SECTION S: Colon

Introduction and Overview

Colon Anatomy and Imaging Issues 1-5-2

Infection
Infection Colitis 1-5-6
Pseudomembranous Colitis 1-5-10
Typhlitis 1-5-14

Inflammation and Ischemia

Ulcerative Colitis 1-5-16
Toxic Megacolon 1-5-20
Appendicitis 1-5-22
Mucocele of the Appendix 1-5-26
Diverticulitis 1-5-28
Epiploic Appendagitis 1-5-32
Ischemic Colitis 1-5-36

Neoplasm
Colonic Polyps 1-5-40
Colon Carcinoma 1-5-44
Rectal Carcinoma 1-5-48
Villous Adenoma 1-5-52
Familial Polyposis 1-5-56
Gardner Syndrome 1-5-60

Miscellaneous
Sigmoid Volvulus 1-5-62
Cecal Volvulus 1-5-66
 COLON ANATOMY AND IMAGING ISSUES

Graphic shows schematic representation of various Barium enema shows malignant stricture ("apple core")
processes that may narrow the lumen of the colon (or of the colon; primary carcinoma.
any other part of the gut).

o Ulcerative colitis
I TERMINOLOGY • Presenting symptoms: Diarrhea, rectal bleeding,
Abbreviations and Synonyms pain
• Pathology: Mucosa and submucosa; crypt
• Barium Enema (BE)
5 • Small Bowel (SB)
abscesses; punctate and collar button ulcers
• Radiology: Continuous circumferential
2 involvement starting distally; shortened, ahaustral
colon; colonic strictures (late); SB involvement
I IMAGING ANATOMY only by backwash; no fistulas, sinus tracts, or
• Anatomic splenic flexure is the point atwhich the abscesses; colon cancer and toxic megacolon are
descending colon becomes retroperitoneal (distal to serious risks
radiologic splenic flexure) o Crohn disease
• Sigmoid colon • Presenting symptoms: Diarrhea, pain, weight loss,
o Intraperitoneal colonic segment bridging the palpable mass
retroperitoneal descending colon and the rectum • Pathology: Transmural; granulomas and enlarged
lymphoid follicles; aphthous ulcers; linear and
transverse ulcers; perianal fistulas
I ANATOMY-BASED IMAGING ISSUES I • Radiology: Discontinuous eccentric colonic and SB
involvement; fibrofatty proliferation in
Key Concepts or Questions mesentery; fistulas, sinus tracts, abscesses; colon
• Advantages of double-contrast BE over single-contrast cancer and toxic megacolon rare
BE • How do you distinguish among the various causes of
o Detection of small polypoid lesions colonic luminal narrowing?
o Detection of superficial ulcerations o Benign stricture: Smooth taper, both ends
o Subtle changes from endometriosis and metastases o Malignant stricture: Irregular, abrupt narrowing,
• Advantages of single-contrast BE apple core, shoulders at one or both ends
o Patient comfort o Extrinsic: Intact mucosa, whole lumen is displaced,
o Elderly or arthritic patients oblique angles for mass effect
o Detection of strictures o Submucosal: Intact mucosa, almost right angle
o Known or suspected diverticular disease interface with luminal surface
o Detection of large masses o Mucosal: Irregular mucosal surface, acute angle
o Evaluation for obstruction interface with luminal surface
o Evaluation for ischemia or other submucosal • How common are colonic polyps (detection rate is
pathology good measure of adequacy of examination technique)?
• Indication for water soluble contrast enema o Varies from 3% (age 20 to 30) , to 25% (age 80 to 90)
o Possible perforation o More than half are present in rectum and sigmoid
o Possible fistula • How do you distinguish a barium-coated polyp from a
o Pre-operative emergent study barium-lined diverticulum on an air-contrast barium
o "Therapeutic" (obstipation) enema?
• What criteria are useful to distinguish ulcerative colitis
and Crohn disease?
 COLON ANATOMY AND IMAGING ISSUES

DIFFERENTIAL DIAGNOSIS
Benign tumors POLYPOSIS SYNDROMES
• Hyperplastic polyp
• Adenomatous polyp Adenomatous polyps
• Villous adenoma ·.Familial polyposis coli
• Hamartoma ~. Gardner syndrome
• Spindle cell tumor • :1\1rcotsyndrome
• =>(Upoma, leiomyoma, etc.) • Attenuated adenomatous polyposis coli
• Carcinoid tumor Hamartomatous polyps
Malignant tumors • Peutz-Jeghers syndrome
• Carcinoma • Juvenile polyposis
• Lymphoma • Cronkhite-Canada syndrome
• Metastases • Cowden syndrome
• Kaposi sarcoma • Bannayan-Riley-Ruvalcaba syndrome
• Squamous cell carcinoma
• =>(Anal)

o Varies with location of polyp (dependent or o May develop malignant anal tumors (squamous,
non-dependent wall) and whether seen in profile or basaloid, etc.)
"en face"
o Easiest when polyp appears as filling defect in
barium pool; diverticulum fills with barium and ICUSTOM DIFFERENTIAL DIAGNOSISI
projects off surface of colon
Heredity non polyposis colon cancer
o Look for "bowler hat" (sessile polyp) or "Mexican
hat" (pedunculated polyp) signs syndrome (HNPCC)
5
o Polyp has sharp inner margins and fuzzy (indistinct) • Five times more common than familial polyposis 3
outer margins • Lynch I
o Diverticulum has sharp outer margins, fuzzy inner o Early onset « SO),right-sided, often multiple colon
• How do you distinguish colon carcinoma from cancers
diverticular disease on imaging? • Lynch II
o Carcinoma: Luminal narrowing is short « 10 cm), o Lynch I + extracolonic tumors
abrupt, irregular and eccentric, may resemble apple • Muir-Torre
core; CT may show lymphadenopathy, metastases o Similar to Lynch II + skin lesions
o Diverticulosis: Luminal narrowing is long (> 10 cm),
transverse folds are thick, irregular, resemble "cog length of colon involvement
wheel" (circular muscle hypertrophy): No • Cancer
pericolonic disease o Short « 10 cm)
o Diverticulitis: Luminal narrowing is long (> 10 cm), • Diverticulitis
asymmetric with combination of circular muscle o Segmental (> 10 cm), usually sigmoid, spares rectum
hypertrophy, spasm, pericolonic inflammation and • Ulcerative colitis
mass (abscess); CT shows pericolonic inflammation o Long segmental, usually distal, includes rectum
± pericolonic extraluminal gas, abscess, fistula • Crohn (granulomatous) colitis
• What is the current role of CT colonography? o Segmental, usually proximal, perirectal involvement
o Competitive with barium enema and endoscopy as a • Ischemia
screening procedure for colonic polyps o Segmental (90%), usually splenic flexure or sigmoid
o Must be performed and interpreted with expertise to • Infectious colitis (e.g., C. difficile)
achieve comparable results o Long segmental or pan colitis, involves rectum
o Main rationale is to provide screening for patients • Neutropenic colitis (typhlitis)
who are resistant to, or poor candidates for barium o Segmental, ascending colon + cecum
enema or colonoscopy
Aphthoid ulcers
• Amebic colitis
I CLINICAL IMPLICATIONS • Crohn disease
• CMV + herpes colitis
Clinical Importance • Salmonella + Shigella colitis
• Normal stratified squamous epithelium of the anal • Myotonic dystrophy
canal can be infected by human papilloma virus • Beh~et disease
(sexually transmitted) • Lymphoma
o May develop benign condyloma (locally invasive)
 COLON ANATOMY AND IMAGING ISSUES

Graphic shows the profile and en face appearance of Spot film from air-contrast BE shows a "bowler hat"
various polyps (A,B,D) and a diverticulum (C) on an air appearance of a small sessilepolyp (arrow).
contrast barium enema (lower row of pictures).

o Ulcerative colitis
Colonic (or small bowel) submucosal o Crohn disease
thickening • Infectious
• Air density = pneumatosis o Pseudomembranous colitis
5 o E.g., bowel infarct, "benign" pneumatosis o Neutropenic colitis (typhlitis)
o CMV colitis
• Fat density
4 o E.g., chronic inflammatory bowel disease (lED), o Other rare
cytoreductive therapy, obesity • Neoplastic
• Near-water density o Lymphoma
o E.g., acute inflammation, ischemia, "shock bowel" o Metastases
• Soft tissue density • Miscellaneous
o E.g., tumor, inflammation, ischemia o Pneumatosis cystoides coli
• Higher density o Endometriosis
o E.g., hemorrhage in bowel wall o Cirrhosis (portal hypertension)

Colonic Ileus (pseudo-obstruction) Ahaustral (smooth) colon

• Systemic acute inflammatory/traumatic • Normal (descending colon, elderly)
o Pneumonia, myocardial infarction • Ulcerative colitis (> Crohn)
o Pancreatitis, appendicitis, peritonitis • Cathartic abuse
o Trauma; spinal injury • Radiation colitis (late)
o Post-operative • Ischemic colitis (late)
• Drug effect
o Narcotics
o Antidepressants I SELECTED REFERENCES
o Antipsychotics 1. Koeller KK, et al (eds) Radiologic Pathology (2nd ed)
o Antiparkinsonian Washington, DC, Armed Forces Institute of Pathology,
o Anticholinergics 2003
• Endocrine disorder 2. Gore RM: Colon: Differential Diagnosis. In Gore RM,
o Hypothyroidism Levine MS (eds) Textbook of Gastrointestinal Radiology.
o Hypoparathyroidism 2nd ed. Philadelphia, WB Saunders. 1159-65, 2000
3. Diihnert W: Radiology Review Manual (4th ed),
o Diabetes
Philadelphia: Lippincott, 2000
• Neuromuscular disorders 4. Eisenberg RL: Gastrointestinal Radiology: A Pattern
o Parkinson disease Approach (3rd ed). Philadelphia: JB Lippincott, 1996
5. Reeder MM: Reeder and Felson's Gamuts in Radiology (3rd
Colonic thumbprinting ed) New York: Springer Verlag, 1993
• Vascular lesions
o Ischemic colitis
o Intramural hemorrhage (anticoagulation, trauma)
o Vasculitis (e.g., Henoch-Schonlein purpura)
o Hereditary angioneurotic edema
• Inflammatory
 COLON ANATOMY AND IMAGING ISSUES
IMAGE GALLERY
Typical
(Left) Air-contrast BE shows
many shallow aphthoid
ulcerations of the hepatic
flexure; Crohn
(granulomatous) colitis.
(Right) BE shows ahaustral
colon due to chronic
ulcerative colitis.

Typical
(Left) Axial CECT shows
marked water density
submucosal colonic wall
thickening;
pseudomembranous (c.
difficile) colitis. (Right) Axial
5
CECT shows fat density
5
submucosal thickening of the
rectal wall; chronic
ulcerative colitis.

Typical
(Left) BE shows
"thumbprinting" of the
colonic wall near the splenic
flexure; ischemic colitis.
(Right) Axial CECT shows
"thumbprinting" of
ascending colon; cirrhosis
and portal hypertension with
colonic edema.
 INFECTIOUS COLITIS
Axial CECT shows pancolitis with colonic wall
thickening and mesenteric hyperemia. Campylobacter
colitisin 78 year old woman.
ITERMINOlOGY
Definitions
• Inflammation of the colon caused by bacterial, viral,
5 fungal, or parasitic infections
6 granularity of rectum
I IMAGING FINDINGS
General Features
• Best diagnostic clue: Focal or diffuse colonic wall
thickening with mucosal ulcerations
• Location: Dependent on etiology
Radiographic Findings
• Fluoroscopic-guided barium enema
o Focal or diffuse; segmental colitis or pancolitis
o Lumen narrowing & loss of haustra (edema/spasm)
o Thickened folds & colonic wall (edema)
o Ulceration - mucosal irregularity
o Superficial or deep "collar button" ulcers
o Discrete punctate, aphthous or large oval ulcers;
may simulate Crohn disease
o ± Small nodules or inflammatory polyps
o ± Diffuse, mucosal granularity; may simulate
ulcerative colitis
o ± Extrinsic mass with inflammatory changes -
distortion, short strictures; may simulate carcinoma
DDx: long Segment Wall Thickening
Pseudomem. Colitis Granulom. Colitis
Axial CECT shows mural thickening of ascending +
transverse colon plus dilated mesenteric vessels.
Campylobacter colitis.
o ± Thumbprinting; may simulate ischemic colitis
o ± Fistulas or sinus tracts
o Typhoid fever (Salmonellosis)
• Cecum or right colon; invariably in ileum
• Ileal fold thickening and ulceration
o Shigellosis: Predominantly in left colon; mucosal
o Campylobacteriosis: Small bowel and colon
o Yersinia enterocolitis: Predominantly in right colon,
occasionally in left; invariably in terminal ileum
o E. coli colitis: Transverse colon; extends to right, left
or both sides of colon
o Tuberculosis
• Right & proximal transverse colon, involves ileum
• Oval/circumferential, transverse ulcers, loss of
ileum & right colon anatomic demarcation
• Fleischner sign: Right-angle intersection between
ileum and cecum with marked hypertrophy of
ileocecal valve
• Exuberant mural thickening; > than Crohn disease
• Can cause "apple core" colonic stricture;
indistinguishable from carcinoma
o Actinomycosis: Rectosigmoid colon (intrauterine
devices) or ileocecal region (appendectomy)
o Gonorrheal, Chlamydia, Herpesvirus colitis:
Rectosigmoid colon
o Cytomegalovirus (CMV) colitis: Cecum & proximal
colon; extends to distal ileum
Ulcerative Colitis Ischemic Colitis
 INFECTIOUS COLITIS
Key Facts
Terminology
• Inflammation of the colon caused by bacterial, viral,
fungal, or parasitic infections
Imaging Findings
• Best diagnostic clue: Focal or diffuse colonic wall
thickening with mucosal ulcerations
• Lumen narrowing & loss of haustra (edema/spasm)
• Discrete punctate, aphthous or large oval ulcers; may
simulate Crohn disease
• ± Diffuse, mucosal granularity; may simulate
ulcerative colitis
• ± Thumbprinting; may simulate ischemic colitis
• ± Fistulas or sinus tracts
• Best imaging tool: Fluoroscopic-guided barium enema
o Histoplasmosis
• Ileocecal region; polyps in rectum
• Pericecal masses; may simulate appendicitis
o Mucormycosis: Right colon; polypoid mass
o Anisakiasis: Occasionally in right colon, rarely in
transverse colon
o Amebiasis
• Right colon; terminal ileum spared
• Skip lesions (in 95%); may simulate
granulomatous colitis
• Ameboma (in 10%): Marked granulation in short
segments of bowel, located in right colon
• Can produce "apple core" type colonic stricture
• Discrete ulcers appearing as marginal defects or
granularity with barium flecks
• Residual deformity and strictures after treatment
o Schistosomiasis
• Left or sigmoid colon
• Hallmark is inflammatory polyps (granulation
response to eggs deposited in bowel wall)
o Trichuriasis
• Clumping & granularity of barium (excessive
mucus)
• Wavy, linear 3-5 cm lucencies, occasionally
terminates in ring shape with central barium
collection (worm)
CT Findings
• Wall thickening and low attenuation (edema)
• Mucosal and serosal enhancement; ascites
• Multiple air-fluid levels; inflammatory pericolic fat
• Salmonellosis: ± Small bowel thickening & effacement
• Tuberculosis
o Changes in lungs, but usually from ingestion
o Low density, marked enlargement of lymph nodes
• Actinomycosis: Large inflammatory masses
• CMV colitis
o Deep ulcers & marked wall thickening (advanced)
o Enhancement of mucosa and serosa with hypodense
thickening of intervening bowel wall (edema)
o Hemorrhage causes 1 attenuation in wall
• Histoplasmosis
o Changes in lungs and skin
Top Differential Diagnoses
• Pseudomembranous colitis
• Granulomatous colitis (Crohn disease)
• Ulcerative colitis
• Ischemic colitis
Clinical Issues
• Usually acute in onset, except tuberculosis (chronic)
• Watery or bloody diarrhea
• Crampy abdominal pain and tenderness
Diagnostic Checklist
• Diagnosis by clinical presentation; lab tests
• Barium enema or CT detects colitis; need clinical
confirmation of specific type
o Mesenteric adenopathy, hepatosplenomegaly with
or without calcifications
• Mucormycosis: Changes in sinuses, lungs & central
nervous system
• Schistosomiasis
o Changes in mesenteric or hemorrhoidal vein,
urinary tract, terminal ileum
o ± Calcification of bowel wall or liver
5
7
Imaging Recommendations
• Best imaging tool: Fluoroscopic-guided barium enema
I DIFFERENTIAL DIAGNOSIS
Pseudomembranous colitis
• Radiography: Colonic wall thickening, nodularity;
may simulate infectious colitis
• CT: "Accordion sign": Trapped oral contrast between
thickened colonic haustral folds
• Usually results in more colonic wall thickening than
other colitides
Granulomatous colitis (Crohn disease)
• Concurrent small bowel (distal ileum) disease
• Barium enema
o Cobbles toning: Longitudinal & transverse
ulcerations produce a paving stone appearance
o Transmural, skip lesions, sinuses, fistulas; may
simulate infectious colitis
• Disease is chronic, compared with infectious colitis
Ulcerative colitis
• Barium enema
o Pancolitis with decreased haustration & multiple
ulcerations; may simulate infectious colitis
o "Mucosal islands" or "inflammatory pseudopolyps"
o Diffuse & symmetric wall thickening of colon
o Chronic phase ~ "lead-pipe" colon
Ischemic colitis
• Usually located in watershed areas; focal or diffuse
• Barium enema: Thumbprinting, ulcerations (1-3 weeks
after onset of disease); strictures (later)
 INFECTIOUS COLITIS
• CT
o ± Pneumatosis, portomesenteric venous gas
o ± Thrombus within splanchnic vessels
• Differentiate by clinical presentation
I PATHOLOGY
General Features
• Etiology
o Bacterial organisms (most common in Western
countries): Salmonella, Shigella, Campylobacter,
Yersinia, Staphylococcus, Escherichia coli
(0157:H7), M. tuberculosis, Actinomyces,
Chlamydia trachoma tis, C. gonorrhea
• Chlamydia is the causative agent for
"lymphogranuloma venereum"
o Viral organisms: Herpes virus, CMY, Norwalk virus,
Rotavirus
o Fungal organisms: Histoplasma, Mucor
o Parasitic organisms (most common in
underdeveloped countries): Anisakis, Amoeba,
Schistosoma, Strongyloides, Trichuriasis
o Risk factors
• Salmonella, Shigella: Outbreaks, warm weather
• E. coli: Travel, nursing homes (0157:H7)
• Tuberculosis, CMV: AIDS
5 • Actinomycosis: Intrauterine devices,
appendectomy
8 • Histoplasma, Mucor: Chronic debilitation or
immunosuppression
• Strongyloides: Severe debilitation
o Pathogenesis
• Ingestion of pathogenic organisms (often
fecal-oral route)
• Chlamydia, Gonorrhea, Herpes virus: Direct
inoculation of rectum (anal intercourse)
Gross Pathologic & Surgical Features
• Varies based on etiology
Microscopic Features
• Varies based on etiology
I CLINICAL ISSUES
Presentation
• Most common signs/symptoms
o Usually acute in onset, except tuberculosis (chronic)
o Watery or bloody diarrhea
o Crampy abdominal pain and tenderness
o Fever, headache, nausea, vomiting, weight loss
o Palpable abdominal mass, anemia, malaise, rash
o Arthritis, pneumonitis, seizures, peripheral
neuropathy, microangiopathy
o Varied incubation period
o E. colli colitis: Traveler's diarrhea, hemolytic-uremic
syndrome (0157:H7)
o Schistosomiasis: Hepatosplenomegaly ~ portal
hypertension
• Lab-Data
o Bacterial organisms: Increased neutrophilic count
o Viral organisms: t Lymphocytes (I in AIDS)
o Fungal, parasitic organisms: Eosinophilia
• Diagnosis
o Stool cultures, blood cultures, endoscopic biopsy,
serology studies
Demographics
• Age: Any age, but incidence t with age
• Gender: M:F = 1:1
Natural History & Prognosis
• Complications
o Toxic megacolon, bacteremia, sepsis, death
o Hemorrhage, perforation, obstruction
o Yersinia enterocolitis: Hepatic abscess
o E. coli colitis: Hemolytic-uremic syndrome
o Amebiasis: Liver and lung abscesses
• Prognosis
o Usually very good, after treatment
o Campylobacteriosis: 25% recurrence if untreated
o E. coli 0157:H7 colitis: t Morbidity, 33% mortality
o CMV colitis: Hemorrhage and ischemia can be fatal
o Mucormycosis, Strongyloidiasis: Fatal
Treatment
• Bacterial organisms: Mostly self-limiting, last 1-2
weeks; up to 1 month
o Salmonellosis: Parenteral cephalosporins if severe
o Shigellosis: Ampicillin in severe cases
o Yersinia enterocolitis: Lasts several months; no
treatment available
o E. coli 0157:H7 colitis: Supportive treatment,
isolation procedures
o Tuberculosis: Antituberculosis drugs, no steroids
• Viral organisms: Mostly self-limiting
o CMV: Treat underlying AIDS
• Parasitic organisms: Antihelminthic drugs
o Anisakiasis: Mostly self-limiting, last 7-10 days
• Fungal organisms: Antifungal drugs
I DIAGNOSTIC CHECKLIST
Consider
• Diagnosis by clinical presentation; lab tests
Image Interpretation Pearls
• Barium enema or CT detects colitis; need clinical
confirmation of specific type
I SELECTED REFERENCES
1. Thielman NM et al: Clinical practice. Acute infectious
diarrhea. N Engl J Med. 350(1):38-47, 2004
2. Horton KM et al: CT evaluation of the colon: inflammatory
disease. Radiographics. 20(2):399-418, 2000
3. Philpotts LEet al: Colitis: use of CT findings in differential
diagnosis. Radiology. 190(2):445-9, 1994
4. Schmitt SLet al: Bacterial, fungal, parasitic, and viral
colitis. Surg Clin North Am. 73(5):1055-62, 1993
5. Wall SD et al: Gastrointestinal tract in the
immunocompromised host: opportunistic infections and
other complications. Radiology. 185(2):327-35, 1992
 INFECTIOUS COLITIS

I IMAGE GALLERY

(Left) Single-contrast BE
shows rectal stricture with
mucosal irregularity due to
"lymphogranuloma
venereum" (Chlamydia
trachomatis). (Right)
Single-contrast BE shows
"apple core" lesion of
ascending colon due to
Mycobacterium tuberculosis.

