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Normal Small Bowel

Non-infiltrated (Stack of Coins)

Submucosal Infiltration
• Edema
• Inflammatory exudates No Dilution
• Blood
• Lymph tissue Sprue
• Tumor Scleroderma

Two patterns
• depends upon the amount of submucosal
infiltration Infiltrated (Picket Fence)
o small amount = “stack of coins”
 little separation of the
+/- Dilated
normal folds Non-dilated
o large amount = “picket fence”
 greater separation of the
normal folds
Whipple’s Disease Edema
Stack of Coins (nodularity) Ischemia

• Celiac disease of the children
• Non-tropical sprue
o Improve on gluten free diet
• Tropical sprue
o Improves with antibiotic and folic
Picket Fence
X-ray Findings
• Hallmark features
o Dilatation
o Dilution- jejunum
• Segmentation – masses of barium
separated from the adjacent clumps
• Fragmentation – exaggerated example of
irregular stippling of residual barium in the
proximal bowel
X-ray Features Scleroderma
• Intusussception • Affects: esophagus, small bowel and colon
• Increase risk of carcinoma and lymphoma • Atrophy of the muscular layer and
• Moulage sign replacement of fibrous tissue
o caused by dilated loops with • Associated with malabsorption
effaced folds
o Looking like tube into which wax X-Ray features
has been poured • Entire small bowel is usually dilated
• “hide-bound appearance”
• Close approximation of the valvulae
• Does not have increase secretions
• May be associated with pneumatosis
Dilatation + Dilution
“Hide-Bound appearance”



Moulage Sign

Whipple’s Disease
• Very rare disease
• Glycoprotein in lamina propria of small
o Sudan-negative
o PAS-negative
o Gram (+) rods are also present
• Clinically
o Abdominal pain, diarrhea, weight • X-ray findings
loss o Changes are present throughout
• Treated with long term antibiotics the small bowel
o Loops are separated due to edema
X-ray Features of walls
• Hallmarks o Folds are quite thick (picket fence)
o Nodules
o Picket fence(markedly thickened
mucosal wall)
• Small bowel may or may not be dilated
• Affects jejunum mostly

Ishemic Bowel Disease

• Thickening of the wall due to edema and
• Localized perforation can produce: air in
bowel wall and air in portal venous

X-ray Findings
• Spasm and irritability
• Narrowed lumen
• Thickened folds – “thumb printing”
• Healing may result in stricture formation

Ischemic Bowel Disease

• RARe
• GI involvement is common
• Associated with malabsorption
• Radiologic features
o Picket fence – markedly thickening
of the valvulae
o No dilation or dilution
o Affects the entire small bowel

Intramural Bleeding
• Suggestive if there is a duodenal
obstruction secondary to trauma
• Localized lesion occur with trauma
• Diffuse lesion seen with anticoagulants

• Resulting from liver or kidney disease
• Usually asymptomatic from intestinal
Radiation Enteritis • Giardia lamblia
• Mucosa is most sensitive to radiation o Flagellated protozoan
• Changes similar to ischemia o Small bowel
• Radiation changes are actually secondary • Signs and symptoms:
to arteritis with occlusion of small bowels o Diarrhea
• Localized to the area of radiation portal o Malabsorption
• Especially in the pelvis of female e
X-ray Findings
patients with endometrial carcinoma
• Usually limited to the duodenum and
• Thickened folds
• Marked spasm and irritability
• Increase secretions

• Most commonly involve the terminal ileum
• Bowel mall is markedly thickened and
mucosa is infiltrated (picket fence)
• “thumb-printing” may be seen
• Loops are widely separated
• Single or multiple mass –producing mass
• are confined ulceration with perforation
• Produces “aneurismal dilatation” of bowel

Aneurysmal Dilatation of Bowel