

Neoplasm
In cases of neoplasm, homogeneous attenuation correlates with size of the tumor. Smaller tumors present either as circumferential areas of bowel wall thickening or as asymmetric areas of bowel wall thickening with homogeneous enhancement. The larger a tumor gets it becomes more heterogenous as it starts running out of its own vascular supply causing areas of ischemic necrosis within it.

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 airfluid levels (curved arrow ). Surgery revealed well-differentiated adenocarcinoma of cecum.

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 smallbowel thickening, mild dilatation of lumen is seen. Findings are strongly suggestive of small-bowel lymphoma. Note retroperitoneal lymphadenopathy (arrowhead ). Biopsy revealed non-Hodgkins lymphoma

 Pitfalls.Residual fluid within the lumen coating the mucosa of the bowel wall may be perceived as a thickened segment without enhancement (Fig. 2). In these cases, a disease process may be difficult to exclude, and correlation with a small-bowel series may be needed

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. A, Axial CT scan through upper abdomen shows apparent homogeneous circumferential thickening of wall of jejunum loops (arrow ), a finding suspicious for lymphoma. B, Radiograph from upper gastrointestinal series performed 2 days after A shows normal small bowel (arrow ).

 Submucosal hemorrhage.The diagnosis of submucosal intestinal hemorrhage is usually made when CT depicts circumferential and symmetric bowel wall thickening with homogeneous high attenuation of the thickened segment and lack of enhancement in patients who are undergoing anticoagulation therapy or who have an underlying bleeding diathesis. The small bowel is affected in a segmental distribution. In patients with suspected submucosal hemorrhage, an unenhanced CT examination is often helpful in establishing the diagnosis by showing high attenuation in the thickened segment. The high attenuation is due to acute bleeding in the bowel wall.

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

 The morphology of the thickening is related to the timing of the examination and to the pathophysiology of the developing anoxic process. In the initial phases of anoxia, mucosal damage occurs first; with more severe and prolonged forms of anoxia, submucosal hemorrhage, edema, and pericolic congestive and edematous changes develop later. Findings may resolve at each of the stages or evolve to infarction. CT appearance is linked to the evolutive phase and may be grouped in three main categories, as shown by Balthazar and colleagues and more recently by Romano and colleagues.

 The wet appearance with a wall thickening with heterogeneous enhancement, showing an acute process. At the initial stage, Romano has described the little rose sign (Fig. 4), attributable to hyperdensity of mucosa and to submucosal edema that is more evident at the level of the left colon in the CT axial scan. Acute pathologic changes, particularly after reperfusion of the ischemic bowel, may be responsible for concentric rings (double halo or target sign) with submucosal edema, which becomes evident (Fig. 5). At the acute phase, there is a shaggy contour of the colon and various degrees of pericolic streakiness

Fig. 4. Little rose appearance of the left colon. This finding is due to the hyperdensity of the mucosa.

Fig. 5. Wet pattern of ischemic colitis. CT (A) shows a target finding with an enhancement of the mucosal and muscular layers and marked fat stranding. This appearance is not specific to ischemia and may be encountered in infections or inflammatory colitis. The disparity of stratification on US (B) is an argument for the ischemic origin.

8.Ischemic bowel with mural thickening and target configuration of attenuation in 71-yearold woman. A, Contrast-enhanced axial CT scan at level of terminal ileum shows circumferential small-bowel wall thickening with target configuration (arrow ).

 The dry appearance with concentric and symmetric mild mural thickening and homogeneous attenuation of the wall of the colon with a sharply defined contour (Fig. 6) and without or with only minimal pericolic streakiness. This finding is the consequence of the progression of the ischemic damage without reperfusion. Detecting lack of enhancement can be difficult, but comparing adjacent loops helps to show this finding. The intramural gas with gas bubbles arranged in a linear fashion (Fig. 7) and best visualized with the window settings for bone or lung

Fig. 6. (A-C) Dry pattern of ischemic colitis. CT shows homogeneous thickening of the colon involving the left part of the transverse colon and the left colon

Fig. 8. (A-D) Ischemia limited to the sigmoid colon. There is a symmetric thickening of the sigmoid wall that is homogeneously enhanced and without fat stranding, suggestive of a dry pattern. The left colon (A) and the rectum (D) are normal

Closed-loop small-bowel obstruction with ischemic bowel in 83-year-old woman. Contrastenhanced axial CT image at level of pelvis shows 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.

Crohns disease
In patients with Crohn's disease, CT patterns of bowel wall thickening correlated with inflammatory activity. Thickened bowel wall with layering enhancement (i.e. target sign or double halo sign) is predictive of acute disease, and that of homogeneous enhancement suggests quiescence. Choi, D., et al. (2003)Clinical Radiology,58, 6874. So in acute active phase Heterogenous attenuation i.e. Target sign. In chronic/ quiescient phase Homogenous attenuation

Chronic radiation changes

Radiation-induced small-vessel occlusions may produce chronic ischemia anywhere in the alimentary tract. Radiation enteritis develops in patients who receive 4,500 cGy or more of radiation. The underlying pathologic process is endarteritis obliterans, and compromise of the microvascular circulation is an important factor in the natural history of radiation changes in the intestine . Factors that predispose to the development of chronic radiation enteritis include prior abdominal surgery with adhesive changes, peritonitis before radiation therapy, hypertension, atherosclerosis, and diabetes. Radiographic findings include thickened valvulae conniventes, wall thickening, later effacement of the mucosal fold pattern, ulceration, single or multiple stenoses, adhesions, and occasional sinuses and fistulas . CT and MR imaging show bowel wall thickening with occasional visualization of the target sign. The important clue for diagnosis is that the bowel changes are confined to the radiation port. So in acute radiation enteritis Heterogenous attenuation i.e. target sign. In chronic radiation enteritis Homogenous attenuation.