Typical
(Left) Axial CECT shows
pancolitis due to
Cytomegalovirus (CMV) in a
patient with AIDS. (Right)
Axial CECT shows
proctocolitis with mural
5
thickening and mesenteric
9
hyperemia in a 32 year old
woman due to CMV colitis.

Typical
(Left) Axial CECT shows
Campylobacter pancolitis in
a previously healthy 26 year
old woman. Note
"thumbprinting" of colonic
wall (arrow). (Right) Axial
CECT of 26 year old woman
with Campylobacter colitis
shows marked mural
thickening of sigmoid colon.
 PSEUDOMEMBRANOUS COLITIS

Graphic shows pancolitis with marked mural thickening Axial CECT shows pancolitis with marked mural
with multiple elevated yellow-white plaques thickening and enteric contrast trapped between
(pseudomembranes) . haustra ("accordion sign").

o Clindamycin causes diarrhea in 20% &

ITERMINOlOGY pseudomembranous colitis in 10% of patients
Abbreviations and Synonyms o C. difficile infection of colon follows insult to gut by
• Pseudomembranous colitis (PMC) antibiotic or chemotherapy
5 • Antibiotic colitis, Clostridium difficile colitis o C. difficile infection is responsible for virtually all
cases of PMC
10 Definitions o C. difficile toxins: Cytotoxic + enterotoxic effects
• Acute inflammation of colon caused by toxins o Complications range from watery diarrhea to
produced by Clostridium difficile bacteria colonic perforation & death
Radiographic Findings
jlMAGING FINDINGS • Radiography
o Colonic ± small bowel ileus
General Features o Gaseous distension of colon + nodular haustral
• Best diagnostic clue: Marked submucosal edema over a thickening
long segment of colon o Thumbprinting: Unusual, wide transverse bands due
• Location to thickening of haustral folds
o Usually entire colon (pancolitis) • Most prominent in transverse colon
o Rectum & sigmoid colon (typically involved in o Severe cases: Polypoid mucosal thickening
80-90% of cases) • Represent pseudomembranous plaques protruding
o Confined to more proximal colon (10% of cases) into air-containing lumen
• Morphology: Plaque-like adhesions of fibrinopurulent o Fulminant cases
necrotic debris & mucus on damaged colonic mucosa • Toxic megacolon
with submucosal edema • Pneumoperitoneum
• Other general features • Fluoroscopic guided contrast enema studies
o PMC is usually associated with antibiotic use, o Enema is contraindicated in severe PMC (due to
especially clindamycin increased risk of perforation)
o Limited role in diagnosis of PMC

DDx: Other Causes of Colitis

Campylobacter CMV Colitis Ulcerative Colitis Ischemic Colitis

 PSEUDOMEMBRANOUS
Key Facts
Terminology
• Pseudomembranous colitis (PMC)
• Antibiotic colitis, Clostridium difficile colitis
• Acute inflammation of colon caused by toxins
produced by Clostridium difficile bacteria
Imaging Findings
• Best diagnostic clue: Marked submucosal edema over
a long segment of colon
• Usually entire colon (pan colitis)
• Rectum & sigmoid colon (typically involved in
80-90% of cases)
• "Accordion sign": Represents trapped enteric contrast
between thickened colonic haustral folds
• Pericolonic stranding
• Ascites common in severe PMC
o Findings vary depending on severity & extent of
disease
o Marked mural thickening & wide haustral folds due
to intramural edema
CT Findings
• CECT with oral contrast
o Colonic wall thickening & nodularity
• Thickening is more irregular & shaggy compared
to symmetric & homogeneous in Crohn
o "Accordion sign": Represents trapped enteric
contrast between thickened colonic haustral folds
• Alternating bands of high attenuation (contrast) +
low attenuation (edematous haustra)
• Usually seen in advanced cases
• Highly suggestive of PMC
o "Target sign"
• Mucosa: Intense enhancement (hyperemia)
• Submucosa: Thickened, non-enhancing, I HU
(edema)
o Extent of disease
• Pancolitis is most common
• Rectum & sigmoid colon (80-90% of cases)
• Right colon involved exclusively in some cases
o Pericolonic stranding
• Usually mild (due to primary mucosal &
submucosal nature of PMC)
• Relative paucity of pericolonic inflammation +
marked colonic wall thickening differentiates
PMC from other colitides
o Ascites common in severe PMC
• Uncommon in other inflammatory bowel diseases
o ± Pneumatosis coli or air in intrahepatic portal vein
o Small pleural effusions & subcutaneous edema
• May be due to primary disease or debilitated state
Imaging Recommendations
• Best imaging approach is CECT with oral contrast
o 125 ml LV contrast at ~ 2.5 mllsec
COLITIS
Top Differential Diagnoses
• Granulomatous colitis (Crohn disease)
• Ulcerative colitis
• Ischemic colitis
• Neutropenic enterocolitis
Pathology
• Antibiotic therapy (clindamycin most common) due
to overgrowth of resistant enteric C. difficile
Clinical Issues
• Clinical profile: Patient with history of watery
diarrhea after antibiotic use or hospitalization
Diagnostic Checklist
• Check history of antibiotic use or debilitating diseases
• Suspect in any hospitalized patient with acute colitis
I DIFFERENTIAL DIAGNOSIS
Other infectious colitis
• Campylobacter, cytomegalovirus, etc.
• May be indistinguishable from pseudomembranous
colitis
• Often have less severe colonic wall thickening 5
Granulomatous colitis (Crohn disease) 11
• Concurrent small bowel (distal ileum) disease usually
• Cobblestoning: Longitudinal & transverse ulcerations
produce a paving stone appearance
• Segmental distribution
• Transmural, skip lesions, sinuses, fissures, fistulas
• CT shows fibrofatty proliferation of mesentery &
enlarged mesenteric lymph nodes
Ulcerative colitis
• Classic imaging appearance
o Pancolitis with decreased haustration & multiple
ulcerations on barium enema
• Colorectal narrowing; 1 presacral space> 1.5 em
• "Mucosal islands" or "inflammatory pseudopolyps"
• Diffuse & symmetric wall thickening of colon
• Backwash ileitis: Distal ileum involvement (10-40%)
• Chronic phase
o "Lead-pipe" colon: Rigid colon with loss of haustra
Ischemic colitis
• Usually seen in watershed areas; focal or diffuse
o Left side colon: Typical in elderly (hypoperfusion)
• Splenic flexure: Junction of SMA & IMA
o Right-side colon: Younger patients
• Due to decreased collateral blood supply
• Barium findings
o Thumbprinting: Submucosal edema or hemorrhage
o Ulceration: 1-3 weeks after onset of disease
o Stricture: Seen in late phase
• CT findings
o Bowel wall thickening ± luminal dilatation
o ± Pneumatosis, portomesenteric venous gas
o ± Thrombus within splanchnic vessels
• Has less wall thickening than PMC
 PSEUDOMEMBRANOUS COLITIS
• Typically takes 48 hours to confirm
Neutropenic enterocolitis o Proctosigmoidoscopy or colonoscopy
• Clinical history of neutropenia & immunosuppression • Adherent yellow plaques 2-10 mm in diameter
• Usually focal disease in right colon & cecum
• Mural thickening limited to right colon & distal ileum Demographics
• Thumbprinting, luminal narrowing, ulceration • Age
• Immunocompromised with PMC mimics neutropenic o Elderly age group> young age group
colitis when localized to cecum & right colon • Elderly are at higher risk for developing PMC &
recurrent PMC than young
• Gender: Equal in both males & females (M = F)
!PATHOLOGY Natural History & Prognosis
General Features • Complications
• Etiology o Toxic megacolon, sepsis, perforation & death
o Antibiotic therapy (clindamycin most common) due • Prognosis
to overgrowth of resistant enteric C. difficile o If treated early, full recovery expected
• Antibiotic therapy usually within 2 days to 2 o Recurrence rate higher in women & elderly
weeks & rarely up to 6 months o Severe cases may need colectomy
• Ampicillin, tetracycline, erythromycin, penicillin o Untreated cases can lead to perforation, acute
(less common) abdomen & death (mortality rate 1.1-3.5%)
o Other causes
Treatment
• Abdominal surgery, colonic obstruction, uremia,
prolonged hypotension or hypoperfusion of bowel • Mild cases: Discontinue offending antibiotic therapy
• Severe debilitating diseases (e.g., lymphoma, • Severe cases
leukemia, AIDS) o Metronidazole (drug of choice) or oral vancomycin
o Pathogenesis o Fulminant & toxic megacolon: Colectomy
• Antibiotic therapy (clindamycin)
5 • Inhibits & alters normal intestinal micro flora
• Overgrowth of resistant enteric C. difficile I DIAGNOSTIC CHECKLIST
• Enterotoxin (toxin A) & cytotoxin (toxin B) ~ Consider
12
mucosal damage
• Check history of antibiotic use or debilitating diseases
• Epidemiology
• Suspect in any hospitalized patient with acute colitis
o 1-10 cases per 1,000 patient discharges from hospital
o 1 case per 10,000 antibiotic prescriptions written Image Interpretation Pearls
outside hospital • Marked submucosal edema over long segment of colon
Gross Pathologic & Surgical Features • "Accordion sign": Trapped oral contrast between
thickened colonic haustral folds
• Inflamed colon with multiple elevated, yellow-white
• Usually pancolitis; rectum & sigmoid colon involved
plaques (pseudomembranes)
in 80-90% of cases
• When removed during endoscopy, reveals
erythematous & inflamed mucosa
Microscopic Features I SELECTED REFERENCES
• Colonization of colon by clostridium difficile 1. Gore RM et al: Inflammatory conditions of the colon.
• Mild-early: Focal necrosis of surface epithelial cells in Semin Roentgenol. 36(2):126-37, 2001
glandular crypts with neutrophilic infiltration & fibrin 2. Kirkpatrick ID et al: Evaluating the CT diagnosis of
plugging of capillaries in lamina propria and mucus Clostridium difficile colitis: should CT guide therapy? A]R
Am] Roentgenol. 176(3):635-9,2001
hypersecretion in adjacent crypts
3. Horton KM et al: CT evaluation of the colon: inflammatory
• Moderate: Crypt abscesses disease. Radiographies. 20(2):399-418, 2000
• Severe-late: Necrosis & denudation of mucosa with 4. Kawamoto S et al: Pseudomembranous colitis: spectrum of
thrombosis of submucosal venules imaging findings with clinical and pathologic correlation.
Radiographies. 19(4):887-97, 1999
5. Macari M et al: The accordion sign at CT: a nonspecific
I CLINICAL ISSUES finding in patients with colonic edema. Radiology.
211(3):743-6, 1999
Presentation 6. Ros PR et al: Pseudomembranous colitis. Radiology.
198(1):1-9, 1996
• Most common signs/symptoms
7. Gore RM et al: Radiologic investigation of acute
o Mild cases: Watery diarrhea
inflammatory and infectious bowel disease. Gastroenterol
o Severe cases: Acute abdomen Clin North Am. 24(2):353-84, 1995
• Fever, abdominal pain & tenderness, tachycardia 8. Fishman EK et al: Pseudomembranous colitis: CT
• Dehydration, leukocytosis & sepsis evaluation of 26 cases. Radiology. 180(1):57-60, 1991
• Clinical profile: Patient with history of watery diarrhea 9. Rubesin SE et al: Pseudomembranous colitis with
after antibiotic use or hospitalization rectosigmoid sparing on barium studies. Radiology. 170(3
• Diagnosis Pt 1):811-3, 1989
o Demonstration of C. difficile toxins in stool
 PSEUDOMEMBRANOUS COLITIS

I IMAGE GALLERY
Typical
(Left) Axial CECT shows
massive submucosal edema
of the transverse colon with
luminal narrowing + striking
mucosal enhancement.
(Right) Axial CECT shows
transmural involvement of
entire colon, plus ascites,
raising the concern for
perforation.

(Left) Single-contrast BE
shows pan colitis, with
"thumbprinting" indicating
submucosal edema or
hemorrhage. (Right) Photo of
opened resected colon
5
shows sloughed, necrotic
13
mucosa and raised yellow
plaques or
pseudomembranes.

Typical
(Left) Axial CECT shows
marked mural thickening of
transverse colon, plus
extraluminal gas (arrow) and
enteric contrast media (open
arrow). Fatalcolonic
perforation. (Right) Axial
CECT shows marked wall
thickening of ascending
colon with high density
ascites. C. difficile colitis with
perforation.
 TYPHLITIS

Single contrast BE shows marked irregular narrowing of Axial CECT shows thickening of the wall of the cecum +
the lumen of the cecum. Small bowel is dilated. ascending colon. The lumen of the cecum is narrowed;
ascending colon dilated.

o Thumbprinting due to bowel edema

ITERMINOLOGY o ± Pneumatosis: Speckled or linear pattern
Abbreviations and Synonyms • Fluoroscopic guided water-soluble contrast enema
• Synonym(s): Neutropenic colitis, ileocecal syndrome, o Usually not recommended (possible perforation)
5 cecitis, necrotizing enteropathy o Mural thickening & mucosal thumbprinting
o Luminal narrowing or dilatation of cecum
14 Definitions o ± Dilated adjacent bowel loops (paralytic ileus)
• Inflammatory or necrotizing process involving cecum, o Shallow or deep ulcerations
ascending colon & occasionally distal ileum/appendix
CT Findings
• NECT
IIMAGING FINDINGS o Cecal luminal distention or narrowing
o Circumferential wall thickening of cecum ±
General Features ascending colon & distal ileum
• Best diagnostic clue: Massive mural thickening of cecal o I Bowel-wall attenuation (due to edema)
± ascending colon wall o Pericecal fat stranding + thickened fascial planes
• Location: Cecum + ascending colon (more common) o Pericolonic fluid collection
• Morphology: Dilated or narrow lumen, thickened wall o ± Pneumatosis, pneumoperitoneum
• Other general features o ± Dilated adjacent bowel loops (paralytic ileus)
o Usually seen in severely neutropenic patients • CECT: Heterogeneous enhancement of bowel wall
• Post chemotherapy or bone marrow transplant
Ultrasonographic Findings
o More common in children than adults
o Clinical syndrome of fever & right lower quadrant • Real Time
tenderness in immunosuppressed host o Hypoechoic or hyperechoic thickened bowel wall
o Anechoic free fluid; ± mixed echoic abscess
Radiographic Findings
Imaging Recommendations
• Radiography
o Ileocecal dilatation with air-fluid levels • Helical CT: Study of choice for diagnosis of typhlitis
o RLQ soft tissue mass • Water-soluble contrast; colonoscopy (contraindicated)

DDx: Fold Thickening, Contraction of Cecum

,,-.

Cecal Carcinoma
,.~.
•••••
App. Abscess
' ..
Diverticulitis Pseudomem. Colitis
 TYPHLITIS

Key Facts
Imaging Findings • Cecal diverticulitis
• Best diagnostic clue: Massive mural thickening of • Crohn disease
cecal ± ascending colon wall • Pseudomembranous colitis
• Pericecal fat stranding + thickened fascial planes Pathology
• CECT: Heterogeneous enhancement of bowel wall
• Hemorrhagic, thick, boggy cecum & adjacent colon
Top Differential Diagnoses Diagnostic Checklist
• Cecal carcinoma
• Check for history of chemotherapy for leukemia or
• Appendicitis bone marrow transplantation

I DIFFERENTIAL DIAGNOSIS Demographics

• Age: Children & young adults> older adults
Cecal carcinoma
• Gender: Equal in both males & females (M=F)
• "Apple core" lesion: Narrow lumen; irregular mucosa
Natural History & Prognosis
Appendicitis
• Complications: Abscess, necrosis, perforation, sepsis
• Thickened cecal wall adjacent to inflamed appendix • Prognosis: Early stage (good); late stage (poor)
Cecal diverticulitis Treatment
• Bowel wall thickening, fat stranding, free fluid or air • Medical: High doses of antibiotics & IV fluids
• Cecal outpouching differentiates from typhlitis • Complicated case
Crohn disease o CT signs of perforation: Surgical resection
• Segmental, transmural, cobblestone mucosa o Granulocyte transfusions
• Luminal narrowing, typically seen in terminal ileum 5
Pseudomembranous colitis I DIAGNOSTIC CHECKLIST 15
• Due to Clostridium difficile bacteria
• Usually affects all or most of colon Consider
• Check for history of chemotherapy for leukemia or
bone marrow transplantation
I PATHOLOGY Image Interpretation Pearls
General Features • Cecal wall thickening & pericolonic inflammation in
severely neutropenic patients
• Etiology
o Neutropenic conditions
• Leukemia, lymphoma, any malignancy, organ or
bone marrow transplant cases on chemotherapy
I SELECTED REFERENCES
• AIDS; viral, bacterial & fungal infections 1. Horton KM et al: CT evaluation of the colon: Inflammatory
• Idiopathic, aplastic anemia, ischemia, antibiotics disease. RadioGraphies. 20: 399-418, 2000
o Mechanism 2. Adams GW et al: CT detection of typhlitis. Journal of
Computed Assisted Tomography. 9: 363-5, 1985
• Chemotherapy/antibiotics ~ immunosuppression
3. Frick MP et al: Computed tomography of neutropenic
~ neutropenia ~ infection ~ typhlitis colitis. AJR. 143: 763-5, 1984
• Epidemiology: Incidence: Children> adults
• Associated abnormalities: Neutropenic diseases
Gross Pathologic & Surgical Features I IMAGE GALLERY
• Hemorrhagic, thick, boggy cecum & adjacent colon
Microscopic Features
• Inflammatory, ischemic, necrotic, ulcerative changes

I CLINICAL ISSUES
Presentation
• Most common signs/symptoms
o Fever, RLQ pain, watery diarrhea, ± hematochezia
o Fullness; palpable mass; RLQ tenderness (± rebound)
• Lab data: Neutropenia, leukopenia; ± blood in stool
• Diagnosis: Imaging, clinical & lab correlation (Left) Axial CECT in leukemic patient. Cecal wall is massively
thickened, lumen narrowed, with per/colonic infiltration. (Right) Axial
CECT shows cecal wall thickening, obliteration of lumen.
 ULCERATIVE COLITIS

Graphic shows innumerable "collarbutton" ulcers and Single-contrastbarium enema (BE) shows innumerable
loss of haustra throughout descending and sigmoid "collar button" ulcers and loss of haustra throughout
colon. descending colon.

ITERMINOLOGY o Begins in rectum & extends proximally to involve

part or all of the colon
Abbreviations and Synonyms o Backwash ileitis: 10-40% of chronic UC patients,
• Ulcerative colitis (UC) distal ileum is inflamed
5 Definitions
o Ulcerative colitis> common than Crohn disease
o Incidence: First-degree relatives 30-100 times>
16 • Chronic, idiopathic diffuse inflammatory disease that general population
primarily involves colorectal mucosa & submucosa o I Risk of colorectal cancer in UC than Crohn colitis
• Annual incidence: 10% after first decade of UC
• 75-80% who develop colon cancer have pan colitis
I IMAGING FINDINGS • 25% UC cases have multiple carcinomas (often
flat & scirrhous, difficult to image)
General Features
• Best diagnostic clue: Pancolitis with I haustration + Radiographic Findings
multiple ulcerations on barium enema • Fluoroscopic guided barium contrast enema
• Location: Rectum (30%); rectum + colon (40%); o Acute changes
pancolitis (30%) • Colorectal narrowing + incomplete filling (spasm
• Morphology + irritability)
o Narrow lumen, superficial ulcers, pseudopolyps • Fine mucosal granular pattern (edema/hyperemia)
o "Lead-pipe" colon & lack of haustra in chronic phase • Mucosal stippling: Punctate barium collections
• Other general features (crypt abscesses erode ~ ulcers & barium
o Chronic relapsing inflammatory bowel disease with collection)
acute features • "Collar button" ulcers (flask-like): Due to
o Disease with continuous concentric + symmetric undermining of ulcers (ulcers enlarge ~
colonic involvement configuration lost ~ mucosal islands + polyps)
o Inflammation limited to mucosa & submucosa • Haustra: Edematous & thickened
o Characterized by pseudopolyps/crypt microabscesses • Polyps: Inflammatory & postinflammatory
pseudopolyps (remnants of mucosa & submucosa)
o Chronic changes

DDx: Ulceration, Wall Thickening of Colon

Granulomatous Colitis Pseudomem. Colitis Ischemic Colitis Cathartic Colon

 ULCERATIVE COLITIS
Key Facts
Terminology
. pseudo polyps (remnants of mucosa & submucosa
• Chronic, idiopathic diffuse inflammatory dIsease that
primarily involves colorectal mucosa & submucosa
Imaging Findings
• Best diagnostic clue: Pan colitis with I haustration +
multiple ulcerations on barium enema
• Location: Rectum (30%); rectum + colon (40%);
pancolitis (30%)
• Fine mucosal granular pattern (edema/hyperemia)
• Mucosal stippling: Punctate barium collections (crypt
abscesses erode ~ ulcers & barium collection)
• "Collar button" ulcers (flask-like): Due to
undermining of ulcers (ulcers enlarge ~
configuration lost ~ mucosal islands + polyps)
• Haustra: Edematous & thickened
• Shortening of colon with depression of flexures
(reversible)
• "Lead-pipe" colon: Rigidity + luminal narrowing
• Haustrations: Blunted or complete loss
• Backwash ileitis: Distal 5-25 cm of ileum is
inflamed (seen in 10-40% cases)
• Luminal narrowing & widened presacral space
(more than 1.5 cm)
• Benign strictures: Local sequelae of UC (seen in
10% of patients)
o Rectal valve abnormalities (double contrast study)
• Lateral rectal view: Normally at least one rectal
valve should be visible
• Fold is usually seen at the level of S3 & S4 (less
than 5 mm thick)
• Proctitis: Valve thickness> 6.5 mm or absent
CT Findings
• NECT
o Colorectal narrowing
o Widening of presacral space: > 1.5 cm
• Due to perirectal fibrofatty proliferation
o Diffuse + symmetric wall thickening of colon
• Less than 10 mm (average 7.8 mm)
o Mural thickening & luminal narrowing
• Seen in subacute & chronic ulcerative colitis
• CECT
o "Target" or "halo" sign
• Enhancing inner ring of bowel wall (mucosa)
• Nonenhancing middle ring of bowel wall
(submucosa): Due to edema in acute or halo of fat
in chronic phase
• Enhancing outer ring of bowel wall (muscularis
propria)
o Enhancement of
• "Mucosal islands" or inflammatory "pseudopolyps"
• Inflammatory peri colonic stranding
Imaging Recommendations
• Barium enema (single & double contrast studies);
helical NE + CECT
• Polyps: Inflammatory & postinflammatory )
• "Lead-pipe" colon: Rigidity + luminal narrowing
• Widening of presacral space: > 1.5 cm
• Diffuse + symmetric wall thickening of colon
Top Differential Diagnoses
• Granulomatous colitis (Crohn disease)
• Pseudomembranous colitis (PMC)
• Ischemic colitis
• Neutropenic enterocolitis
• Diverticulitis
Diagnostic Checklist .
• Continuous concentric & symmetric involvement
• Consider UC in any patient with sclerosing
cholangitis
I DIFFERENTIAL DIAGNOSIS
Granulomatous colitis (Crohn disease)
• Barium enema findings
o Aphthae: Punctate central collections of barium
o Cobbles toning: Longitudinal & transverse
ulcerations produce a paving stone 5
o Segmental distribution
• Involve both colon & small bowel (60% cases) 17
• Isolated to colon (20% cases)
o Transmural, skip lesions, sinuses, fissures, fistulas
o In late stage indistinguishable from ulcerative colitis
due to haustral loss & pseudopolyps
• CT shows
o Bowel wall thickening (1-2 cm)
o "Creeping fat" or fibrofatty proliferation of
mesentery
o Enlarged mesenteric lymph nodes
o "Comb" sign: Mesenteric hypervascularity
• Indicates active disease
Pseudomembranous colitis (PMC)
• Synonym(s): Antibiotic colitis or C. difficile colitis
• Usually involves entire colon (pan colitis)
• CT findings
o Colonic wall thickening & nodularity
o "Accordion" sign: Represents trapped enteric
contrast between thickened colonic folds
o Ascites common in PMC & unusual in other lED
Ischemic colitis
• Usually seen in watershed areas; focal or diffuse
o Left side colon: Typical in elderly (hypoperfusion)
• Splenic flexure: Junction of SMA & IMA
o Right-side colon: Young patients
• Due to decreased collateral blood supply
• Barium findings
o Thumbprinting: Submucosal edema or hemorrhage
o Ulceration: 1-3 Weeks after onset of disease
o Stricture: Seen in late phase
• CT findings
o Bowel wall thickening, ± luminal dilatation
o ± Pneumatosis, portomesenteric venous gas
 ULCERATIVE COLITIS
o ± Thrombus within splanchnic vessels
Cathartic colon
• Due to long term use/abuse of laxatives + cathartics
• Appearance of ahaustral "rigid" colon simulates
ulcerative colitis
Neutropenic enterocolitis
• Clinical history: Neutropenia & immunosuppression
• Usually focal disease in right colon & cecum
• Imaging findings
o Mural thickening limited to right colon ± distal
ileum
o Thumbprinting: Due to bowel edema
o Luminal narrowing
o Shallow or deep ulcerations ± pneumatosis
Diverticulitis
• CT findings
o Location: Most common in sigmoid colon
o Bowel wall & fascial thickening; fat stranding; free
fluid & air
o Pericolic inflammatory changes
• Abscess, sinuses, fistulas
o "Arrowhead" sign: Due to diverticular orifice edema
o Focal area of eccentric luminal narrowing
o Diverticulosis uncommon in patients with ulcerative
colitis
5 • Rule out other inflammatory
18 I PATHOLOGY
General Features
• Genetics
o 1 Frequency in monozygotic twins
o HLA B5, BW52 & DR2linked to UC
• Etiology
o Genetic, familial, environmental, neural, hormonal
o Infectious, nutritional, immunological, vascular
o Traumatic, psychological & stress factors
o Smoking decreases risk factor
• Epidemiology: Incidence 2-10 cases/lOO,OOO people
• Associated abnormalities
o Primary sclerosing cholangitis (PSC), uveitis
o Ankylosing spondylitis, rheumatoid arthritis
o Pyoderma gangrenosum, sacroiliitis
Gross Pathologic & Surgical Features
• Rectum + colon involved
• Continuous involvement
• Superficial ulcers, pseudopolyps
Microscopic Features
• Inflammatory infiltrate, crypt microabscesses
• Limited to mucosa & submucosa
I CLINICAL ISSUES
Presentation
• Most common signs/symptoms
o Relapsing bloody mucus diarrhea
o Fever, weight loss, abdominal pain & cramps
o Systemic manifestations
• Lab-data: Blood & mucus in stool
• Diagnosis: Mucosal biopsy & histology
Demographics
• Age: 15-25 years (small peak at 55-65 years)
• Gender: Males less than females (M < F)
• Ethnicity: More common in Caucasians & Jews
Natural History & Prognosis
• Complications
o Toxic megacolon, colorectal cancer, strictures
o Increased incidence of colon carcinoma up to 50%
after 25 years of disease
• Prognosis
o Improves with diagnosis & management
o Mortality: First 2 years of UC in > 40 years old
• Males (2.1%); females (1.5%)
Treatment
• Medical
o Sulfasalazine, steroids, azathioprine
o Methotrexate, LTB4 inhibitors
• Surgical: Total or proctocolectomy + Brooke or
continent ileostomy (Kock pouch)
I DIAGNOSTIC CHECKLIST
Consider
diseases of colon
Image Interpretation Pearls
• Colorectal narrowing + punctate & collar button ulcers
• Continuous concentric & symmetric involvement
• "Lead-pipe" (rigid) colon & haustral loss (late phase)
• Consider UC in any patient with sclerosing cholangitis
I SELECTED REFERENCES
1. Carucci LR et al: Radiographic imaging of inflammatory
bowel disease. Gastroenterol Clin North Am. 31(1):93-117,
ix, 2002
2. Horton KM et al: CT evaluation of the colon: inflammatory
disease. Radiographies. 20(2):399-418, 2000
3. Kawamoto S et al: Pseudomembranous colitis: spectrum of
imaging findings with clinical and pathologic correlation.
Radiographies. 19(4):887-97, 1999
4. Balthazar EJ et al: Ischemic colitis: CT evaluation of 54
cases. Radiology. 211(2):381-8, 1999
5. Antes G: Inflammatory disease of the small intestine and
colon: Contrast enema and CT. Radiology. 38: 41-5, 1998
6. Gore RM et al: CT features of ulcerative colitis and Crohn's
disease. AJR. 167: 3-15, 1996
7. Jacobs JE et al: CT of inflammatory disease of the colon.
Semin Ultrasound CT MR. 16(2):91-101, 1995
8. Gore RM et al: CT findings in ulcerative, granulomatous,
and indeterminate colitis. AJRAm J Roentgenol.
143(2):279-84, 1984
9. Kelvin FM et al: Double contrast barium enema in Crohn's
disease and ulcerative colitis. AJRAm J Roentgenol.
131(2):207-13, 1978
10. Laufer I et al: The radiological differentiation between
ulcerative and granulomatous colitis by double contrast
radiology. Am J Gastroenterol. 66(3):259-69, 1976
 ULCERATIVE COLITIS

I IMAGE GALLERY
Typical
(Left) Axial CECT shows
narrowed lumen and
thickened wall of descending
colon. Submucosal halo of
low density (edema) and
engorged blood vessels
indicate active disease.
(Right) Axial CECT shows
narrowed lumen and
thickened wall of sigmoid
colon with submucosal
edema and engorged vessels.

(Left) Single-contrast BE
shows prominent, thickened
haustra in right colon, but
diminished haustra in left
colon. (Right) Oblique new
single-contrast BEshows
5
narrowed lumen, ahaustral
19
left colon with diffuse
ulceration (collar button +
flask-shaped) .

(Left) Double-contrast BE
shows filiform polyps in a
patient with chronic Uc,
now in remission. (Right)
Single-contrast BE shows
ahaustral colon due to
chronic uc. Apple core
stricture of transverse colon
(arrow) due to
adenocarcinoma.
 TOXIC MEGACOLON

Supine radiograph shows ahaustral colon in an acutely Supine radiograph shows diffusely dilated bowel in an
ill patient with chronicuc. The transverse colon is acutely ill patient with ulcerative colitis. The transverse
dilated and "shaggy" in appearance due to sloughed colon is dilated, ahaustral with an irregular mucosal
mucosa and pseudopolyps. surface.

ITERMINOLOGY Radiographic Findings

Definitions
• Acute transmural fulminant colitis with
5 neuromuscular degeneration & colonic dilatation
20
I IMAGING FINDINGS
General Features
• Best diagnostic clue: Dilated ahaustral colon with
pseudopolyps & air-fluid levels
• Location: Transverse colon (least dependent part in
supine position)
• Other general features
o Most severe, life-threatening complication of
inflammatory bowel disease
o More common in ulcerative colitis (1.6-13% cases)
o May be the initial manifestation of ulcerative colitis
o Most common cause of death directly related to
ulcerative colitis
o Diagnosis: Based on clinical status of patient +
radiographic evidence
o Precipitating factors of toxic megacolon
• Endoscopy; use of opiates & anticholinergic drugs
• Progressive metabolic alkalosis; aerophagia
• Radiography
o Marked colonic dilatation is hallmark
• Transverse colon dilatation most common
(because least dependent on supine view)
• i Colon caliber on serial radiographs
• Mean diameters of dilated segments (8.2-9.2 em)
• Absolute colonic diameter: Not a diagnostic
criterion
o "Mucosal islands" or "pseudopolyps": Common
finding (indicate severe disruption of mucosa)
o Radiologically thick bowel wall (due to subserosal +
omental edema), pathologically, wall is thin
o Radiolucent stripe parallel to colon: Pericolic fat line
o Loss of haustral pattern
• Due to profound inflammation + ulceration
• Presence of normal haustra excludes diagnosis
o ± Air-fluid levels in colon; ± Small bowel distention
o Pneumatosis coli ± pneumoperitoneum
CT Findings
• Distended colon filled with air, fluid, blood
• Distorted or absent haustral pattern
• Irregular nodular contour of colonic wall
• Intramural air ± blood
• ± Mesenteric abscess or pneumoperitoneum

DDx: Dilated Transverse Colon

Sigmoid Volvulus Colon Cancer Colon Cancer

 TOXIC MEGACOLON

Key Facts
Terminology Top Differential Diagnoses
• Acute transmural fulminant colitis with • Colonic obstruction
neuromuscular degeneration & colonic dilatation • Adynamic or paralytic ileus
Imaging Findings Pathology
• Best diagnostic clue: Dilated ahaustral colon with • Ulcerative colitis (most common), other colitides
pseudopolyps & air-fluid levels
• Presence of normal haustra excludes diagnosis Diagnostic Checklist
• (Barium enema: Contraindicated, 1 risk perforation) • Check prior history of underlying colonic pathology

• Gender: Males less than females (M < F)

Imaging Recommendations
• Plain x-ray abdomen: Supine & lateral decubitus views Natural History & Prognosis
• Helical NECT • Complications: Perforation, abscess, peritonitis
• (Barium enema: Contraindicated, 1risk perforation) • Prognosis
o Good: After colectomy without complications
o Poor: With perforation & complications
I DIFFERENTIAL DIAGNOSIS Treatment
Colonic obstruction • Surgery (colectomy); treat complications
• Etiology: Carcinoma (55%); volvulus (11%)
• Usually subacute or chronic in onset
• Gas + stool-filled colon to point of obstruction I DIAGNOSTIC CHECKLIST
• Retained haustral pattern excludes toxic megacolon
Adynamic or paralytic ileus
Consider
• Check prior history of underlying colonic pathology
5
• Etiology: Post-op, medications, post injury, ischemia 21
• Dilated small & large bowel loops up to rectum Image Interpretation Pearls
• Normal haustral pattern excludes toxic megacolon • Extensive ahaustral colonic dilatation with air-fluid
levels & "mucosal islands" or "pseudopolyps"

I PATHOLOGY
I SELECTED REFERENCES
General Features 1. Halpert RD: Toxic dilatation of the colon. Radiologic
• Etiology Clinics of North America 25: 147-155, 1987
o Ulcerative colitis (most common), other colitides 2. Truelove SC et al: Toxic megacolon: Part 1. Pathogenesis,
o Pseudomembranous & ischemic colitis diagnosis & treatment. Clinical Gastroenterology 10: 107:
o Amebiasis, strongyloidiasis, bacillary dysentery 114, 1981
3. Fazio VW: Toxic megacolon in ulcerative colitis and Crohn
o Typhoid fever, cholera, Behcet's syndrome
disease. Clinical Gastroenterology 9: 389-407, 1980
• Epidemiology
o Incidence: Seen in 1.6-13% of ulcerative colitis cases
o Medical & surgical mortality: 21.5%
I IMAGE GALLERY
Gross Pathologic & Surgical Features
• Grossly dilated colon + air & fluid; mucosal ulceration
• Absence of haustral pattern (thin bowel wall 2-3 mm)
Microscopic Features
• Transmural inflammation
• Large areas of denuded mucosa + edema
• Fissuring ulcers with extension to serosa

I CLINICAL ISSUES
Presentation
• Most common signs/symptoms: Fever, pain, (Left) Axial CECT shows dilated transverse colon with pneumatosis,
tenderness, abdominal distension, bloody diarrhea intraluminal bleeding, sloughed mucosa. Toxic megacolon due to C.
• Lab-data: 1 WBC; 1 ESR;+ ve fecal occult blood test difficile colitis. (Right) Axial CECT shows generalized ileus. Ascending
+ descending colon are distended with blood + sloughed mucosa. C.
Demographics difficile colitis.
• Age: 20-35 years
 APPENDICITIS

Anatomic drawing of acute appendicitis. Note enlarged, Acute appendicitis on sonography. Sagittal color
inflamed appendix (arrow). Doppler sonogram of enlarged non-compressible
appendix demonstrates abnormal mural flow (arrow)
consistent with appendicitis.

ITERMINOlOGY Radiographic Findings

• Radiography
Definitions
o Appendicolith in 5-10% of patients
• Acute appendiceal inflammation due to luminal
5 obstruction and superimposed infection
o Air-fluid levels within bowel in RLQ
o Splinting
o Loss of right psoas margin
22
o Free peritoneal air very uncommon
I IMAGING FINDINGS o With perforation
General Features • Small bowel obstruction
• RLQ extraluminal gas
• Best diagnostic clue
• Displacement of bowel loops from RLQ
o Distended non-compressible appendix (~ 7 mm) on
US or CECT • Fluoroscopy
o Barium Enema
o Abnormal mural enhancement of appendix on
• Non-filling of appendix (normal in 1/3 of
CECT
patients)
o Periappendiceal fat stranding on CECT
• Focal mural thickening of medial wall of cecum
• Location: Cecal tip
("arrowhead deformity")
• Size
o Noncompressible appendix> 6 mm has sensitivity CT Findings
of 100%, but specificity of only 64% • NECT
o Noncompressible appendix> 7 mm has sensitivity o Dilated appendix ~ 7 mm
of 94% and specificity of 88% o Periappendiceal fat stranding
o Noncompressible appendix 6-7 mm equivocal size; o Appendicolith
increased flow on color Doppler in appendix • May be incidental finding
indicates positive study • Seen much more frequently on CT than on
• Morphology: Tip of appendix is often first site of radiography
inflammation and appendiceal perforation o With perforation
• Small bowel obstruction

DDx: Mimics of Appendicitis

Mesenteric Adenitis Ileocolitis PID Diverticulitis

 APPENDICITIS

Key Facts
Terminology • Ileocolitis
• Acute appendiceal inflammation due to luminal • Pelvic inflammatory disease
obstruction and superimposed infection • Cecal diverticulitis

Imaging Findings Pathology

• Dilated appendix::: 7 mm; abnormal enhancement of
appendiceal wall on CECT; appendicolith mayor
may not be present; focal bowel wall thickening of
cecal tip
• In pediatric patients, thin young adults & pregnant
patients: US first imaging method, to avoid excessive
radiation
• CT performed for patients with inconclusive US, if
perforation suspected or if obese
Top Differential Diagnoses
• Mesenteric adenitis
• General path comments: Obstructed appendiceal
lumen: Appendicolith or hypertrophied Peyer
patches; pus-filled lumen; thickened appendiceal wall
with infiltration by inflammatory cells
Clinical Issues
• Periumbilical pain migrating to RLQ; peritoneal
irritation @ McBurney point; atypical signs in 1/3 of
patients
• Nonspecific presentation more common in young
children

• Inflammatory fluid collections demonstrating

mass effect, most commonly in RLQ or dependent
pelvis (cul-de-sac)
• CECT
o Dilated appendix::: 7 mm; abnormal enhancement
of appendiceal wall on CECT; appendicolith mayor
may not be present; focal bowel wall thickening of
cecal tip
• Sensitivity 95%, specificity 95%
Ultrasonographic Findings
• Real Time
o Non-compressible appendix::: 7mm
o Sonographic "McBurney sign" with focal pain over
appendix
o Shadowing, echogenic appendicolith
o RLQ fluid, phlegmon, abscess
• Color Doppler
o Flow within wall of appendix is abnormal,
indicating inflammation
• Sensitivity 85%, specificity 90%
Imaging Recommendations
• Best imaging tool
o In pediatric patients, thin young adults & pregnant
patients: US first imaging method, to avoid excessive
radiation
o CT performed for patients with inconclusive US, if
perforation suspected or if obese
o CT procedure of choice for
• Elderly: Consider cecal or appendiceal tumor
• Subacute symptoms or palpable mass
• Helps differentiate inflammation, abscess, tumor
• Protocol advice
o Oral contrast alone or rectal contrast alone may be
given
o NECT may be performed in patients with ample
intraperitoneal fat
o CECT
• Visualize early appendicitis (abnormal mural
enhancement)
• Diagnose perforation with non-enhancement of
appendix & surrounding inflammation or abscess
I DIFFERENTIAL DIAGNOSIS
Mesenteric adenitis
• Enlarged and clustered lymphadenopathy in
mesentery and RLQ
• Normal appendix
• May have ileal wall thickening due to GI involvement 5
• Pain when pressure applied with US transducer over
nodes 23
• Diagnosis of exclusion as appendicitis (especially
perforated appendicitis) may have enlarged mesenteric
nodes
Ileocolitis
• Crohn disease or infectious (e.g., Yersinia)
• US: Mural thickening of cecum and terminal ileum;
increased mural flow on color Doppler
• CECT: Submucosal edema of cecum and terminal
ileum; surrounding cecal inflammation
Pelvic inflammatory disease
• Complex adnexal mass
• Dilated fallopian tube with fluid-fluid level
(pyosalpinx)
• "Indefinite uterus" sign with obscuration of posterior
wall of myometrium
Cecal diverticulitis
• Cecal diverticulum with mural thickening
• Pericecal inflammatory changes
• Thickening of lateral conal fascia
• Abscess in anterior pararenal space
Appendiceal tumor
• Soft tissue density mass infiltrating and/or obstructing
appendix
• Usually little surrounding infiltration
• Carcinoma; lymphoma; carcinoid
Cecal carcinoma
• May obstruct appendiceal orifice
• Appendix is dilated but no periappendiceal
inflammation
 APPENDICITIS
• Circumferential cecal mass and lymphadenopathy • Prognosis
suggest tumor rather than appendicitis o Excellent with early surgery

I PATHOLOGY I DIAGNOSTIC CHECKLIST

General Features Consider
• General path comments: Obstructed appendiceal • Mesenteric adenitis if appendix normal and nodes
lumen: Appendicolith or hypertrophied Peyer patchesi enlarged
pus-filled lumeni thickened appendiceal wall with
infiltration by inflammatory cells Image Interpretation Pearls
• Etiology: Obstruction of appendiceal lumen by • Distended non-compressible appendix :2: 7 mm
appendicolith or Peyer patches • Mayor may not have appendicolith
• Epidemiology: 7% of all individuals in western world • Peri appendiceal fat stranding on contrast
develop appendicitis during their lifetime enhancement

Gross Pathologic & Surgical Features

• Distended appendix with or without appendicolith I SELECTED REFERENCES
• Surrounding adhesions
1. Andersson RE: Meta-analysis of the clinical and laboratory
Microscopic Features diagnosis of appendicitis. Br J Surg. 91(1):28-37, 2004
2. O'Malley ME et al: US of gastrointestinal tract
• Pus in lumen abnormalities with CT correlation. Radiographies.
• Leukocyte infiltration of appendiceal wall 23(1):59-72,2003
• Mucosal ulceration 3. Paulson EK et al: Clinical practice. Suspected appendicitis.
• Necrosis if gangrenous N Engl J Med. 348(3):236-42, 2003
4. Wijetunga R et al: The CT diagnosis of acute appendicitis.
Staging, Grading or Classification Criteria Semin Ultrasound CT MR. 24(2):101-6, 2003
• Nonperforated 5. Jacobs JE et al: CT imaging in acute appendicitis:
5 o No evidence for necrosis and/or perforation techniques and controversies. Semin Ultrasound CT MR.
24(2):96-100, 2003
• Perforated
24 o May have surrounding periappendiceal abscess or 6. Lee JH: Sonography of acute appendicitis. Semin
Ultrasound CT MR. 24(2):83-90, 2003
soft tissue inflammation of mesentery and omentum
7. Horrow MM et al: Differentiation of perforated from
nonperforated appendicitis at CT. Radiology. 227(1):46-51,
2003
[CLINICAL ISSUES 8. Morgan AC: Unveiling appendicitis. Contemp Nurse.
15(1-2):114-7,2003
Presentation 9. Puylaert JB: Ultrasonography of the acute abdomen:
• Most common signs/symptoms gastrointestinal conditions. Radiol Clin North Am.
o Periumbilical pain migrating to RLQ; peritoneal 41(6):1227-42, vii, 2003
irritation @ McBurney pointi atypical signs in 1/3 of 10. Macari M et al: The acute right lower quadrant: CT
patients evaluation. Radiol Clin North Am. 41(6):1117-36, 2003
11. Neumayer L et al: Imaging in appendicitis: a review with
o Other signs/symptoms
special emphasis on the treatment of women. Obstet
• Anorexia, nausea, vomiting, diarrhea, possible Gynecol. 102(6):1404-9,2003
fever 12. Dixon MR et al: An assessment of the severity of recurrent
• Nonspecific presentation more common in young appendicitis. Am J Surg. 186(6):718-22; discussion 722,
children 2003
• Clinical profile 13. Morris KT et al: The rational use of computed tomography
o Highly variable and not reliable scans in the diagnosis of appendicitis. Am J Surg.
183(5):547-50,2002
o WBC mayor may not be elevated
14. Raman SS et al: Accuracy of nonfocused helical CT for the
Demographics diagnosis of acute appendicitis: a 5-year review. AJR Am J
Roentgenol. 178(6):1319-25,2002
• Age: All ages affected
15. Albiston E: The role of radiological imaging in the
• Gender: M = F diagnosis of acute appendicitis. Can J Gastroenterol.
16(7):451-63, 2002
Natural History & Prognosis 16. See TC et al: Appendicitis: spectrum of appearances on
• Treatment helical CT. Br J Radiol. 75(897):775-81, 2002
o Surgery if non-perforated or if minimal perforation 17. Bendeck SE et al: Imaging for suspected appendicitis:
o Percutaneous drainage if well-localized abscess> 3 negative appendectomy and perforation rates. Radiology.
em 225(1):131-6,2002
o Antibiotic therapy if peri appendiceal soft tissue 18. van Breda Vriesman AC et al: Epiploic appendagitis and
inflammation and no abscess omental infarction. Eur J Surg. 167(10):723-7,2001
19. Jones PF: Suspected acute appendicitis: trends in
• Complications
management over 30 years. Br J Surg. 88(12):1570-7, 2001
o Gangrene and perforationi abscess formation 20. Rosendahl K et al: Imaging strategies in children with
o Peritonitis; septicemia; liver abscess suspected appendicitis. Eur Radiol. 2004
o Pyelophlebitis
 APPENDICITIS

I IMAGE GAllERY
Typical
(Left) Color Doppler
sonography in acute
appendicitis demonstrates
marked hyperemia in wall of
appendix (arrow) consistent
with acute appendicitis.
(Right) Endovaginal coronal
view of right adnexa
demonstrates hyperemia of
appendix (arrow), consistent
with pelvic appendicitis.