Chronic radiation enteritis in a 48-year-old man with a history of radiation therapy after surgery for paraganglioma in the paraaortic space. Contrast-enhanced CT scan shows a stricture of the jejunum with considerable bowel wall thickening (arrows) due to desmoplastic reaction.

Acute radiation enteritis in a 71-year-old man with a history of radiation therapy for periureteral metastases from rectal cancer. Contrast-enhanced CT scan shows diffuse bowel wall thickening with the target sign (arrows) confined to the radiation port.

Heterogeneous (Stratified) Attenuation

When the attenuation of a thickened bowel wall is heterogeneous, the wall may display a stratified pattern or a mixed pattern of attenuation.

 The stratified pattern may be in the form of a double halo or a target configuration. The double halo sign consists of an inner lowattenuation (edema) ring surrounded by an outer higher attenuation ring. In the target sign, inner and outer layers of high attenuation surround a central area of decreased (edema) attenuation. These signs are best visualized during the late arterial and early portal venous phases of IV contrast material enhancement. On unenhanced or delayed (>2 min) IV contrast enhanced CT, these signs may not be visualized. The high attenuation present with these signs is related to hyperemia. When submucosal edema is severe, the target sign may be demonstrated at nonenhanced CT (4). The high attenuation of the mucosal layer is best demonstrated when the bowel is distended with waterattenuation contrast material

 The inner and outer layers of the target sign represent the mucosa and the muscularis propria, respectively, with the high attenuation being a consequence of contrast enhancement (2). The lower attenuation of the middle layer is believed to result from edema (thought to be the dominant component of this layer) and is assumed to be located in the submucosa. The target sign indicates hyperemia in the mucosa and the muscularis propria, serosa, or both with submucosal edema or inflammation.

Diagram shows cross section of bowel wall with three layers of high (inner black layer), low (middle gray layer), and high (outer black layer) attenuation. Together, these layers create a target appearance known as the target sign.

 The target sign does not allow a specific diagnosis, but it does allow one to predict that, since the sign uncommonly occurs with malignancy, the thickened bowel wall is most likely caused by inflammatory disease as opposed to neoplasm A notable exception to this general rule is the occurrence of the target sign in cases of infiltrating scirrhous carcinoma of the rectum

Transverse CT scan of the abdomen after administration of oral and intravenous contrast material in a 42-year-old man with ischemic colitis. Layers representing target sign grossly correspond to muscularis propria (straight white arrow), submucosa (curved arrow), and mucosa (black arrow).

Fat halo sign

The fat halo sign is seen on computed tomographic (CT) scans of the abdomen and appears as a thickened bowel wall demonstrating three layers: an inner and an outer layer of soft-tissue attenuation, between which lies a third layer of fatty attenuation. The inner layer of soft-tissue attenuation represents the bowel (small and/or large) mucosa, while the layer of low attenuation (18 to 64 HU) results from widening and fatty infiltration of the submucosa. The outer soft-tissue attenuation layer represents the muscularis propria and serosa (2,4,68). The fat halo sign can be depicted on CT scans obtained without intravenous (IV) contrast material because of the marked differences in tissue attenuation (3). However, the different layers of attenuation can also be appreciated during the late arterial and early portal venous phases of IV contrast enhancement

Diagram of the fat halo sign shows the cross-section of bowel wall in benign intestinal disease, with inner mucosal (M) and outer muscularis and serosa (M-S) layers of soft-tissue attenuation between which is a layer of fatty attenuation (S). Llumen.

 The fat halo sign is seen in various diseases of the bowel in which fatty infiltration of the submucosa is present . The sign has been described as typically appearing in patients with chronic inflammatory bowel disease (Crohn disease and ulcerative colitis). Reports of two other uncommon, acute manifestations (cytoreductive therapy and graft vs host disease) that cause the fat halo sign have been published.

 In ulcerative colitis, this finding is symmetric and diffuse, whereas patients with Crohn disease display eccentric and discrete involvement, with affected intestinal regions alternating with spared areas, referred to as skip areas . Although the fat halo sign can also be seen in a patient undergoing cytoreductive therapy and in graft versus host disease , the observation of this sign in the small intestine is, for all intents and purposes, highly diagnostic of Crohn disease and by itself is a sign of a chronic phase. When found in the colon, this sign is associated with the same diseases as those occurring in the small intestine (eg, cytoreductive therapy, graft vs host disease, and Crohn disease). Nonetheless, ulcerative colitis should be included in the differential diagnosis. When this sign is seen in both the small and the large bowel, the fat halo sign is considered evidence of Crohn disease. When only the colon is affected, the degree and geographic distribution of bowel wall thickness are signs used to distinguish ulcerative colitis from Crohn disease.

Fat halo sign in ulcerative colitis. Transverse CT scan shows the central fatty submucosal layer of low attenuation () surrounded by higher-attenuation inner (long arrow) and outer (short arrow) layers grossly corresponding to the mucosa and muscularis propria and serosa of the descending colon, respectively.

Target sign or stratified attenuation is seen in acute inflammatory or ischemic conditions of bowel. A notable exception to this accepted general rule (target sign = inflammation) is the rare occurrence of this sign in infiltrating scirrhous carcinoma of the stomach and colon. Rigidity (after attempted air insufflation), severe luminal narrowing, abrupt transition, and regional lymphadenopathy usually help in establishing the correct diagnosis

Thank you.
AJR 2001;176:11051116: CT of Bowel Wall Thickening