Typical
(Left) Longitudinal sonogram
demonstrates enlarged (10
mm) appendix (open
arrows) with adjacent
hypoechoic inflammation
(arrows). (Right) Transverse
5
sonogram of appendix
25
demonstrates focal necrosis
of appendiceal wall (arrow)
and small adjacent abscess
(open arrow).

Typical
(Left) Axial CECT of
perforated appendicitis. Note
multiple calcified
appendicoliths (arrow) and
lack of enhancement of
appendiceal tip (open
arrow). (Right) Axial CECT of
perforated appendicitis. Note
marked surrounding
periappendiceal
inflammation (arrows).
 MUCOCELE OF THE APPENDIX

Axial CECT shows oval, thin-walled, calcified mass at Axial CECT shows oval, partially calcified thin-walled
the tip of the cecum. "cyst" near tip of cecum.

• 1 Risk of perforation, forming peritoneal implants

ITERMINOLOGY o Pseudomyxoma peritonei
Definitions • Due to rupture: Malignant> benign mucocele
• Chronic cystic dilatation of appendiceal lumen by • Peritoneal cavity filled with mucus seedlings
5 mucin accumulation o Myxoglobulosis
• Rare variant with multiple small globules
26 • Calcify & produce 1-10 mm mobile calcifications
I IMAGING FINDINGS • Differentiate from phleboliths & calcified nodes
Radiographic Findings
General Features
• Fluoroscopic guided barium enema
• Best diagnostic clue: Round or oval, thin-walled, cystic
o Appendix: Fails to fill on barium enema
mass near tip of cecum
o Cecum: Indented on its medial aspect by
• Size: 3-6 cm in diameter
smooth-walled globular mass
• Other general features
o Ileum: Terminal part is displaced
o Mucocele of appendix is a rare entity
o Classified into three groups based on histology CT Findings
• Focal or diffuse mucosal hyperplasia • NECT
• Mucinous cystadenoma o Mucocele
• Mucinous cystadenocarcinoma • Well-defined cystic mass RLQ (near water HU)
o Focal or diffuse mucosal hyperplasia • Calcification (curvilinear) within wall or lumen
• Resembles hyperplastic polyp of colon o Mucinous cystadenoma
• Does not perforate • Encapsulated low attenuation cyst
o Mucinous cystadenoma • Indistinguishable from retention mucocele
• A benign neoplasm o Mucinous cystadenocarcinoma
• Most common type of mucocele • Large irregular mass with thickened nodular wall
• 20% of cases perforate with mucus seeding • Components: Solid & cystic; Ca++ in solid area
o Mucinous cystadenocarcinoma o Pseudomyxoma peritonei
• One fifth as common as cystadenomas • Massive ascites + septations (heterogeneous HU)

DDx: Dilation or Mass of Appendix; RLQ Cystic Mass

..•..•.. ~ --.
,..........••
~: ..

•••
,.~
,

Appendiceal Abscess Appendiceal Ca

.....•

~
., "._>'~'
. 'I', • '._.~.. ,,,."

Appy. Lymphoma
"
'>~""

"."""

-~i_:..' ...;....-
.. ~
'-,$'

Cecal Carcinoma
 MUCOCELE OF THE APPENDIX

Key Facts
Terminology Top Differential Diagnoses
• Chronic cystic dilatation of appendiceal lumen by • Acute appendicitis (abscess)
mucin accumulation • Appendiceal carcinoma
• Ovarian cystic mass
Imaging Findings
• Best diagnostic clue: Round or oval, thin-walled, Pathology
cystic mass near tip of cecum • Obstructing lesions can cause mucocele formation
• Calcification (curvilinear) within wall or lumen • Associated abnormalities: Colonic adenocarcinoma
(6-fold risk)

• CECT: Loculated ascites; scalloped surface of liver +

spleen Gross Pathologic & Surgical Features
• Mucocele: Thin-walled, mucin-filled cystic structure
MR Findings
• Mucocele with t fluid content: Long T1 & T2 Microscopic Features
o T1WI: Hypointense • Mucoid material; malignant cells-cystadenocarcinoma
o T2WI: Hyperintense
• Mucocele with t mucin content: Short T1 & long T2
o T1WI & T2WI: Mucocele appears hyperintense I CLINICAL ISSUES
Ultrasonographic Findings Presentation
• Real Time • Most common signs/symptoms: Asymptomatic; pain
o Anechoic or cystic + internal echoes (septations) & tenderness RLQ; palpable mass
o Increased through transmission is characteristic • Complications: Rupture, torsion, bowel obstruction
o Complex cystic mass; ± calcification
Demographics 5
o Gravity-dependent echoes (inspissated mucus)
• Age: Mean age: SS years 27
Imaging Recommendations • Gender: M:F = 1:4
• NE + CECT, MR, us Natural History & Prognosis
• Mucocele & cystadenoma (good); carcinoma (poor)
I DIFFERENTIAL DIAGNOSIS Treatment
• Surgical resection
Acute appendicitis (abscess)
• More inflammatory changes
• Thick irregular abscess wall I SELECTED REFERENCES
Appendiceal carcinoma 1. Lim HK et al: Primary mucinous cystadenocarcinoma of
• Irregular mixed density mass (solid & cystic) the appendix: CT findings. AJR. 173: 1071-4, 1999
2. Kim SH et al: Mucocele of the appendix: Ultrasonographic
Appendiceal lymphoma and CT findings. Abdominal Imaging. 23: 292-6, 1998
• Soft tissue mass near tip of cecum 3. Madwell D et al: Mucocele of the appendix: Imaging
findings. AJR. 159: 69-72, 1992
Cecal carcinoma
• May cause dilated appendix
Ovarian cystic mass
I IMAGE GAllERY
• Distinguish by relation to broad ligament vs. cecal tip

!PATHOlOGY
General Features
• Etiology
o Obstructing lesions can cause mucocele formation
• Post appendicitis scarring (most common)
• Fecalith, appendiceal carcinoma, endometrioma
• Carcinoid, polyp, volvulus, Ca of cecum & colon
• Epidemiology: Seen in 0.3% appendectomy specimens
• Associated abnormalities: Colonic adenocarcinoma (Left) Axial CECT shows complex ascites with scalloped surface of
(6-fold risk) liver + spleen. Pseudomyxoma peritonei due to ruptured mucinous
cystadenocarcinoma of appendix. (Right) Axial CECT shows
pseudomyxoma peritonei.
 DIVERTICULITIS
Craphic shows sigmoid diverticula, luminal narrowing +
wall thickening (circular muscle hypertrophy). Penco/ic
abscess due to perforated diverticulum. Rectum spared.
[TERMINOLOGY
Definitions
• Inflammation or perforation of colonic diverticula,
5 which are acquired herniations of mucosa and
submucosa through muscular layers of bowel wall
28
I IMAGING FINDINGS
General Features
• Best diagnostic clue: Small colonic outpouchings with
irregular wall thickening & pericolic fat stranding
• Location: Most common in sigmoid colon
• Size: Diverticula: Usually about 0.5-1.0 em
• Morphology: Saccular outpouchings of colon with
perforation, inflammation & abscess formation
• Other general features
o Most common colonic disease in Western world
o Diverticula occur mainly where vasa recta vessels
pierce muscularis propria, between mesenteric &
anti mesenteric taeniae
o Colonic diverticula are pseudodiverticula
• Mucosa + submucosa; no muscularis propria
o Diverticular diseas~ of colon represents a collection
or sequence of events
• Pre diverticular phase: Circular muscular
thickening of colonic wall (myochosis)
DDx: Wall Thickening, Pericolonic Infiltration
Sigmoid Cancer Radiation Colitis
Axial CECT shows a pericolonic abscess (arrow)
adjacent to the sigmoid colon, with luminal narrowing,
gas-filled diverticula, and pericolonic fat infiltration.
• Diverticulosis: Frank outpouchings (diverticula)
• Diverticulitis: Perforation + localized pericolic
inflammation or abscess
Radiographic Findings
• Diverticulosis: Fluoroscopic guided barium enema
(single contrast preferred)
o Immature diverticula
• En face: Resemble punctate ulcer
• In profile: Conical or triangular (1-2 mm high)
o Mature: Shape varies based on angle & degree of
barium filling
• In profile: Flask-like protrusion, long or large neck
• Diverticulum with long & narrow neck: Mimic
pedunculated polyp on air-contrast enema
• Diverticulum with large neck: Mimics sessile polyp
• En face: Ring shadow or round barium collection
• "Bowler hat" sign: Dome of hat points away from
bowel wall (diverticulum); toward lumen (polyp)
o In progressive disease: Due to muscular
hypertrophy, diverticula are irregular, lumen
narrowed with serrated or "cog-wheel" appearance
• Diverticulitis: Fluoroscopic guided water soluble
contrast enema (not recommended)
o Focal area of eccentric luminal narrowing caused by
pericolic or intramural inflammatory mass (abscess)
+ mucosal tethering
o Marked thickening + distortion of haustral folds
o Extraluminal contrast (due to peridiverticulitis)
Pseudomem. Colitis Epiploic Appendagitis
 DIVERTICULITIS
Key Facts
Terminology
• Inflammation or perforation of colonic diverticula,
which are acquired herniations of mucosa and
submucosa through muscular layers of bowel wall
Imaging Findings
• Best diagnostic clue: Small colonic outpouchings with
irregular wall thickening & pericolic fat stranding
• Location: Most common in sigmoid colon
• CT is very accurate in diagnosis (> 95%)
• Helical CT: Oral & IV ± rectal contrast for acutely ill
Top Differential Diagnoses
• Colon carcinoma
• Radiation colitis
• Ischemic colitis
• Pseudomembranous colitis (PMC)
• "Double-tracking": Longitudinal intramural
fistulous tract (connecting ruptured diverticula) is
parallel to sigmoid lumen
• Pericolonic fistulous tracts: Bladder, bowel, vagina
• Pericolonic collection: Abscess compresses colon
o Sigmoid colon obstruction with zone of transition
can mimic cancer
• Tethered or saw-toothed luminal configuration
suggests diverticular disease
CT Findings
• Diverticulosis
o Mural thickening of colon (4 to 15 mm)
o Multiple air or contrast or stool-containing
outpouchings (diverticula)
• Diverticulitis
o CT is very accurate in diagnosis (> 95%)
o Bowel wall thickening, fat stranding, thickened base
of sigmoid mesocolon, free fluid
o Long segment (> 10 em) of colonic involvement
o Pericolic abscess, sinus tracts, fistulas
o Intramural or abdomino-pelvic abscess
o "Arrowhead" sign: Due to edema at orifice of
inflamed diverticulum
o Inflammation usually localized to pericolonic area
o Free air + peritonitis (less common)
• Omentum acts as "band-aid" to limit spread
• Immunocompromised at 1 risk: Peritonitis/sepsis
o ± Gas or thrombus in mesenteric & portal veins
• Follow course of inferior mesenteric vein
o ± Liver abscesses
Ultrasonographic Findings
• Real Time
o Diverticulosis
• Thickened bowel wall (> 4 mm)
• Diverticula: Round or oval hypo-/hyperechoic foci
protruding from colonic wall with focal disruption
of normal layer ± acoustic shadows
o Diverticulitis
• Pericolic inflammation: 1 Echogenicity ±
ill-defined hypoechoic areas
• Pericolic abscess: Hypoechoic ± internal echoes
Pathology
• Most common complication of diverticulosis, in 30%
of patients with moderate diverticulosis
• Very common in Western society, rare in less
developed countries due to more processed food &
less fiber in diet
Clinical Issues
• Percutaneous abscess drainage can eliminate surgery
or allow elective one-step procedure in most cases
Diagnostic Checklist
• Check whether patient has signs & symptoms of
diverticulitis
• Long segment colonic involvement, extensive
inflammatory changes & absence of nodes or
metastases favors diverticulitis over colon cancer
Imaging Recommendations
• Helical CT: Oral & IV ± rectal contrast for acutely ill
• Diverticulosis: Single contrast barium enema
• Double contrast barium enema: Hard to distinguish
polyps from diverticula
5
I DIFFERENTIAL DIAGNOSIS 29
Colon carcinoma
• Asymmetric bowel wall thickening ± irregular surface
• Wall thickening, fat stranding & pericolonic
infiltration mimics diverticulitis
• CT findings favoring cancer
o Short segment involvement « 10 em)
o Wall thickness: More than 2 em
o Mesenteric lymphadenopathy
o Metastases
Radiation colitis
• Barium enema findings
o Acute radiation colitis & proctitis
• Disrupted or distorted mucosal pattern (due to
edema or hemorrhage)
o Chronic radiation colitis & proctitis
• Diffuse or focal narrowing with tapered margins
• Colonic stricture or fistula may be seen
• Widened presacral space (in profile view)
• CT findings
o More uniform wall thickening + luminal narrowing,
less peri colonic inflammation than diverticulitis
o Colonic luminal narrowing or stricture
o ± Sinuses or fistulas
• Diagnosis: History of radiation therapy
Ischemic colitis
• Usual sites
o Splenic flexure> recto-sigmoid junction
• Barium enema findings
o Thumbprinting (usually within 24 hrs after insult)
• Due to submucosal edema or hemorrhage
o Ulceration: Sloughing of mucosa (46-60% cases)
• Usually develops 1-3 weeks after onset of disease
 DIVERTICULITIS
• CT findings
o More uniform, extensive wall thickening & less
pericolonic infiltration than diverticulitis
o Bowel wall attenuation
• Hypoattenuation: Submucosal or diffuse edema
• Hyperattenuation: Submucosal or diffuse bleeding
o ± Pneumatosis & portomesenteric venous gas
• Diagnosis
o History of non occlusive vascular disease
• Hypoperfusion in elderly people
• Example: CHF, arrhythmia, shock & drugs
Pseudomembranous colitis (PMC)
• Synonym(s): Antibiotic colitis or C. difficile colitis
• CT findings
o Massive wall thickening, usually pancolonic
o Often transmural with pericolonic infiltration
o "Accordion" sign: Represents trapped enteric
contrast between thickened colonic folds
o Full recovery with early diagnosis, discontinuation
of offending antibiotic & metronidazole treatment
I PATHOLOGY
General Features
• General path comments
5 o Diverticulitis
• Most common complication of diverticulosis, in
30% of patients with moderate diverticulosis
30
• Etiology
o Diverticulitis: Due to fecal impaction at mouth of
diverticulum with subsequent perforation
o Contributing factors to development of diverticula
• Pressure gradient between lumen & serosa
(sigmoid): Narrowest of colon + 1 pressure +
dehydrated stool
• Bowel wall weakness: Between mesenteric &
antimesenteric taeniae
• Epidemiology
o Incidence
• 33-50% cases, over 50 years old have diverticulosis
• More than 50% have diverticulosis after 80 years
• Can occur in young adults « 30 years old)
o Very common in Western society, rare in less
developed countries due to more processed food &
less fiber in diet
• Associated abnormalities: Liver abscesses
Gross Pathologic & Surgical Features
• Outpouchings from sigmoid colon between taenia coli
Microscopic Features
• Diverticula: Mucosal herniation through a defect in
circular layer of muscle
• Diverticulitis: Perforation with inflammation &
micro-/macroabscess
I CLINICAL ISSUES
Presentation
• Most common signs/symptoms
o Diverticulosis
• Asymptomatic; pain & rectal bleeding (30% cases)
• Alternating constipation + diarrhea due to luminal
narrowing (circular muscle hypertrophy)
o Diverticulitis
• LLQ colicky pain, tenderness & palpable mass
• Fever, altered bowel habits
o Lab-data
• 1 WBC count; anemia; ± blood in stool
Demographics
• Age: 5th to 8th decade (peak); not rare in younger
• Gender: Equal in both males & females (M = F)
Natural History & Prognosis
• Complications
o Perforation, pericolonic abscess, fistula, sinus
o Obstruction, hemorrhage
o Peritonitis & sepsis (uncommon)
o Pylephlebitis (portal vein thrombus); liver abscesses
• Via mesenteric + portal vein ~ liver abscesses
• Prognosis: Early stages & after surgery (good)
Treatment
• High-fiber diet (preventive)
• Antibiotics, IV fluids, bowel rest
• Percutaneous abscess drainage can eliminate surgery or
allow elective one-step procedure in most cases
I DIAGNOSTIC CHECKLIST
Consider
• Check whether patient has signs & symptoms of
diverticulitis
Image Interpretation Pearls
• Bowel wall thickening, pericolic infiltration & fat
stranding affecting sigmoid colon
• Long segment colonic involvement, extensive
inflammatory changes & absence of nodes or
metastases favors diverticulitis over colon cancer
I SELECTED REFERENCES
1. Jang HJ et al: Acute diverticulitis of the cecum and
ascending colon: the value of thin-section helical CT
findings in excluding colonic carcinoma. AJRAm J
Roentgenol. 174(5):1397-402,2000
2. Horton KM et al: CT evaluation of the colon: inflammatory
disease. Radiographies. 20(2):399-418, 2000
3. Gore RM et al: Helical CT in the evaluation of the acute
abdomen. AJR 174: 901-13, 2000
4. Chin tap alii KN et al: Diverticulitis versus colon cancer:
differentiation with helical CT findings. Radiology.
210(2):429-35, 1999
5. Rao PM et al: Colonic diverticulitis: evaluation of the
arrowhead sign and the inflamed diverticulum for CT
diagnosis. Radiology. 209(3):775-9, 1998
6. Padidar AM et al: Differentiating sigmoid diverticulitis
from carcinoma on CT scans: mesenteric inflammation
suggests diverticulitis. AJRAm J Roentgenol. 163(1):81-3,
1994
7. Balthazar EJ et al: Limitations in the CT diagnosis of acute
diverticulitis: comparison of CT, contrast enema, and
pathologic findings in 16 patients. AJRAm J Roentgenol.
154(2):281-5, 1990
 DIVERTICULITIS
I IMAGE GALLERY

(Left) Single contrast BE

shows an intramural track of
barium (arrow) paralleling
the sigmoid lumen, due to
submucosal spread of
infection from perforated
diverticulum. (Right) Single
contrast water soluble
enema shows marked
distortion of sigmoid lumen
mostly due to circular
muscle hypertrophy.
Broad-based intramural +
extrinsic mass effect (arrows)
due to diverticulitis.

Typical
(Left) Axial CECT shows
shows extensive infiltration of
pelvic/pericolic fat. Bladder
has gas-fluid level and a
fistula (arrow) to the sigmoid
colon. (Right) Axial CECT
5
shows diverticulosis of
31
descending colon. Perforated
diverticulitis resulted in
extensive abscess in
retroperitoneum (arrow),
with dissection throughout
the abdominal wall (open
arrow).

(Left) Axial CECT shows

sigmoid diverticulitis with
irregular luminal narrowing +
mild pericolic infiltration;
subacute diverticulitis.
(Right) Axial CECT in patient
with subacute diverticulitis
shows a pyogenic liver
abscess due to bacterial
seeding from inferior
mesenteric-portal vein.
 EPIPLOIC APPENDAGITIS

Graphic shows two normal epiploic appendages and Axial CECT shows oval pericolonic fatty nodule (arrow)
one that is twisted and infarcted (arrow). with hyperdense ring and surrounding inflammation.

ITERMINOLOGY o Typically seen in obese people in 2nd-5th decades of

life, can occur in children
Abbreviations and Synonyms o Benign self-limiting disease
• Epiploic appendagitis (EA) o Torsion of epiploic appendage
5 Definitions
o Spontaneous venous thrombosis of draining
appendageal vein
32 • Acute inflammation or infarction of epiploic o Rarely diagnosed clinically but has highly
appendages characteristic CT features
o Radiological (CT) potential misdiagnosis of EA as:
Diverticulitis or appendicitis
I IMAGING FINDINGS CT Findings
General Features • Normal epiploic appendages
• Best diagnostic clue: Small oval pericolonic fatty o Small lobulated masses of pericolonic fat
nodule with hyperdense ring + surrounding • Rectosigmoid most evident
inflammation o Seen on CT scans only when outlined by ascites
• Location • 1-4 cm, oval-shaped, fat density paracolic lesion with
o Left lower quadrant> right lower quadrant adjacent fat stranding
• Rectosigmoid junction (57%); ileocecal (26%); • Thickened & compressed bowel wall
ascending colon (9%) • Thickened visceral & parietal peritoneum
• Transverse colon (6%); descending colon (2%); • ± Central increased attenuation "dot" within inflamed
occasionally appendix appendage (indicates thrombosed vein)
• Morphology: Epiploic appendages: Small adipose • Hyperattenuating ring sign: Characteristic finding of
structures protruding from serosal surface of colon EA on postcontrast
• Other general features o Pericolonic round fat-containing mass + thin
o Uncommon inflammatory & ischemic condition hyperattenuating ring
o Uncommon cause of acute abdomen o Ring: Thickened visceral peritoneum of inflamed
epiploic appendage
o May calcify when infarcted

DDx: Pericolonic Infiltration

Appendicitis Pseudomem. Colitis Ulcerative Colitis

 EPIPLOIC APPENDAGITIS
Key Facts
Terminology
• Acute inflammation or infarction of epiploic
appendages
Imaging Findings
• Best diagnostic clue: Small oval pericolonic fatty
nodule with hyperdense ring + surrounding
inflammation
• Left lower quadrant> right lower quadrant
• ± Central increased attenuation "dot" within inflamed
appendage (indicates thrombosed vein)
• Pericolonic round fat-containing mass + thin
hyperattenuating ring
• Infarcted EA: Probably accounts for otherwise
unexplained smooth calcified "stones" occasionally
found in dependent peritoneal recesses
• Infarcted EA: Probably accounts for otherwise
unexplained smooth calcified "stones" occasionally
found in dependent peritoneal recesses
MR Findings
• T1 & T2WI breath-hold spoiled gradient echo (SGE)
images
o Increased signal lesion + hypointense central dot +
thin hypointense ring
• T1 C+ fat suppressed gradient echo image
o Increased enhancement of ring
Ultrasonographic Findings
• Real Time
o Solid hyperechoic noncom pres sible ovoid mass
adherent to colonic wall
o Surrounded by a hypoechoic ring (corresponds to t
HU ring on CT scan)
Imaging Recommendations
• Helical CECT
I DIFFERENTIAL DIAGNOSIS
Diverticulitis
• Most common complication of diverticulosis
• Barium enema findings
o Focal eccentric luminal narrowing
o Marked thickening & distortion of haustral folds
o Colonic obstruction with zone of transition
o "Double-track": Intramural fistulous tract
• CT findings
o Location: Most common in sigmoid colon
o Bowel wall & fascial thickening, luminal narrowing
o Pericolonic fat stranding, free fluid & air
o Pericolic inflammatory changes
• Abscess, sinuses, fistulas
o "Arrowhead" sign: Due to diverticular orifice edema
• Clinically simulates epiploic appendagitis
Appendicitis
• Best imaging clue on CT
Top Differential Diagnoses
• Diverticulitis
• Appendicitis
• Pseudomembranous colitis (PMC)
• Ulcerative colitis
Pathology
• Appendages: Small pouches of peritoneum
protruding from serosal surface of colon filled with
fat + small vessels
Diagnostic Checklist
• Differentiate epiploic appendagitis especially from
diverticulitis (LLQ) & appendicitis (RLQ)
• Pericolonic round fatty mass (1-4 em) with
hyperdense rim (most common in rectosigmoid area)
• Not limited to left colon or elderly
o Appendicolith (usually calcified) within distended
tubular appendix
• Distended enhancing appendix with surrounding
inflammation (fat stranding)
• Wall thickening of cecum or terminal ileum
• Right lower quadrant (RLQ) lymphadenopathy
• In perforated cases
o Fluid collection most commonly in RLQ or in
5
dependent pelvis (Cul-de-sac)
33
o Abscess, small-bowel obstruction
• Ultrasound findings
o Echogenic appendicolith with posterior shadowing
o Noncompressible blind-ending tubular structure
over 7 mm in diameter
o Fluid or abscess collection in RLQ
• Right colonic EA clinically may simulate appendicitis
Pseudomembranous colitis (PMC)
• Synonym(s): Antibiotic colitis or C. difficile colitis
• Usually involves entire colon (pancolitis)
• CT findings
o Colonic wall thickening, nodularity, thumbprinting
o "Accordion" sign: Represents trapped enteric
contrast between thickened colonic folds
o Ascites common in PMC
o Full recovery with early diagnosis, discontinuation
of offending antibiotic & treatment with
metronidazole
Ulcerative colitis
• Pathology: Continuous, not transmural, pseudopolyps,
crypt microabscesses
• Classic imaging appearance
o Pancolitis with decreased haustration & multiple
ulcerations on barium enema
• Colorectal narrowing; 1 presacral space> 1.S em
• "Mucosal islands" or "inflammatory pseudopolyps"
• Diffuse & symmetric wall thickening of colon
• Backwash ileitis: Distal ileum involvement (10-40%)
• Chronic phase
o "Lead-pipe" colon: Rigid colon with loss of haustra
 EPIPLOIC APPENDAGITIS
I PATHOLOGY
General Features
• General path comments
o Appendages: Small pouches of peritoneum
protruding from serosal surface of colon filled with
fat + small vessels
• Seen along free tenia & tenia omentalis between
cecum & sigmoid colon
• Etiology
. 0 Torsion & venous thrombosis of appendages
o Predisposing factors for torsion & infarction of
epiploic appendages
• Precarious blood supply from colic arterial
branches
• Pedunculated morphologyi 1 mobility & obesity
• Epidemiology
o Though uncommon, not as rare as assumed
o Seen in 2.3-7.1 % of clinically suspected colonic
diverticulitis
o Reported in 1.0% of suspected appendicitis cases
Gross Pathologic & Surgical Features
• Round fat containing paracolic lesion, fat stranding,
thickened wall
Microscopic Features
5 • Visceral peritoneal lining of inflamed epiploic
appendage covered with a fibrinoleukocytic exudates
• Fat necrosis within appendage
34
I CLINICAL ISSUES
Presentation
• Most common signs/symptoms
o Sudden onset of focal abdominal pain
• Usually left or right lower quadrant
o Pain worsening with: Coughing, deep breathing,
abdominal stretching
o Symptoms usually subside within one week of onset
o Physical exam
• Localized tenderness, some guarding, no rigidity
o Lab-data
• WBC count (normal or slightly 1 in most cases)
Demographics
• Age: 2nd-Sth decades (obese people)
• Gender: Equal in both males & females (M = F)
Natural History & Prognosis
• Complications of epiploic appendages
o Recurrent episodes of inflammation (unusual)
o Intraperitoneal loose bodies
o Infarction
• Prognosis
o Benign self-limiting process with spontaneous
resolution within 1 week
o Good: After medical or surgical treatment
Treatment
• Medical: Conservative treatment with analgesics
• Surgical: Simple ligation & excision of infarcted
epiploic appendage
o Rarely required if accurately diagnosed
I DIAGNOSTIC CHECKLIST
Consider
• Differentiate epiploic appendagitis especially from
diverticulitis (LLQ) & appendicitis (RLQ)
Image Interpretation Pearls
• Pericolonic round fatty mass (1-4 cm) with hyperdense
rim (most common in rectosigmoid area)
• Not limited to left colon or elderly
I SELECTED REFERENCES
1. van Breda Vriesman AC: The hyperattenuating ring sign.
Radiology. 226(2):556-7, 2003
2. Ghosh BC et al: Primary epiploic appendagitis: diagnosis,
management, and natural course of the disease. Mil Med .
168(4):346-7, 2003
3. Chowbey PK et al: Torsion of appendices epiploicae
presenting as acute abdomen: laparoscopic diagnosis and
therapy. Indian] Gastroenterol. 22(2):68-9, 2003
4. Hollerweger A et al: Primary epiploic appendagitis:
sonographic findings with CT correlation. ] Clin
Ultrasound. 30(8):481-95, 2002
5. Son H] et al: Clinical diagnosis of primary epiploic
appendagitis: differentiation from acute diverticulitis. ]
Clin Gastroenterol. 34(4):435-8, 2002
6. van Breda Vriesman AC et al: Epiploic appendagitis and
omental infarction: pitfalls and look-alikes. Abdom
Imaging. 27(1):20-8, 2002
7. Chung SP et al: Primary epiploic appendagitis. Am] Emerg
Med. 20(1):62, 2002
8. Sirvanci M et al: Primary epiploic appendagitis: MRI
findings. Magn Reson Imaging. 20(1):137-9, 2002
9. Legome EL et al: Epiploic appendagitis: the emergency
department presentation.] Emerg Med. 22(1):9-13, 2002
10. Horton KM et al: CT evaluation of the colon: inflammatory
disease. Radiographies. 20(2):399-418, 2000
11. Rao PM et al: Case 6: primary epiploic appendagitis.
Radiology. 210(1):145-8, 1999
12. Habib FA et al: Laparoscopic approach to the management
of incarcerated hernia of appendices epiploicae: report of
two cases and review of the literature. Surg Laparosc
Endosc. 8(6):425-8, 1998
13. Rao PM et al: Misdiagnosis of primary epiploic
appendagitis. Am] Surg. 176(1):81-5, 1998
14. Rao PM et al: Primary epiploic appendagitis: evolutionary
changes in CT appearance. Radiology. 204(3):713-7, 1997
15. Rioux M et al: Primary epiploic appendagitis: clinical, US,
and CT findings in 14 cases. Radiology. 191(2):523-6, 1994
16. Ghahremani GG et al: Appendices epiploicae of the colon:
radiologic and pathologic features. Radiographics.
12(1):59-77, 1992
17. Derchi LE et al: Appendices epiploicae of the large bowel.
Sonographic appearance and differentiation from
peritoneal seeding.] Ultrasound Med. 7(1):11-4, 1988
 EPIPLOIC APPENDAGITIS

I IMAGE GALLERY
(Left) Axial CECT shows
ascites outlining the fat
density of normal epiploic
appendages (arrows) of the
sigmoid colon. (Right) Axial
CECT in a patient with
suspected diverticulitis
shows an oval pericolonic fat
density nodule (arrow) with
a hyperdense ring; epiploic
appendagitis.

(Left) Axial CECT shows a fat

density nodule (arrow) with
a hyperdense ring and
surrounding inflammation.
(Right) Axial NECT shows
calcified epiploic appendage
5
(arrow) of the descending
35
colon. Such infarcted
appendages may detach
from the colon and result in
loose bodies in the
peritoneal cavity.

(Left) Axial CECT shows

epiploic appendagitis of the
hepatic flexure (arrow) with
typical findings. (Right) Axial
CECT shows infiltrated fat
near the hepatic flexure just
cephalan to the inflamed or
infarcted epiploic
appendage.
 ISCHEMIC COLITIS

Graphic shows luminal narrowing and wall thickening Single-contrast BE shows narrowed lumen of the splenic
neilr the splenic flexure, the "watershed" area between flexure with "thumbprinting" (thickened haustral folds)
the vascular distribution of the SMA and IMA. due to submucosal edema or hemorrhage. Elderly
patient with heart disease.

• Hemorrhagic, septic or hypovolemic shock

ITERMINOLOGY • Congestive heart failure (CHF); drugs like digitalis
Definitions o 20% Colonic ischemia are proximal to obstruction
• Compromise of mesenteric blood supply leading to • Colon cancer, volvulus, closed loop obstruction
5 colonic injury o Common cause of abdominal pain in elderly with
history of heart disease
36 o Most common form is segmental (90%) or pancolitis
I IMAGING FINDINGS o Usually a partial mural (nontransmural)
superficial mucosal ischemia
&

General Features o Spectrum of diseases caused by colonic ischemia

• Best diagnostic clue: Evidence of pneumatosis, • Reversible or transient ischemic colitis (> frequent)
mesenteric venous gas, symmetric bowel wall • Colonic stricture, gangrene of colon & perforation
thickening or thumb printing on CT
Radiographic Findings
• Location
o Commonly watershed segments of colon • Radiography
o Plain x-ray abdomen (supine view)
• Splenic flexure: Junction of SMA & IMA (Griffith
point) • Normal or nonspecific ileus
• Thumbprinting (submucosal edema or bleeding)
• Rectosigmoid: Junction of IMA & hypogastric
• Luminal narrowing or transverse ridging (spasm)
artery (Sudeck point)
• Ahaustralloops (rare)
• Left-side colon: Typical in elderly with I perfusion
• Fluoroscopic guided barium enema
• Right-side: Young patients (I collateral blood
o Hallmark: Serial change on studies performed over
supply); chronic renal failure
days, weeks or months
• Other general features
o Thumbprinting (usually within 24 hrs after insult)
o Most common vascular disorder of GI tract
• Smooth, round, polypoid scalloped filling defects
6 Most common cause of colitis in elderly & is often
along lumen (submucosal edema or hemorrhage)
self limiting
• Most consistent & characteristic finding-7S% cases
o Major predisposing cause in elderly: Nonocclusive
• Occurs within first 24 hrs, resorbs in less than a
vascular disease (hypoperfusion)
week or may persist for weeks

DDx: Wall Thickening; Pericolonic Infiltration

. __ t •••

,..
, 'T_ I -..
••.. ).if

••• ,~. or J

~
Diverticulitis Pseudomem. Colitis Ulcerative Colitis Colon Cancer
 ISCHEMIC COLITIS
Key Facts
Terminology
• Compromise of mesenteric blood supply leading to
colonic injury
Imaging Findings
• Best diagnostic clue: Evidence of pneumatosis,
mesenteric venous gas, symmetric bowel wall
thickening or thumbprinting on CT
• Commonly watershed segments of colon
• Thumbprinting (usually within 24 hrs after insult)
• Ulceration: Sloughing of mucosa (46-60% cases)
• Bowel wall thickening (normal range 3-5 mm)
• Hypoattenuation: Submucosal or diffuse edema
• Hyperattenuation: Submucosal or diffuse bleeding
• ± Pneumatosis
• ± Portomesenteric venous gas
• May also seen in other inflammatory bowel
diseases or infectious colitides
o Transverse ridging: Less common finding-13% cases
• Parallel, symmetric thickened folds running
perpendicular to bowel lumen
• Caused by edema or spasm; early finding &
o
usually resolves rapidly
Ulceration: Sloughing of mucosa (46-60% cases)
• Longitudinal/discrete; superficial/deep; small/large
• Usually develop 1-3 weeks after onset of disease
o Intramural barium: Unusual (sloughing of necrotic
portion of wall ~ tracking of barium intramurally)
o Stricture: 12% cases heal with stricture formation
CT Findings
• NECT
o Bowel wall thickening (normal range 3-5 mm)
• Circumferential, symmetric wall thickening ±
thumbprinting
• Due to submucosal edema or hemorrhage
o Bowel wall attenuation
• Hypoattenuation: Submucosal or diffuse edema
• Hyperattenuation: Submucosal or diffuse bleeding
• Heterogeneous: Outer serosa & muscular layers
o ± Luminal narrowing or dilatation & air-fluid levels
o Loss of haustral pattern (rare); pericolic streakiness;
paracolic fluid collections
o ± Pneumatosis
• Small gas bubbles within ischemic bowel wall
• Circumferential or band like pneumatosis
o ± Portomesenteric venous gas
• Portal venous gas collects in periphery of liver
• CECT
o Double halo or target sign: Concentric layers of low
& high attenuation
• Enhancement of mucosa & serosa (hyperemia or
hyperperfusion during recovery)
• Nonenhancement of submucosa (due to
submucosal edema or hemorrhage)
o ± Thrombus within splanchnic vessels
Ultrasonographic Findings
• Color Doppler
Top Differential Diagnoses
• Diverticulitis
• Pseudomembranous colitis (PMC)
• Ulcerative colitis (UC)
• Granulomatous colitis (Crohn disease)
• Colon carcinoma
Pathology
• Nonocclusive vascular disease (in elderly people)
• Hypoperfusion: Predisposing factors
• Hypotensive episodes: Hemorrhagic, cardiogenic or
septic shock
• CHF, arrhythmia, drugs, trauma
Diagnostic Checklist
• Check for history of cardiac, bowel, renal problems &
hypotensive medication use in elderly people
o Hypoechoic thickening of bowel wall
o Absence of arterial flow in wall of ischemic colon
Angiographic Findings
• Usually not helpful in diagnosis
o Ischemic colitis: Usually nonocclusive ischemia
Imaging Recommendations 5
• Helical NE + CECT; plain x-ray abdomen
• Single contrast barium enema (for chronic disease) 37
I DIFFERENTIAL DIAGNOSIS
Diverticulitis
• Most common complication of diverticulosis
• Barium enema findings
o Focal eccentric luminal narrowing
o Marked thickening & distortion of haustral folds
o Colonic obstruction with zone of transition
o "Double-tracking": Longitudinal intramural fistulous
tract
• CT findings
o Location: Most common in sigmoid colon
o Bowel wall & fascial thickening; fat stranding; free
fluid & air
o Pericolic inflammatory changes
• Abscess, sinuses, fistulas
o "Arrowhead" sign: Due to diverticular orifice edema
o Focal area of eccentric luminal narrowing
Pseudomembranous colitis (PMC)
• Synonym(s): Antibiotic colitis or C. difficile colitis
• Usually involves entire colon (pancolitis)
• Barium enema (contraindicated in acutely ill)
o Small, irregular plaques on mucosal surface
• Represent pseudomembranes
o Small, subtle elevated, round nodules
• Single contrast study: Shows thumb printing
indistinguishable from ischemic colitis
• CT findings
o Colic wall thickening & nodularity
o "Accordion" sign: Represents trapped enteric
contrast between thickened colonic folds
 ISCHEMIC COLITIS
o Ascites common in PMC
• Full recovery with early diagnosis, discontinuation of
offending antibiotic & treatment with metronidazole
Ulcerative colitis (UC)
• Pathology: Continuous, not transmural, pseudopolyps,
crypt microabscesses
• Classic imaging appearance
o Pancolitis with decreased haustration & multiple
ulcerations on barium enema
• Colorectal narrowing; i presacral space> 1.5 em
• "Mucosal islands" or "inflammatory pseudopolyps"
• Diffuse & symmetric wall thickening of colon
o Ischemic colitis usually shows segmental (watershed
areas) bowel wall thickening & thumbprinting
• Backwash ileitis: Distal ileum involvement (10-40%)
• Chronic phase
o "Lead-pipe" colon: Rigid colon with loss of haustra
Granulomatous colitis (Crohn disease)
• Barium enema findings
o Cobblestoning: Longitudinal & transverse ulceration
produce a paving stone appearance
o Segmental in distribution
• Involve both colon & small-bowel (60% cases)
• Isolated to colon (20% cases)
o Transmural, skip lesions, sinuses, fissures, fistulas
5 • CT findings
o Bowel wall thickening (1-2 em)
o "Creeping fat" or mesenteric fibrofatty proliferation
38
o Enlarged mesenteric lymph nodes
o "Comb" sign: Hypervascularity (active disease)
Colon carcinoma
• Asymmetric mural thickening with irregular surface
• Classic annular "apple core" lesion
o Circumferential bowel narrowing + mucosal
destruction with shelf-like, overhanging borders
o High grade obstruction + ischemia shows proximal
bowel dilatation with thumbprinting
• Extracolonic tumor extension
o Strands of soft tissue: Serosal surface ~ pericolic fat
o Loss of fat planes between colon & adjacent muscles
I PATHOLOGY
General Features
• General path comments
o Normal mesenteric vascular anatomy
• Superior mesenteric artery (SMA):Vascular supply
from 3rd part of duodenum to splenic flexure
• Inferior mesenteric artery (IMA): Splenic flexure to
rectum
• Etiology
o Nonocclusive vascular disease (in elderly people)
o Hypoperfusion: Predisposing factors
• Hypotensive episodes: Hemorrhagic, cardiogenic
or septic shock
• CHF, arrhythmia, drugs, trauma
• Arteriosclerotic disease, chronic renal failure
• Vasculitis, colonic obstruction
• Epidemiology: Mortality rate: 7% of cases
Gross Pathologic & Surgical Features
• Segmental or focal; localized or diffuse
• Thick bowel wall; dark red or purple
o Edematous, hemorrhagic, ulcerated
Microscopic Features
• Mucosal erosions, ulceration, necrosis
• Submucosal edema, hemorrhage
I CLINICAL ISSUES
Presentation
• Most common signs/symptoms
o Mild or severe abdominal pain
o Rectal bleeding, bloody diarrhea, hypotension
• Lab-data
o i Leukocytosis; positive guaiac stool test
o Negative blood cultures; EKG changes may be seen
Demographics
• Age: Usually elderly age group (> 50 years)
• Gender: Equal in both males & females (M = F)
Natural History & Prognosis
• Complications
o Transmural bowel infarction ~ perforation ~ death
• Prognosis
o Partial mural ischemia: Good prognosis
o Transmural infarction: Poor prognosis
Treatment
• Partial mural ischemia (nonocclusive type)
o Conservative medical treatment
• Transmural infarction: Surgical resection
I DIAGNOSTIC CHECKLIST
Consider
• Check for history of cardiac, bowel, renal problems &
hypotensive medication use in elderly people
Image Interpretation Pearls
• Segmental bowel wall thickening in watershed areas,
thumbprinting, pneumatosis, portal venous gas
I SELECTED REFERENCES
1. Wiesner W et al: CT of acute bowel ischemia. Radiology.
226(3):635-50, 2003
2. Horton KMet al: Volume-rendered 3D CTof the
mesenteric vasculature:normal anatomy, anatomic
variants, and pathologic conditions. Radiographies.
22(1):161-72, 2002
3. Horton KMet al: Multi-detector row CTof mesenteric
ischemia: can it be done? Radiographies.21(6):1463-73,
2001
4. Horton KMet al: CTevaluation of the colon: inflammatory
disease.Radiographies.20(2):399-418, 2000
5. BalthazarEJet al: Ischemic colitis: CTevaluation of 54
cases.Radiology.211(2):381-8, 1999
6. Iida M et al: Ischemic colitis: serial changes in
double-contrast barium enema examination. Radiology.
159(2):337-41, 1986
 ISCHEMIC COLITIS

IIMAGE GALLERY

(Left) Single-contrast BE in a
60 year old man with
chronic heart disease, shows
strictures of distal transverse
+ proximal descending colon
due to subacute colonic
ischemia. (Right) Axial CECT
in a 60 year old paUent with
subacute colonic ischemia
shows wall thickening
. (arrows), submucosal
edema, and luminal
narrowing of the colon.

Variant
(Left) Axial CECT of a patient
24 hours post abdominal
trauma (motor vehicle crash)
shows portal venous gas
(arrow). (Right) Axial CECT 5
shows intramural and
mesenteric venous gas. At 39
surgery, patient had
"degloving" injury (serosal
tear + devascularization)
with cecal infarction.

Variant
(Left) Axial CECT shows a
mass in the pancreatic head
with a biliary stent (arrow).
The superior mesenteric
artery + vein (open arrow)
are encased and narrowed.
Gas is present in the colon
wall. (Right) Axial CECT in
patient with pancreatic
cancer. Intramural +
mesenteric venous (arrow)
gas are present due to colon
infarction.
 COLONIC POLYPS

Graphic shows tubulovil/ous adenoma on a long stalk Single contrast BE shows tubulovil/ous adenoma with a
and a small sessile polyp. large "head" (arrow) and a long stalk (open arrow).
Small sessile polyp (curved arrow) also noted.

• Dependent wall: Radiolucent filling defect

ITERMINOLOGY • Nondependent wall: Ring shadow with
Definitions barium-coated white rim
• A protruding, space-occupying lesion within the • "Bowler hat" sign: Dome of hat points toward
5 colonic lumen lumen of bowel (en face view); brim and dome of
hat represents base and head of polyp
40 o Pedunculated polyps
IIMAGING FINDINGS • "Mexican hat" sign: Characterized by a pair of
concentric rings; outer and inner ring represents
General Features head and stalk of polyp
• Best diagnostic clue: Radiolucent filling defect, o Tubular adenomatous polyps
contour defect or ring shadow • Small size; pedunculated polyps
• Location: Cecum (4%); ascending colon (6%); hepatic • Minor degree of villous changes
flexure (4%); transverse (2%); splenic flexure (8%); o Tubulovillous adenomatous polyps
descending (20%); sigmoid (41%); rectum (23%) • Medium size; sessile polyps
• Morphology • Fine nodular or reticular surface pattern
o Sessile polyps: Broad base with little or no stalk • Filling of barium within interstices of adenoma
o Pedunculated polyps: Arise from narrow stalk o Villous adenomatous polyps
• Other general features • Larger size; sessile polyps
o 2 Types of colon polyps • Barium trapped between frond-like projections ~
• Neoplastic: Adenomatous (tubular, tubulovillous polypoid lesion with granular or reticular pattern
& villous) • "Carpet" lesion: Flat, lobulated; localized or diffuse
• Non-neoplastic: Hyperplastic, hamartomatous and o "Carpet" lesion
inflammatory • Location: Rectum, cecum & ascending colon
• Subtle alteration in surface texture of colon with
Radiographic Findings little or no protrusion into lumen
• Fluoroscopic-guided double contrast barium enema • Irregular contour in contrast to smooth, fine
o Sessile polyps contour of adjacent normal bowel (profile view)

DDx: Filling Defect in Colon

Feces Oivertics. + Polyp Cancer + Lipoma Spasm + Feces

 COLONIC POLYPS
Key Facts
Terminology
• A protruding, space-occupying lesion within the
colonic lumen
Imaging Findings
• Best diagnostic clue: Radiolucent filling defect,
contour defect or ring shadow
• Sessile polyps: Broad base with little or no stalk
• Pedunculated polyps: Arise from narrow stalk
• "Carpet" lesion: Flat, lobulated; localized or diffuse
• Best imaging tool: Air-contrast barium enema
Top Differential Diagnoses
• Retained fecal debris
• Colonic diverticula
• Colon carcinoma
• Intramural mass
• Tiny, coalescent nodules and plaques ~ finely
nodular or reticular pattern with sharply
demarcated border (en face view)
o Hyperplastic polyps
• Location: Rectosigmoid colon
• Smooth round sessile nodules; < 5 mm (common)
• Lobulated or pedunculated; > 1 cm (occasional)
o Hamartomatous polyps
• Multiple, scattered radiolucent filling defects
• Vary in size; no "carpet" lesion
o Inflammatory polyps
• Islands of elevated, inflamed, edematous mucosa
surrounded by ulceration (inflammatory)
• Small & round, long & filiform or bush-like;
simulate villous adenoma (postinflammatory)
CT Findings
• CT "virtual colonoscopy"
o Small or large, sessile or pedunculated lesions
extending from colonic wall
o Polyps ~ 10 mm: Sensitivity 90%
o Adenoma ~ 10 mm: Sensitivity 94%
o Advantages: Shorter procedural time, I risk to
patient and no IV sedation
Ultrasonographic Findings
• Real Time Transrectal Ultrasonography
o Determine depth of invasion by a sessile polyp
Imaging Recommendations
• Best imaging tool: Air-contrast barium enema
• Protocol advice
o Patient rotated 180 or in upright position
0 General Features
• Confirm presence of a pedunculated polyp
• Visualize stalk in profile view
I DIFFERENTIAL DIAGNOSIS
Retained fecal debris
• Mobile & on dependent surface in barium pool
• Inconsistent location; irregular configuration;
impregnated with barium
Pathology
• Spectrum of adenoma: Tubular - tubulovillous -
villous
• Adenoma-carcinoma sequence (7-10 years): Benign
adenoma ~ malignant transformation
Clinical Issues
• Asymptomatic (75%)
• Colonoscopic polypectomy if polyps> 1 cm
• Colonoscopy or fluoroscopic-guided double contrast
barium enema for periodic surveillance
Diagnostic Checklist
• Family history of colonic polyps & colon carcinoma
• Polypectomy if changes noted on follow-up imaging
• If patient has known diverticulosis, single contrast
barium enema is easier for polyp detection
• Adherent stool can be difficult to differentiate; repeat
fluoroscopic-guided barium enema
• Proper cleansing of bowel can reduce confusion
Colonic diverticula
• "Bowler hat" sign: Dome of hat points away from
lumen of bowel
• Nondependent wall: Ring shadow with barium-coated 5
white rim (en face view); simulates polyps
41
o Rotate patient 90 to see outpouchings from wall
0
versus protrusion into lumen (profile view)
• Inverted diverticula can be difficult to differentiate
Colon carcinoma
• Sessile or pedunculated polyps seen in early cancer
• Biopsy is necessary to differentiate
Intramural mass
• Example: Leiomyoma, lipoma
• Leiomyoma
o Filling defect mimics villous adenoma (en face view)
o Abrupt well-defined borders of bowel wall
• Lipoma
o Commonly arises near ileocecal valve
o Soft + deformable with compression
o CT diagnostic with fat density
• Usually single; polyps often multiple
• Biopsy is necessary for diagnosis
I PATHOLOGY
• General path comments
o Neoplastic colonic polyps
• ,From proliferative dysplasia ~ adenoma
• Slow growing (doubling every 10 years)
• Single or multiple (more common)
• Spectrum of adenoma: Tubular - tubulovillous
- villous
o Tubular adenoma
• 80-86% of neoplastic polyps (most common)
• > 80% of glands are branching, tubule type
o Tubulovillous adenoma
 COLONIC POLYPS
• 8-16% of neoplastic polyps
o Villous adenoma
• 3-16% of neoplastic polyps
• > 80% of glands are villiform (shaggy surface)
o Non-neoplastic colonic polyps
• From abnormal mucosal maturation, architecture
or inflammation
• 90% of all epithelial polyps
• Small; occur at distal colon
o Hyperplastic polyps
• Almost never undergo malignant degeneration
o Hamartomatous polyps
• Varied polyp appearances & wide-range of ages,
depends on etiology
o Inflammatory polyps
• Also known as "pseudopolyps"
• 2 Types: Inflammatory and postinflammatory
• Postinflammatory: Mucosal healing ~ overgrowth
• Etiology
o Family history
• Adenomatous polyps (e.g., hereditary
nonpolyposis colorectal cancer syndrome, familial
polyposis, Gardner syndrome & Turcot syndrome)
• Hamartomatous polyps (e.g., Peutz-]eghers
syndrome and juvenile polyposis)
o Acquired
• Adenomatous polyps (e.g., sporadic adenoma)
5 • Hyperplastic polyps
• Hamartomatous polyps (e.g., Cronkhite-Canada
42 syndrome)
• Inflammatory polyps (e.g., ulcerative colitis)
o Risk factors: Diet, alcohol, smoking and obesity
o Pathogenesis
• Adenoma: Precursor to colon carcinoma
• Adenoma-carcinoma sequence (7-10 years):
Benign adenoma ~ malignant transformation
• Epidemiology
o Incidence of colon polyps: 3% in third decade; 5%
in fourth; 7% in fifth; 11% in sixth; 10% in seventh;
18% in eighth; 26% in ninth
o 1 Age ~ incidence of polyps shifts to right colon
o Hyperplastic polyps increases with age
• Associated abnormalities
o Colon carcinoma (adenocarcinoma)
• Polyps < 1 cm: 1% adenocarcinoma
• Polyps 1-2 cm: 10-20% adenocarcinoma
• Polyps> 2 cm: 40-50% adenocarcinoma
• 1 Villous changes or "carpet" lesion ~ 1 risk
• Lobulated contour or a basal indentation ~ 1 risk
• Tubular adenoma: < 1 cm: 1% with cancer; 1-2
cm: 10%; > 2 cm: 35%
• Tubulovillous adenoma: < 1 cm: 4% with cancer;
1-2 cm: 7%; > 2 cm: 46%
• Villous adenoma: < 1 cm: 10% with cancer; 1-2
cm: 10%; > 2 cm: 53%
Gross Pathologic & Surgical Features
• Tubular adenoma: Thin stalk and tufted head
• Villous adenoma: "Cauliflower-like" with broad base
Microscopic Features
• Adenomatous polyps
o Tubular, tubulovillous or villous structure lined by
columnar epithelium
o Tubular: Tubular glands with smooth surface
o Tubulovillous: Mixture of tubular & villous
o Villous: Surface consists of frondlike structures
o ± Cellular atypia, mitosis or loss of normal polarity
• Hyperplastic polyps
o Colonic crypts are elongated and epithelial cells
assume papillary configuration
o No cytologic atypia; epithelium is well-differentiated
I CLINICAL ISSUES
Presentation
• Most common signs/symptoms
o Asymptomatic (75%)
o Lower abdominal pain, rectal bleeding and diarrhea
Demographics
• Age
o Adenomatous polyps: 24-47% > 50 years of age
o Hyperplastic polyps: 50% > 60 years of age
• Gender
o Adenomatous polyps
• M:F = 2:1
Natural History & Prognosis
• Good, after resect benign or carcinoma in situ polyps
• Poor, with invasive colon carcinoma
Treatment
• Colonoscopic polypectomy if polyps> 1 cm
o Completely resect villous adenoma or "carpet" lesion
o In patients with neoplastic polyps caused by genetic
mutations, prophylactic colectomy is required prior
to malignant transformation
• Follow-up (20% recur at 5 years; 50% recur at 15 years)
o Colonoscopy or fluoroscopic-guided double contrast
barium enema for periodic surveillance
I DIAGNOSTIC CHECKLIST
Consider
• Family history of colonic polyps & colon carcinoma
• Polypectomy if changes noted on follow-up imaging
Image Interpretation Pearls
• If patient has known diverticulosis, single contrast
barium enema is easier for polyp detection
I SELECTED REFERENCES
1. YeeJ et al: Colorectal neoplasia: Performance
characteristics of CT colonography for detection in 300
patients. Radiology 219: 685-92, 2001
2. Macari M et al: Comparison of time-efficient CT
colonography with two and three-dimensional colonic
evaluation for detecting colorectal polyps. AjR 174: 1543-9,
2000
3. Levine MS et al: Diagnosis of colorectal neoplasms at
double-contrast barium enema examination. Radiology
216: 11-8, 2000
 COLONIC POLYPS

I IMAGE GALLERY

(Left) Air contrast BEshows

a large sessile polyp (arrow)
in the cecum; villous
adenoma. (Right) Single
contrast BEshows a
cauliflower-like polypoid
cecal mass (arrow); villous
adenoma.

(Left) Air contrast BE shows

a large pedunculated polyp
(arrows) in sigmoid colon;
tubulovillous adenoma.
(Right) Air contrast BE shows 5
numerous diverticula; also a
large pedunculated polyp on 43
a stalk (arrows);
tubulovillous adenoma.

(Left) Air contrast BE shows

small sessile tubular
adenoma (arrow). The dome
of the" bowler hat" points
toward the colonic lumen.
(Right) Air contrast BE shows
a small polyp on a short stalk
(arrow). The outer rim of the
"Mexican hat" is the head of
the polyp; the inner ring is
the stalk.
 COLON CARCINOMA

Graphic shows "apple core" constricting tumor of Single contrast BE shows classic "apple core" lesion of
sigmoid colon with circumferential narrowing of the colon. There is a short segment irregular, circumferential
lumen and a nodular tumor surface. narrowing of the lumen with destroyed mucosa and
nodular "shoulders".

ITERMINOlOGY o Early cancer: Sessile (plaquelike) lesion

• Typical early colon cancer
Definitions • Flat, protruding lesion with a broad base and little
• Malignant transformation of colon mucosa elevation of mucosa (in profile view)
5 • Discrete borders and shallow central ulcers (in
profile view)
44 [IMAGING FINDINGS • Curvilinear or undulating lines (in en face view)
o Early cancer: Pedunculated lesion
General Features • Short and thick polyp stalk
• Best diagnostic clue: Short segment luminal wall • Irregular or lobulated head of polyp
thickening o Advanced cancer: Polypoid lesion (large)
• Location: Cecum (10%); ascending colon (15%); • Dependent wall: Filling defect in barium pool
transverse colon (15%); descending colon (5%); • Nondependent wall: Etched in white
sigmoid colon (25%); rectosigmoid colon (10%); o Advanced cancer: Semi-annular (saddle) lesion
rectum (20%) • Transition to annular carcinoma: Polypoid ~
• Morphology semi-annular ~ annular
o Early cancer: Sessile or pedunculated tumors • Convex barium-etched margins (in profile view)
o Advanced cancer: Annular, semi annular, polypoid o Advanced cancer: Annular (apple-core) lesion
or carpet tumors • Circumferential narrowing of bowel; Shelf-like,
• Other general features overhanging borders (mucosal destruction)
o Radiology is critical for screening, diagnosis, • High-grade obstruction and ischemia:
treatment and follow-up of colon cancer Thumbprinting of dilated proximal colon
o Screening: Fluoroscopic-guided double contrast o Advanced cancer: Carpet lesion
barium enema or CT "virtual colonoscopy" are • Malignant villous tumor may appear as carpet
comparable to colonoscopy for cancer detection lesion with minimal protrusion into lumen
• Radiolucent nodules surrounded by barium-filled
Radiographic Findings grooves; finely nodular or reticular pattern
• Fluoroscopic-guided double contrast barium enema

DDx: luminal Narrowing, Wall Thickening of Colon

Diverticulitis Ischemic Stricture Tuberculosis Endometriosis

 COLON CARCINOMA

Key Facts
Imaging Findings • Infectious colitis
• Best diagnostic clue: Short segment luminal wall Pathology
thickening
• !Fiber + t fat and animal protein diet
• Early cancer: Sessile or pedunculated tumors
• Advanced cancer: Annular, semiannular, polypoid or Clinical Issues
carpet tumors • Melena, hematochezia, iron deficiency
• Asymmetric mural thickening ± irregular surface • Overall 5 year survival is 50%
• Hepatic metastases most common • CT: Follow-up 3-4 months after surgery, then every 6
• Detection: Fluoroscopic-guided double contrast months for 2-3 years, then annually for 5 years
barium enema • PET-CTis best for recurrence and surveillance
• Staging: Helical CT
• Tumor recurrence and surveillance: PET-CT Diagnostic Checklist
• Evaluate entire colon for synchronous lesions
Top Differential Diagnoses • Tumor mass with irregular margins; apple-core lesion;
• Diverticulitis pericolonic extension and distant metastases
• Ischemic colitis

• Fluoroscopic-guided double contrast barium enema

CT Findings o "Thumbprinting" (submucosal edema or bleeding)
• Asymmetric mural thickening ± irregular surface o Stricture: Smooth, tapered margins, but no mass
• Wall thickness: < 3 mm: Normal; 3-6 mm: effect (chronic)
Indeterminate; > 6 mm: Abnormal • CT: Bowel wall thickening; ± pneumatosis,
• Tumor within lumen portomesenteric venous gas
o Smooth outer bowel margins
• Extracolonic tumor extension Infectious colitis 5
o Mass with irregular border • Example: Tuberculosis and Amebiasis
45
o Strands of soft tissue extending from serosal surface • Rare in the U.S.; usually in proximal colon
into perirectal or pericolic fat • Stricture formation may simulate carcinoma (chronic)
o Loss of tissue fat planes between colon and
surrounding muscles
Ulcerative colitis
• Metastases to mesenteric nodes, peritoneum • Significant etiology of colon carcinoma
• Hepatic metastases most common • Bowel wall thickening, luminal narrowing
• Fluoroscopic-guided double contrast barium enema
Nuclear Medicine Findings o Punctate and collar button ulcers
• PET:Fluorine 18-labeled deoxyglucose uptake is 2 fold o Continuous, concentric and symmetric colonic
higher in tumors than normal or nonmalignant involvement
lesions o "Lead pipe" colon and absent haustra (chronic)
• PET-CT
o Combines morphologic information (of CT) with
Extrinsic lesions
metabolic information (of PET) • Endometriosis, ovarian cancer, "drop" metastases
• Smooth, eccentric, obtuse angles with colonic wall
Imaging Recommendations
• Best imaging tool
o Detection: Fluoroscopic-guided double contrast I PATHOLOGY
barium enema
o Staging: Helical CT General Features
o Tumor recurrence and surveillance: PET-CT • General path comments
o Most common cancer of gastrointestinal tract
o Second most common cancer mortality
I DIFFERENTIAL DIAGNOSIS o 5% of colon cancers have synchronous colonic
tumors
Diverticulitis • Genetics
• CT findings o Mutations of genes
o Location: Most common in sigmoid colon • Proto-oncogene (K-ras): 50% of colon cancers
o Bowel wall and fascial thickening; fat stranding; free • Tumor suppressor genes (APC, DCC, SMAD4, p53,
air and fluid TGF-Sl RII): 70-75% of colon cancers
o Pericolic inflammatory changes: Abscess, sinuses, • DNA mismatch repair genes: 15% of colon cancers
fistulas or strictures • Etiology
o Risk factors
Ischemic colitis • !Fiber + t fat and animal protein diet
• Usually seen in watershed areas; focal or diffuse • History of colon adenoma or carcinoma
 COLON CARCINOMA
• Benign polyps> 1 cm • Diagnosis: Colonoscopy with mucosal biopsy
• Inflammatory bowel disease
Demographics
• Family history
o Family history • Age: > 50 years of age; peak at 70 years of age
• Colon cancer in first-degree relatives (1 2-3 fold) • Gender: M:F = 3:2
• Familial Adenomatous Polyposis « 1%), Gardner, Natural History & Prognosis
familial juvenile polyposis and hereditary
• Complications
nonpolyposis colorectal cancer o Hemorrhage, obstruction, perforation and fistula
o Pathogenesis
• Prognosis
• Adenoma-carcinoma sequence (7-10 years): o Overall 5 year survival is 50%
Benign adenoma ~ malignant transformation
• Duke's stage A: 81-85%
• Inflammatory bowel disease: Inflammation ~
• Duke's stage B: 64-78%
dysplasia ~ carcinoma
• Duke's stage C: 27-33%
• De novo colon carcinoma: Normal mucosa ~
• Duke's stage D: 5-14%
small, aggressive, ulcerated tumors
o Hereditary nonpolyposis colorectal cancer (HNPCC) Treatment
• 6% of colon cancer • Complete surgical resection (2. 5 cm on each side of
• Discrete adenoma, not polyposis tumor) with removal of lymphatic drainage vessels ±
.• Autosomal dominant with high penetration adjuvant chemotherapy
• Epidemiology • Pre- & post-operative radiation therapy (selected cases)
0> Common in N. America, Europe & New Zealand • Follow-up
• Incidence in U.S. is 135,000 per year oCT: Follow-up 3-4 months after surgery, then every
• Mortality in U.S. is 57,000 per year 6 months for 2-3 years, then annually for 5 years
o 1 Age ~ incidence of cancers shifts to right colon o CEA titer: If elevated, CT is indicated
• Associated abnormalities o PET-CT is best for recurrence and surveillance
o 5% of colon cancers: Metachronous carcinomas
o 33% of colon cancers: Adenomatous polyps
5 Gross Pathologic & Surgical Features I DIAGNOSTIC CHECKLIST
46 • Cecum and proximal colon: Bulky and polypoid, Consider
outgrowing their blood supply ~ necrosis • Evaluate entire colon for synchronous lesions
• Distal colon and rectum: Annular constriction or
"napkin-ring" appearance ~ obstruction & ulceration Image Interpretation Pearls
• Tumor mass with irregular margins; apple-core lesion;
Microscopic Features
pericolonic extension and distant metastases
• Adenocarcinoma (> 95% of colon cancers)
o Mucin-producing glands
o Mucinous: "Signet-ring" cells
o Colloid (15%): Large lakes of mucin contain
I SELECTED REFERENCES
scattered collections of tumor cells 1. Bar-Shalom R et al: Clinical performance of PET/CT in
evaluation of cancer: additional value for diagnostic
• Squamous cell carcinoma « 5%)
imaging and patient management. J Nucl Med.
Staging, Grading or Classification Criteria 44(8):1200-9,2003
2. Cohade C et al: Direct comparison of (18)F-FDG PETand
• Surgical-pathologic (modified Dukes) staging of colon
PET/CT in patients with colorectal carcinoma. J Nucl Med.
cancer with TNM correlation 44(11):1797-803,2003
o Stage A (TlNOMO): Limited to mucosa ± submucosa 3. Pickhardt PJ et al: Computed tomographic virtual
o Stage B (T2 or 3 & NOMO): Limited to serosa or into colonoscopy to screen for colorectal neoplasia in
adjacent tissues asymptomatic adults. N Engl] Med. 349(23):2191-200,
o Stage C (T2 or 3 & N1MO): Lymph node metastases 2003
o Stage D (any T and N, M1): Distant metastases 4. Levine MS et al: Diagnosis of colorectal neoplasms at
double-contrast barium enema examination. Radiology
216: 11-8,2000
5. Gazelle GS et al: Screening for colorectal cancer. Radiology.
I CLINICAL ISSUES 215(2):327-35,2000
6. Horton KM et al: Spiral CT of colon cancer: imaging
Presentation features and role in management. Radiographies.
• Most common signs/symptoms 20(2):419-30, 2000
o Melena, hematochezia, iron deficiency 7. Thoeni RF:Colorectal cancer: cross-sectional imaging for
o Abdominal pain & changes in bowel habit staging of primary tumor and detection of local recurrence.
o Colonic obstruction (50%, most common cause) AJRAm J Roentgenol. 156(5):909-15, 1991
o Weight loss, fever and weakness 8. Balthazar EJ et al: Carcinoma of the colon: detection and
preoperative staging by CT. AJRAm J Roentgenol.
• Lab-Data 150(2):301-6, 1988
o Positive or negative fecal occult blood test 9. Kelvin FM et al: Colorectal carcinoma detected initially
o ± Micro- to normocytic anemia with barium enema examination: site distribution and
o Carcinoembryonic antigen (CEA) > 2.5 I-Ig/L implications. Radiology. 169(3):649-51, 1988
 COLON CARCINOMA
I IMAGE GALLERY
Typical
(Left) Single contrast BE
shows bulky mass at hepatic
flexure with abrupt transition
to normal colon. Little or no
obstruction in spite of large
mass + luminal narrowing.
(Right) Axial CECT shows
mass at hepatic flexure with
circumferential wall
thickening, narrowed lumen.
Infiltrated fat (arrow) +
mesenteric adenopathy
(open arrow) indicate local
spread of disease.

(Left) Single contrast BE

shows short segment luminal
narrowing of ascending
colon with "apple core"
appearance, but no
obstruction. (Right) Axial
5
CECT shows large eccentric
47
mass in ascending colon
with extensive infiltration of
pericolonic fat +
lymphadenopathy (open
arrow).

Variant
(Left) Axial CECT shows wall
thickening + luminal
narrowing of transverse
colon near splenic flexure
with abrupt transition to
normal colon. Mesenteric
adenopathy (open arrow).
(Right) Axial CECT of patient
with colon cancer near
splenic flexure. Long segment
of wall thickening + luminal
narrowing with submucosal
low density. At resection
found to represent ischemic
colitis.
 RECTAL CARCINOMA

Single contrast BE shows mass (arrow) arising from Double contrast BE shows rectal mass (arrows) outlined
anterior rectal wall as a filling defect in the barium pool. by a coating of barium.

• Discrete borders and shallow central ulcers (profile

ITERMINOLOGY view)
Definitions • Curvilinear or undulating lines (en face view)
• Malignant transformation of rectal mucosa o Early cancer: Pedunculated lesion
5 • Short and thick polyp stalk
• Irregular or lobulated head of polyp
48 IIMAGING FINDINGS o Advanced cancer: Polypoid lesion
• Dependent wall: Filling defect in barium pool
General Features • Nondependent wall: Etched in white
• Best diagnostic clue: Polypoid mass with irregular o Advanced cancer: Semi-annular (saddle) lesion
surface • Transition to annular carcinoma
• Morphology • Convex barium-etched margins (profile view)
o Early cancer: Sessile or pedunculated tumors o Advanced cancer: Annular (apple-core) lesion
o Advanced cancer: Annular, semiannular, polypoid • Circumferential narrowing of bowel; shelf-like,
or carpet tumors overhanging borders (mucosal destruction)
o Most common in rectum: Sessile and polypoid • High grade obstruction and ischemia:
• Other general features Thumbprinting of dilated proximal colon
o Radiologic features are similar to colon carcinoma o Advanced cancer: Carpet lesion
o Transrectal ultrasonography for tumor staging • Malignant villous tumor may appear as carpet
o Types of rectal cancer: Adenocarcinoma (80%) and lesion with minimal protrusion into lumen
squamous cell carcinoma (20%) • Radiolucent nodules surrounded by barium-filled
grooves; finely nodular or reticular pattern
Radiographic Findings
• Fluoroscopic-guided barium enema CT Findings
o Early cancer: Sessile (plaque-like) lesion • Mass & focal or circumferential wall thickening
• Most typical early colorectal cancer • Asymmetric mural thickening ± irregular surface
• Flat, protruding lesion with a broad base and little • Wall thickness: < 3 mm: Normal; 3-6 mm:
elevation of mucosa (profile view) Indeterminate; > 6 mm: Abnormal
• Tumor within lumen

DDx: Rectal Mass or Luminal Narrowing

J .~<~
.~
Cervical Cancer Rectal Ulcer Lymphogranuloma Hemorrhoids
 RECTAL CARCINOMA
Key Facts
Imaging Findings
• Best diagnostic clue: Polypoid mass with irregular
surface
• Radiologic features are similar to colon carcinoma
• Types of rectal cancer: Adenocarcinoma (80%) and
squamous cell carcinoma (20%)
• May have lung and bone metastases before liver
metastases
• Metastases to lymph nodes: Spherical, hypoechoic &
distinct margins
• Transrectal ultrasonography: Visualize layers of rectal
wall & depth of tumor penetration
Top Differential Diagnoses
• Local invasion
• Villous adenoma
o Smooth outer bowel margins
• Extracolonic tumor extension
o Mass with irregular border
o Strands of soft tissue extending from serosal surface
into perirectal fat
o Loss of tissue fat planes between rectum and
surrounding muscles
• Metastasis to lymph nodes at external iliac and
para-aortic chain, inguinal, retroperitoneum or porta
hepatis
• May have lung and bone metastases before liver
metastases
MR Findings
• Mass; pericolonic infiltration, lymphadenopathy
shown slightly better than by CT
• Endorectal coil - improves resolution, but may not be
worth the effort
Ultrasonographic Findings
• Real time transrectal ultrasonography
o Hypoechoic mass with disruption of wall segments
o Focal or circumferential wall thickening
o Metastases to lymph nodes: Spherical, hypoechoic &
distinct margins
o Rings of different echogenicities (center ~ outer)
• Innermost ring: Hyperechoic; interface between
balloon and mucosa
• Second ring: Hypoechoic; muscularis mucosae
• Third ring: Hyperechoic; submucosa
• Fourth ring: Hypoechoic; muscularis propria
• Fifth ring: Hyperechoic; perirectal fat or serosa
o Sonographic staging based on TNM classification
• Tl: Confined to mucosa/submucosa; middle
echogenic layer intact
• T2: Confined to rectal wall; outermost echogenic
layer is intact
• T3: Penetrates into perirectal fat; disrupting outer
hyperechoic ring
Nuclear Medicine Findings
• PET: Fluorine I8-labeled deoxyglucose uptake is 2 fold
higher in tumors than normal or nonmalignant
lesions
• Trauma
• Infection
Pathology
• ~ Fiber + 1 fat and animal protein diet
• HIV positive homosexual males
• Human papilloma virus (HPV): Type 16, 18, 45, 46
Clinical Issues
• Hematochezia, rectal pain, change in bowel habits
• Anal pain, anal discharge & tenesmus
• Overall 5 year survival is 50%
Diagnostic Checklist
• Evaluate entire colon for synchronous lesions
• Image detection of perirectal tumor spread is vital;
requires pre-operative radiation ± chemotherapy
• PET-CT
o Combines morphologic information (of CT) with
metabolic information (of PET)
Imaging Recommendations
• Best imaging tool
o Detection: Fluoroscopic-guided barium enema
o Staging: Helical CT and transrectal ultrasonography 5
o Transrectal ultrasonography: Visualize layers of
49
rectal wall & depth of tumor penetration
o Tumor recurrence, surveillance: PET-CT
• Protocol advice: Transrectal ultrasonography: Pass
transducer proximal to tumor into the colon for
complete assessment of mural and nodal pathology
I DIFFERENTIAL DIAGNOSIS
local invasion
• Example: Carcinoma of the cervix, prostate, bladder
• Direct extension to pelvic sidewall and adjacent
structures including rectum
• Circumferential narrowing ± lymphadenopathy
• Depends on size of tumor; can be hard to differentiate
Villous adenoma
• Polypoid lesion with a granular or reticular appearance
• High risk of malignant degeneration
• Similar to "carpet" lesion in advanced rectal cancer
Trauma
• Penetrating injuries: Anal intercourse & insertion of
foreign bodies
• Fibrosis and stricture (chronic) can simulate cancer
• Perianal and rectal mucosa ulceration
Infection
• Mucosal ulceration or granular mucosal pattern
• Mechanism: Anal sex, spread from vaginal discharge
or lymphatic extension from inguinal lymph nodes
• Most common: C. trachomatis ~ lymphatic tissue
infection ~ Lymphogranuloma venereum (LGV)
• Other STDs include N. gonorrhoeae, HSV and syphilis
 RECTAL CARCINOMA
• Progress to fistula, perirectal abscess or stricture o Hematochezia, rectal pain, change in bowel habits
(chronic)i similar in complications of rectal cancer o Perineal or sacral pain (chronic)
o Squamous cell carcinoma:
• Anal pain, anal discharge & tenesmus
I PATHOLOGY • Lab-Data
o ± HIV (PCR) test
General Features o Carcinoembryonic antigen (CEA) > 2.5 I-lg/L
• General path comments • Diagnosis
o Colon cancer: Rectum (20%) & rectosigmoid (15%) o Sigmoidoscopy with mucosal biopsy
o Rectal cancer tends to invade locally (lack serosa)
o Metastases: Upper 2/3 of rectum Demographics
• Portal system - liver • Age: Adenocarcinoma: Age: > 50 years of agei peak at
• Batson vertebral venous plexus - lumbar & 70 years of age
thoracic vertebra • Gender: M:F = 3:2
o Metastases: Lower 1/3 of rectum
Natural History & Prognosis
• Superior hemorrhoidal vein - portal - liver
• Middle hemorrhoidal vein - IVC - lung .• Complications
• Genetics: Adenocarcinoma: Mutation in o Hemorrhage, obstruction, perforation and fistula
proto-oncogene, tumor suppressor genes or DNA • Prognosis
mismatch repair genes o Overall 5 year survival is 50%
• Etiology • Duke's stage A: 81-85%
o Adenocarcinoma • Duke's stage B: 64-78%
• j Fiber + 1 fat and animal protein diet
• Duke's stage C: 27-33%
• History of colorectal adenoma or carcinoma • Duke's stage D: 5-14%
• Benign polyps> 1 cm Treatment
• Family history & Inflammatory bowel disease
• Surgical resection (depends on location) & removal of
o Squamous cell carcinoma
lymphatic drainage vessels ± adjuvant chemotherapy
5 • HIV positive homosexual males
• Human papilloma virus (HPV): Type 16, 18, 45, 46
• Pre- & post-operative radiation ± chemotherapy
therapy (selected cases)
50 • Lubricants, cleansers & mechanical irritation
• Follow-up
o Pathogenesis
oCT: Follow-up 3-4 months after surgery, then every
• Adenocarcinoma: Adenoma-carcinoma sequence
6 months for 2-3 years, then annually for 5 years
• Squamous cell carcinoma: Squamous metaplasia
o CEA titer: If elevated, CT is indicated (PET-CT best)
- dysplasia - carcinoma
• Epidemiology: Adenocarcinoma: More common in N.
America, Europe & New Zealand
I DIAGNOSTIC CHECKLIST
Gross Pathologic & Surgical Features
Consider
• Flat, infiltrative, annular or ulcerative & rolled borders
• Annular constriction or "napkin-ring" appearance - • Evaluate entire colon for synchronous lesions
obstruction, ulceration and intramural spread Image Interpretation Pearls
• Squamous cell carcinoma: Mass from epithelium of • Image detection of perirectal tumor spread is vitali
anorectal junction (dentate line) requires pre-operative radiation ± chemotherapy
Microscopic Features
• Adenocarcinoma: Mucin-producing glands
• Squamous cell (cloacogenic) carcinoma I SELECTED REFERENCES
o Mixture of basaloid cell, transitional cell with 1. Fuchsjager MH et al: Comparison of transrectal sonography
squamous differentiation, adenoid cyst and and double-contrast MR imaging when staging rectal
mucoepithelial cell cancer. A]RAm] Roentgenol. 181(2):421-7,2003
2. Winawer 5] et al: A comparison of colonoscopy and
Staging, Grading or Classification Criteria double-contrast barium enema for surveillance after
• Surgical-pathologic (modified Dukes) staging of colon polypectomy. New Eng] Med 342: 1766-72,2000
3. Maier AG et al: Transrectal sonography of anal sphincter
cancer with TNM correlation
infiltration in lower rectal carcinoma. A]R Am]
o Stage A (TINOMO): Limited to mucosa ± submucosa Roentgenol. 175(3):735-9,2000
o Stage B (T2 or 3 & NOMO): Limited to or invades 4. Levine MS et al: Diagnosis of colorectal neoplasms at
adjacent tissues double-contrast barium enema examination. Radiology
o Stage C (T2 or 3 & NIMO): Lymph node metastases 216: 11-8, 2000
o Stage D (any T and N, Ml): Distant metastases 5. Thompson WM et al: Computed tomography of the
rectum. Radiographies. 7(4):773-807, 1987
6. Cohan RH et al: Computed tomography of epithelial
I CLINICAL ISSUES neoplasms of the anal canal. A]RAm] Roentgenol.
145(3):569-73, 1985
Presentation
• Most common signs/symptoms
 RECTAL CARCINOMA
I IMAGE GALLERY

(Left) Single contrast BE

shows large rectal mass with
markedly irregular surface;
carcinoma arising from
villous adenoma. (Right) Air
contrast BE shows large mass
arising from lateral wall of
the rectum.

Typical
(Left) Axial CECT shows
large mass that fill the rectal
lumen and infiltrates the
perirectal fat. Extensive
lymphadenopathy (arrows).
(Right) Transrectal
5
ultrasonography shows a
51
bulky rectal mass (arrows)
with invasion through
submucosa; T3 stage.

Typical
(Left) Axial CECT shows
calcified periaortic and
retrocrural nodes, no liver
metastases. Mucinous rectal
adenocarcinoma. (Right)
Axial CECT shows extensive
pulmonary metastases from
rectal cancer in a patient
with no liver metastases.
 VILLOUS ADENOMA

,. ~.

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f. •. _,. r

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/"'"
:'\.•
'
",.
1,
"'e'
~,...'--:;' II...•

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Graphic shows polypoid mass in rectosigmoid colon Single contrast BE shows a polypoid mass in the
having a shaggy, nodular surface, rectosigmoid colon (arrow) with a very nodular surface,
Barium within the rectum is diluted by mucous secreted
by the tumor.

ITERMINOlOGY • Villous adenoma: 10% of neoplastic polyps;

villous change more than 75%
Abbreviations and Synonyms • Tubulovillous adenoma: 15%; villous change
• Villous tumor between 25-50%
5 Definitions
o As adenoma increases in size, degree of villous
change usually increases
52 • Adenomatous polyp that contains predominantly o Villous adenoma has highest risk of malignant
villous elements ("villous" means "shaggy surface") degeneration
o Risk of cancer is related to proportion of villous
change in adenoma
I IMAGING FINDINGS o Greater risk of carcinoma in villous tumors of
stomach & duodenum than colon
General Features • Stomach: Carcinoma in 50% of lesions 2-4 cm &
• Best diagnostic clue: Polypoid lesion with a nodular or 80% in more than 4 cm
frond-like surface on barium enema • Duodenum: Carcinoma in 30-60% of villous
• Location: Rectosigmoid> cecum> ascending colon> tumors more than 4 cm
stomach> duodenum • Colon: Carcinoma in situ in 10% & invasive
• Size carcinoma in up to 45% of cases
o Range from < 1-10 cm in diameter
o Giant villous tumor: 10-15 cm Radiographic Findings'
• Morphology: "Cauliflower-like" sessile growth with a • Fluoroscopic guided double contrast barium enema
broad base or flat "carpet" lesion o Two types of villous adenomas
• Other general features • Polypoid mass
o Villous adenoma is one of the histological types of • "Carpet" lesion
adenomatous polyps (true neoplasms) o Polypoid mass
• Tubular adenoma: 75% of neoplastic polyps; • May look like a cauliflower within colon
villous change less than 25% • Nodular, lace or soap bubble pattern
• Due to trapping of barium between frond-like
projections (interstices)

DDx: Irregular Solitary Filling Defect

Rectal Cancer Colon Cancer Fecal Mass Colon Lipoma

 VILLOUS ADENOMA
Key Facts
Terminology
• Adenomatous polyp that contains predominantly
villous elements ("villous" means "shaggy surface")
Imaging Findings
• Best diagnostic clue: Polypoid lesion with a nodular
or frond-like surface on barium enema
• Location: Rectosigmoid> cecum> ascending colon>
stomach> duodenum
• Range from < 1-10 cm in diameter
• Malignant transformation in a bulky adenoma:
Annular lesion with shelf-like, overhanging borders
• Localized "carpet" lesion: Subtle alteration in surface
texture
• Extensive "carpet" lesion: Involves a large area of
colon, encircling lumen
• Malignant transformation in a bulky adenoma:
Annular lesion with shelf-like, overhanging
borders
o "Carpet" lesion
• Flat, lobulated lesion
• Localized or extensive
o Localized "carpet" lesion: Subtle alteration in surface
texture
o Extensive "carpet" lesion: Involves a large area of
colon, encircling lumen
• En face: Fine nodular, reticular pattern with
sharply demarcated border
• Profile: Irregular contour in contrast to smooth,
fine contour of adjacent normal bowel
o Malignant transformation in "carpet" lesion (1 risk)
• Radiolucent nodules surrounded by barium-filled
grooves (produce fine nodular or reticular pattern)
• Polypoid carcinoma with surrounding mucosal
change represents underlying adenoma
• Seen in rectum, cecum, ascending colon, stomach
& duodenum
CT Findings
• Large villous adenoma
o Low-attenuation irregular polypoid mass
o Convolutional gyral enhancement pattern
o Corrugated, feathery appearance due to trapping of
oral contrast in interstices of villous adenoma
MR Findings
• Large villous adenoma
o Tl WI: Low signal intensity mass with multiple
frond-like projections & central cord-like structure
o T2WI: Frond-like projections will be more
prominent
• Villous adenoma with 1 mucin producing cells
o Short Tl & long T2 times
o Tl WI & T2WI: Adenoma appears hyperintense
Ultrasonographic Findings
• Transrectal sonography
o Determine depth of invasion into colonic wall by
adenoma
Top Differential Diagnoses
• Colon carcinoma
• Fecal mass
• Intramural mass
Pathology
• Family history, idiopathic inflammatory disease
• Malignant potential: 5% in lesions < 1 cm; 10% in
lesions 1-2 cm; 53% in > 2 cm lesions
• Gray-tan lesion
Diagnostic Checklist
• Check for family history of colonic polyps & evaluate
entire colon for synchronous lesions
• Cauliflower-like sessile mass with a broad base or
carpet lesion with reticular or soap-bubble surface
pattern
Imaging Recommendations
• Double-contrast barium enema
o En face, profile & oblique views
• Transrectal US; NE + CECT
I DIFFERENTIAL DIAGNOSIS 5
53
Colon carcinoma
• Barium enema findings
o Early cancer: Sessile (plaquelike) lesion
• Typical early colon cancer
• Flat, protruding lesion with a broad base & little
elevation of mucosa (in profile view)
o Early cancer: Pedunculated lesion
• Short & thick polyp stalk
• Irregular or lobulated head of polyp
o Advanced cancer: Polypoid lesion (large)
• Dependent wall: Filling defect in barium pool
• Nondependent wall: Etched white
o Sessile & pedunculated polypoid cancers may be
indistinguishable from villous adenoma
o Advanced cancer: Semi-annular (saddle) lesion
o Advanced cancer: Annular (apple-core) lesion
• Circumferential narrowing of bowel
• Shelf-like, overhanging borders (mucosal
destruction)
• CT findings
o Asymmetric mural thickening ± irregular surface
o Extracolonic tumor extension
• Mass with irregular borders
• Extension from serosa to pericolic fat
• Loss of fat planes: Colon & adjacent muscles
o Metastases to mesenteric nodes
o Metastases to liver more common
• Diagnosis: Biopsy & histology
Fecal mass
• Large, irregular colonic fecal impaction
o Most common location: Rectum
• Mimic large cauliflower-like sessile polyp
• May cause bowel obstruction + proximal dilatation
 VILLOUS ADENOMA
• Usually seen in elderly, sedentary patients
Demographics
• Diagnosis: Clinical history & colonoscopy
• Age: 60-70 years of age or older
Intramural mass • Gender: Equal in both males & females (M = F)
• Example: Stromal tumors (leiomyoma, sarcoma or
Natural History & Prognosis
GIST)
• Leiomyoma • Complications
o In profile o Malignant transformation or invasion; hemorrhage
• Smooth surface etched in white • Prognosis
• Borders: Right or obtuse angles with adjacent wall o Good: After removal of benign & carcinoma in situ
o En face adenoma
• Seen as a filling defect simulating polypoid type of o Poor: Invasive carcinoma
villous adenoma Treatment
• Intraluminal surface: Abrupt well-defined borders • Colonoscopic, endoscopic or surgical resection
• Leiomyosarcoma
o Bulky stromal tumors most frequently seen in
rectum
o Broad based mass simulating large villous adenoma
I DIAGNOSTIC CHECKLIST
o Large tumors show ulceration or cavitation Consider
o CT shows pericolonic extension (large extraluminal • Check for family history of colonic polyps & evaluate
mass), liver & peritoneal metastases entire colon for synchronous lesions
• Hypervascular on angiography
• Diagnosis: Biopsy Image Interpretation Pearls
• Cauliflower-like sessile mass with a broad base or
carpet lesion with reticular or soap-bubble surface
I PATHOLOGY pattern

General Features
5 • Etiology I SELECTED REFERENCES
o Villous adenoma or tumor
54 1. Smith TR et al: CT appearance of some colonic villous
• Family history, idiopathic inflammatory disease
tumors. A]R Am] Roentgenol. 177(1):91-3,2001
• Malignant potential: 5% in lesions < 1 cm; 10% in 2. Levine MS et al: Diagnosis of colorectal neoplasms at
lesions 1-2 cm; 53% in > 2 cm lesions double-contrast barium enema examination. Radiology
• Epidemiology: Incidence: Least common (10%) of all 216: 11-8, 2000
neoplastic adenomatous polyps 3. Cunnane ME et al: Small flat umbilicated tumors of the
colon: radiographic and pathologic findings. A]RAm]
Gross Pathologic & Surgical Features Roentgenol. 175(3):747-9, 2000
• Usually sessile 4. Chung JJ et al: Large villous adenoma in rectum mimicking
o May be polypoid, broad, flat or carpet-like lesion cerebral hemispheres. A]R Am] Roentgenol. 175(5):1465-6,
o Gray-tan lesion 2000
5. Iida M et al: Endoscopic features of villous tumors of the
• May have a short, broad stalk & focal areas of
colon: correlation with histological findings.
hemorrhage or ulceration Hepatogastroenterology. 37(3):342-4, 1990
Microscopic Features 6. Iida M et al: Villous tumor of the colon: correlation of
histologic, macroscopic, and radiographic features.
• Frond-like papillary projections of adenomatous Radiology. 167(3):673-7, 1988
epithelium 7. Galandiuk S et al: Villous and tubulovillous adenomas of
• ± Well-differentiated areas the colon and rectum. A retrospective review, 1964-1985.
• Carcinoma in situ; invasive cancer Am] Surg. 153(1):41-7, 1987
8. Galandiuk S et al: Villous and tubulovillous adenomas of
the colon and rectum. A retrospective review, 1964-1985.
I CLINICAL ISSUES Am] Surg. 153(1):41-7, 1987
9. Ott D] et al: Single-contrast vs double-contrast barium
Presentation enema in the detection of colonic polyps. A]RAm]
Roentgenol. 146(5):993-6, 1986
• Most common signs/symptoms 10. de Roos A et al: Colon polyps and carcinomas: prospective
o Asymptomatic, diarrhea, pain, rectal bleeding or comparison of the single- and double-contrast examination
melena in the same patients. Radiology. 154(1):11-3, 1985
o Lesion closer to rectum: More likely to have 11. Delamarre] et al: Villous tumors of the colon and rectum:
diarrhea, electrolyte loss double-contrast study of 47 cases. Gastrointest Radiol.
• Lab-data 5(1):69-73, 1980
o Guaiac positive stool
o Iron deficiency anemia
o Decreased protein, K+, Na+
o ± Increased direct bilirubin levels (due to obstruction
of ampulla of Vater (duodenum) by adenoma)
• Diagnosis: Endoscopy, biopsy & histology
 VILLOUS ADENOMA
I IMAGE GALLERY

(Left) Axial CECT shows a

large mass that fills the
rectosigmoid colon with
dilated stool-filled colon,
noted more proximally.
(Right) Axial CECT shows a
large polypoid mass (arrow)
within the rectum.

(Left) Single contrast BE

shows large rectal mass with
frond-like surface. Note
absence of colonic
obstruction. (Right) Air
contrast BE shows rectal
5
mass with nodular surface
55
that fills, but does not
obstruct, the rectal lumen.

(Left) Single contrast BE

shows a cauliflower-like
mass (arrow) in the cecum.
(Right) Air contrast BEshows
cauliflower-like cecal mass;
(arrow) villous adenoma.
 FAMILIAL POLYPOSIS

Graphic shows innumerable small polyps and multifocal Air contrast BE shows innumerable small polyps in
carcinomas (arrows). sigmoid colon.

o Familial polyposis coli: Multiple colonic

!TERMINOlOGY adenomatous polyps
Abbreviations and Synonyms • Entire colonic mucosa is carpeted with polyps
• Familial adenomatous polyposis syndrome (FAPS) o Gardner syndrome: Combination of
5 Definitions
• Familial polyposis coli, osteomas, epidermoid
(sebaceous) cyst
56 • Spectrum of autosomal dominant disease characterized • Soft tissue tumors: Desmoid, mesenteric
by innumerable adenomatous colonic polyps & other fibromatosis, lipoma
associated lesions • Dental abnormalities; periampullary, duodenal &
thyroid carcinomas
o 500-2500 polyps present carpeting colonic mucosa
I IMAGING FINDINGS o Polyps appear around puberty & onset of symptoms
in 3rd or 4th decade
General Features o Most polyps are tubular & tubulovillous,
• Best diagnostic clue: Innumerable colonic filling occasionally villous adenomas
defects or ring shadows ± extraintestinallesions o FAPSadenomas small (80% < 5 mm) & sessile
• Location o Colorectal cancer develops in almost 100% of
o Most common in colon (t predilection-left colon) untreated patients
• Colon> stomach> duodenum> small bowel o 2/3 of afflicted cases are inherited & 1/3 are sporadic
• Size: Varies from pin point to > 1 cm o Abnormal gene has high penetrance (80-100%)
• Morphology: Sessile or pedunculated polypoid lesions o Extracolonic GI tract manifestations of FAPS
• Other general features • Stomach, duodenum, jejunum & ileum
o FAPSis a rare condition, but is most common of o Stomach
polyposis syndromes • Fundic gland polyps & adenomas in > 50% cases
o Two varied expressions of FAPS o Duodenum: Adenomas of 2nd part & periampullary
• Familial polyposis coli: Multiple colonic in > 47% cases
adenomatous polyps • Periampullary cancer: 2nd most frequent site of
• Gardner syndrome cancer outside colon seen in 12% of FAPSpatients

DDx: Multiple Colonic Filing Defects

Retained Feces Ulcerative Colitis Ulcerative Colitis Primary Pneumatosis

 FAMILIAL POLYPOSIS
Key Facts
Terminology
• Familial adenomatous polyposis syndrome (FAPS)
• Spectrum of autosomal dominant disease
characterized by innumerable adenomatous colonic
polyps & other associated lesions
Imaging Findings
• Best diagnostic clue: Innumerable colonic filling
defects or ring shadows ± extraintestinallesions
• Familial polyposis coli, osteomas, epidermoid
(sebaceous) cyst
• Soft tissue tumors: Desmoid, mesenteric fibromatosis,
lipoma
• Dental abnormalities; periampullary, duodenal &
thyroid carcinomas
• FAPSadenomas small (80% < 5 mm) & sessile
o Jejunum & ileum
• Adenomas, lymphoid hyperplasia in > 20% cases
o Associated with 1 incidence: Malignant CNS tumors
Radiographic Findings
• Fluoroscopic guided double contrast barium enema
o Innumerable varied sized radiolucent filling defects
o Carpet entire colon particularly rectosigmoid region
o May be widely scattered radiolucent filling defects
• Fluoroscopic guided double contrast UGI, small bowel
o Multiple small filling defects in stomach,
duodenum, jejunum & ileum
CT Findings
• NECT
o Imaging appearance varies due to relative amounts
of fibroblast proliferation/fibrosis/fat/collagen
content & vascularity of tumor
o Desmoid tumor & mesenteric fibromatosis
• Well or ill-defined; homo-/heterogeneous density
• ± Displacement or compression of bowel loops
• ± Areas of necrosis
• Desmoid location: Mesentery & abdominal wall
• CECT: Both desmoid & mesenteric fibromatosis:
Higher attenuation than muscle
• CT colonography after colonic air insufflation:
Endoluminal images show
o Small or large, sessile or pedunculated polyps
extending from colonic wall
o Polyps 10 mm & above; 90% Sensitivity
MR Findings
• Desmoid tumor & mesenteric fibromatosis
o T1WI: ! Signal intensity relative to muscle
o T2WI: Variable signal intensity (low, medium or
high) relative to muscle
o T1C+: Marked homo-/heterogeneous enhancement
Imaging Recommendations
• Double contrast barium studies (for polyps)
o En face, profile & oblique views
• NE + CECTi MR & T1C+ (for abdominal tumors)
• CT colonography (for polyps)
Top Differential Diagnoses
• Retained feces & food
• Lymphoid hyperplasia
• Metastases & lymphoma
• Pseudo polyps
• Primary colonic pneumatosis
Pathology
• Virtually all untreated patients develop colon cancer
• FAPSis inherited as an autosomal dominant trait
Diagnostic Checklist
• Check for family history: Colonic polyps, abdominal
soft tissue tumors & malignancies at a young age
• 500-2500 polyps carpeting entire colon-rectosigmoid
• Gardner syndrome: Soft tissue tumors, bony
osteomas, dental defects & periampullary cancer
I DIFFERENTIAL DIAGNOSIS
Retained feces & food
• Filling defects in barium pool mimicking polyps
Lymphoid hyperplasia
• Lymphoid follicles
o Aggregates of lymphocytes in muscularis mucosae
5
o Seen in 50% of barium studies (kids); 13% (adults) 57
o Enlarged or hyperplastic: Infectious, neoplastic,
immunologic & inflammatory diseases
• Barium studies
o Innumerable small or tiny radiolucent nodules
o Usually generalized (duodenum, small-bowel, colon)
o Simulate small size adenomatous polyposis
• Distinguished by clinical history & generalized pattern
Metastases & lymphoma
• Metastases (e.g., malignant melanoma, breast, lung)
o Malignant melanoma
• Smooth polypoid submucosal lesions of different
sizes seen as filling defects may mimic polyps
• Polypoid lesion with ulcers & radiating folds form
a typical "spoke-wheel" pattern
o Breast carcinoma: Mural nodules simulating polyps
o Bronchogenic carcinoma
• Single or multiple intramural lesions (flat or
polypoid) indistinguishable from polyps
• Frequently ulcerated, narrowing & obstruction
• Lymphoma
o Distribution: Stomach (51%), small-bowel (33%),
colon (16%), esophagus (<1%)
o Low grade MALT lymphoma
• Seen only in stomach due to H. pylori gastritis
• Confluent varying-sized nodules (filling defects)
• May be indistinguishable from gastric polyps
o Non-Hodgkin lymphoma
• Small or bulky polypoid masses may mimic polyps
• Smooth surface, broad base, sessile lesions ±
central depressions or ulcerations
• Bull's-eye" sign: Polypoid mass with ulceration
• Markedly thickened bowel wall & folds
• Regional or widespread adenopathy seen
 FAMILIAL POLYPOSIS
Pseudopolyps
• Example: Ulcerative colitis (common); granulomatous
colitis
• Two types of pseudopolyps
o Inflammatory pseudopolyps
o Postinflammatory pseudopolyps
• Inflammatory pseudo polyps
o Islands of elevated, inflamed, edematous mucosa
surrounded by ulceration appear as pseudopolyps
• Represent remnants of pre-existing mucosa &
submucosa rather than new growths
o Natural progression of collar button ulcers, which
extend, interconnect & mimics pseudopolyps
• Postinflammatory pseudopolyps (mucosal overgrowth)
o Regenerated mucosa results in polypoid lesions
• May be small & rounded; long & filiform or
bushlike structure simulating a villous adenoma
o Seen during mucosal healing, so they are termed
postinflammatory pseudo polyps
o Also seen after ischemia or after any severe infection
Primary colonic pneumatosis
• Cystic intramural collections of gas in colon
• Asymptomatic
• Not due to ischemia
5 !PATHOLOGY
58 General Features
• General path comments
o Proliferation of mucosa
o Polyps begin in rectosigmoid & spread entire colon
o Polyps are indistinguishable from sporadic
adenomatous polyps
o Virtually all untreated patients develop colon cancer
• Genetics: Abnormal or deletion of APC gene located
on chromosome 5q
• Etiology
o FAPSis inherited as an autosomal dominant trait
o Occasionally due to spontaneous mutations
• Epidemiology: FAPSaffects 1 in 10,000 people in US
Gross Pathologic & Surgical Features
• Innumerable polyps carpeting colonic mucosa
• Desmoid tumor
o Confined to muscle, fascia or deeply infiltrate
o Size: 5-20 em; firm & gritty texture; lack capsule
o Cut surface: Glistening white + trabeculated
Microscopic Features
• Adenomas
o Tubular, tubulovillous & villous; ± atypia or mitosis
• Desmoid tumor
o Spindle shaped cells & dense bands of collagen
I CLINICAL ISSUES
Presentation
• Most common signs/symptoms
o Rectal bleeding & diarrhea (75% cases)
o Asymptomatic, pain, mucus discharge
o Family history of colonic polyps (66% cases)
• Extraintestinal manifestations: Gardner syndrome
o Epidermoid cyst, lipoma, fibroma, desmoid tumors
(3-29%), mesenteric fibromatosis, peritoneal
adhesions, retroperitoneal fibrosis
o Osteomas: Membranous bone-50%; mandible-80%
o Teeth: Odontoma, unerupted supernumerary teeth
o Thyroid cancer: Papillary type more common in
girls & young women
Demographics
• Age: Mean age 16 years; by 35 years 95% have polyps
• Gender: Equal in both males & females
Natural History & Prognosis
• Complications
o Polyps: Malignant transformation
• Colon> periampullary > stomach> jejunum
o Colon carcinoma by age 34-43 years
• Prognosis
o Bad if abdominal desmoids, colonic carcinoma or
ampullary carcinoma develop
Treatment
• Prophylactic total colectomy at about 20 years of age
• Permanent ileostomy, Kock pouch
• Continent endorectal pull-through pouch
I DIAGNOSTIC CHECKLIST
Consider
• Check for family history: Colonic polyps, abdominal
soft tissue tumors & malignancies at a young age
Image Interpretation Pearls
• 500-2500 polyps carpeting entire colon-rectosigmoid
• Gardner syndrome: Soft tissue tumors, bony osteomas,
dental defects & periampullary cancer
I SELECTED REFERENCES
1. Spigelman AD: Extracolonic polyposis in familial
adenomatous polyposis: so near and yet so far. Gut.
53(3):322, 2004
2. Macari M et al: Diagnosis of familial adenomatous
polyposis using two-dimensional and three-dimensional
CT colonography. AJRAm. J. Roentgenol. 173: 249-250,
1999
3. Hizawa K et al: Desmoid tumors in familial adenomatous
polyposis/Gardner's syndrome. J Clin Gastroenterol.
25(1):334-7, 1997
4. Hamed RK et al: The hamartomatous polyposis syndromes:
clinical and radiologic features. AJRAm J Roentgenol.
164(3):565-71, 1995
5. Rustgi AK: Hereditary gastrointestinal polyposis and
nonpolyposis syndromes. N EnglJ Med. 331(25):1694-702,
1994
6. Casillas J et al: Imaging of intra- and extraabdominal
desmoid tumors. RadioGraphies 11: 959-968, 1991
7. Hamed RK et al: Extracolonic manifestations of the
familial adenomatous polyposis syndromes. A]R Am J
Roentgenol. 156(3):481-5, 1991
8. Bartram CI et al: Colonic polyp patterns in familial
polyposis. AJR 142: 305-308, 1984
 FAMILIAL POLYPOSIS

I IMAGE GALLERY
Typical
(Left) Axial CECT shows
subtle polypoid thickening of
descending colon, large mass
in cecum. (Right) Axial
CECT, 25 year old woman
with familial polyposis.
Extensive rectal cancer with
local invasion and
lymphadenopathy.

(Left) Air contrast BEshows

innumerable polyps in
rectosigmoid colon. (Right)
Air contrast BE shows
innumerable polyps in 5
rectosigmoid colon.
59

(Left) Upper GI series shows

polyps in duodenum.
Familialpolyposis-Gardner
syndrome. (Right) Axial
CECT shows extensive liver
metastases in 23 year old
man with familial polyposis.
 GARDNER SYNDROME

Axial CECT in a 30 year old man with Gardner Axial CECT shows thickening of the rectosigmoid wall
syndrome shows multiple hepaUc metastases. due to innumerable polyps + invasive rectal carcinoma.

o Familial polyposis: Innumerable varied sized

ITERMINOLOGY radiolucent filling defects
Definitions
CT Findings
• Familial adenomatous polyposis + extracolonic lesions
5 • NECT
o Desmoid tumors & mesenteric fibromatosis: Well or
ill-defined; homo- or heterogeneous masses
60 I IMAGING FINDINGS o Other carcinomas: Isodense or heterogenous
General Features attenuation of the mass
• Best diagnostic clue: Innumerable, colonic, radiolucent • CECT: Desmoid tumors & mesenteric fibromatosis:
filling defects with extraintestinallesions Increased attenuation; greater than muscles
• Other general features • CT colonography
o Combination of familial polyposis coli and o Familial polyposis: Small or large, sessile or
• Osteomas; dental abnormalities pedunculated polyps extending from wall
• Desmoid tumor & mesenteric fibromatosis o May see colon carcinoma, liver mets
• Epidermoid cysts & fibromas of skin Imaging Recommendations
• Adrenal, thyroid & liver carcinomas • Best imaging tool
• Congenital pigmented lesions of retina o Familial polyposis: Fluoroscopic-guided barium
o Not all extracolonic lesions occur in same patient enema or CT colonography
Radiographic Findings o Osteoma: Radiography
• Radiography o Desmoid tumors & mesenteric fibromatosis: CT
o Osteomas
• Cortical thickening of angle of mandible, sinuses,
outer table of skull, flat bones & long bones I DIFFERENTIAL DIAGNOSIS
• Size: Indiscernible to several cm Retained fecal debris
• Single to dozens; localized or diffuse
• Filling defects on dependent surface in barium pool
• Fluoroscopic-guided barium enema & UGI
mimicking polyps

DDx: Multiple Colonic Filing Defects

Retained Feces Lymphoid Hyperplasia Granulom. Colitis

 GARDNER SYNDROME

Key Facts
Imaging Findings Pathology
• Best diagnostic clue: Innumerable, colonic, • A variant of familial polyposis (very rare)
radiolucent filling defects with extraintestinallesions • Etiology: Autosomal dominant inheritance
Top Differential Diagnoses Diagnostic Checklist
• Retained fecal debris • Family history; colectomy to prevent colon
• Lymphoid hyperplasia carcinoma
• Pseudopolyps • Innumerable polyps carpeting entire colon with
• Metastases & lymphoma extraintestinal manifestations

• Osteomas, dental & retinal abnormalities & epidermal

Lymphoid hyperplasia cysts occur prior to puberty & familial polyposis
• Enlarged or hyperplastic lymphoid follicles • Desmoid tumors & mesenteric fibromatosis usually
• Innumerable small or tiny radiolucent nodules occur post-operation
• Usually generalized (duodenum, small bowel or colon) o Histologically benign but aggressive growth; 1
Pseudopolyps morbidity and mortality
• Inflammatory pseudopolyps Treatment
o Examples: Ulcerative or granulomatous colitis • Prophylactic colectomy to prevent colon carcinoma
o Islands of elevated, inflamed, edematous mucosa
surrounded by ulceration
• Postinflammatory pseudopolyps I DIAGNOSTIC CHECKLIST
o Mucosal healing; mimicking villous adenoma
o Small & round; long & filiform; bushlike Consider
Metastases & lymphoma
• Family history; colectomy to prevent colon carcinoma 5
• Metastases (e.g., Malignant melanoma, breast or lung) Image Interpretation Pearls 61
• Lymphoma (e.g., low grade MALT or non-Hodgkin) • Innumerable polyps carpeting entire colon with
extraintestinal manifestations

!PATHOLOGY
I SELECTED REFERENCES
General Features
1. Van Epps KJ et al: Epidermoid inclusion cysts seen on CT
• General path comments of a patient with Gardner's syndrome. AJRAm J
o A variant of familial polyposis (very rare) Roentgenol. 173(3):858-9, 1999
o Dental abnormalities: Unerupted or supernumerary 2. Kawashima A et al: CT of intraabdominal desmoid tumors:
teeth, dentigerous cysts & odontomas is the tumor different in patients with Gardner's disease?
o Epidermoid (sebaceous) cysts & fibromas of skin: AJRAm J Roentgenol. 162(2):339-42, 1994
Common on legs, face, scalp & arms; mm to em 3. Nannery WM et al: Familial polyposis coli & Gardner's
o Congenital pigmented lesions of retina syndrome. N J Med. 87(9):731-3, 1990
• Single, multiple, bilateral; 0.1 to 1.0 disc diameter
• Darkly pigmented; round, oval or kidney-shaped
• Genetics: Mutation in APC gene at Sq22 I IMAGE GALLERY
• Etiology: Autosomal dominant inheritance
• Associated abnormalities: Colonic adenomatous
polyps - colon carcinoma in 100% if not treated

I CLINICAL ISSUES
Presentation
• Most common signs/symptoms
o rectal bleeding, diarrhea
o Skin, dental or retinal abnormalities
Demographics
• Age: Mean age of diagnosis is 22 years of age (Left) Barium study shows numerous jejunal polyps (adenomas).
• Gender: M:F = 1:1 (Right) Axial CECT in a patient who had colectomy for Gardner
polyposis. Large rapidly-growing mesenteric masses are desmoid
Natural History & Prognosis tumors.
• Congenital pigmented lesions of retina may be earliest
clinically detectable lesion
 SIGMOID VOLVULUS

Graphic shows dilated, twisted, elongated sigmoid Supine radiograph shows dilation of entire colon.
colon with venous engorgement + colonic obstruction. Vertical white line (arrow) represents the apposed walls
of the dilated, inverted sigmoid colon and points toward
the mesenteric volvulus.

0
o Twist> 360 do not resolve spontaneously
/TERMINOLOGY
Radiographic Findings
Abbreviations and Synonyms
• Radiography
• Volvulus of sigmoid colon
5 Definitions
o Sigmoid volvulus
• Vertical dense white line: Apposed inner walls of
62 • Torsion or twisting of sigmoid colon around its sigmoid colon pointing toward the pelvis
mesenteric axis • Closed loop obstruction: Segment of bowel
obstructed at two points
• Gas in proximal small intestine and colon;
I IMAGING FINDINGS absence of gas in rectum
• Absent rectal gas in spite of prone or decubitus
General Features views
• Best diagnostic clue: Dilated sigmoid colon with • "Northern exposure" sign: Dilated, twisted sigmoid
inverted U configuration and absent haustra colon projects above transverse colon
• Location: At midline; directed toward RUQ or LUQ ~ • Apex above TlO vertebra and under left
elevation of hemidiaphragm hemidiaphragm; directed toward right shoulder
• Other general features o Cecal volvulus
o Types of colonic volvulus • Dilated air-filled cecum in an ectopic location
• Sigmoid volvulus: 60-75% • Cecal apex in LUQ
• Cecal volvulus: 22-33% • Kidney or coffee bean-shaped gas-filled cecum
• Transverse colon volvulus: 2-4% • One or two haustral markings usually seen
• Splenic flexure volvulus: < 1% • Markedly distended gas or fluid-filled small bowel;
• Compound volvulus: Very rare little gas in distal colon
o Colonic volvulus is rare in children o Splenic flexure volvulus
• Radiography may be interpreted as normal; used • Dilated, featureless, air-filled bowel loop in LUQ;
to exclude other causes of abdominal pain and separate from stomach
free air o Compound volvulus

DDx: Dilated Colon

Acute Ileus Ogilvie Syndrome Colon Cancer Cecal Volvulus

 SIGMOID VOLVULUS
Key Facts
Terminology
• Torsion or twisting of sigmoid colon around its
mesenteric axis
Imaging Findings
• Best diagnostic clue: Dilated sigmoid colon with
inverted U configuration and absent haustra
• Location: At midline; directed toward RUQ or LUQ -
elevation of hemidiaphragm
• Gas in proximal small intestine and colon; absence of
gas in rectum
• Absent rectal gas in spite of prone or decubitus views
• "Northern exposure" sign: Dilated, twisted sigmoid
colon projects above transverse colon
• "Beaking": Smooth, tapered narrowing or point of
torsion at rectosigmoid junction
• Dilated sigmoid loop in mid-abdomen extending
to RLQ with distended small bowel
• Medially deviated distal left colon
• Fluoroscopic-guided water-soluble contrast enema
o Sigmoid volvulus (can use low pressure barium
enema without balloon inflation)
• "Beaking": Smooth, tapered narrowing or point of
torsion at rectosigmoid junction
• Mucosal folds often show a corkscrew pattern at
point of torsion
• Shouldering: Localized wall thickening at site of
twist (chronic)
o Cecal volvulus
• "Beaking" at mid-ascending colon
o Transverse colon volvulus
• "Beaking" at level of transverse colon
• Two air-fluid levels in dilated transverse colon
(helpful in distinguishing from cecal volvulus)
o Splenic flexure volvulus
• "Beaking" at LUQ
CT Findings
• CECT
o Progressive tapering of afferent and efferent limbs
leading into the twist or "beaking"
o "Whirl" sign: Tightly twisted mesentery and bowel
o Compound volvulus
• Medial deviation of distal left colon with pointed
appearance of its medial border
Imaging Recommendations
• Radiography (supine, upright, prone and decubitus
views)
• Fluoroscopic-guided water-soluble contrast enema;
helical CT
I DIFFERENTIAL DIAGNOSIS
Acute ileus
• Post-op, medication, post-traumatic injury and
ischemia
• Dilated large bowel with no transition point
• "Whirl" sign: Tightly twisted mesentery and bowel
• Radiography (supine, upright, prone and decubitus
views)
Top Differential Diagnoses
• Acute ileus
• Functional megacolon
• Distal colon obstruction
Clinical Issues
• Acute or insidious in onset
• Abdominal pain « 33%), vomiting and distension
Diagnostic Checklist
• Acute abdomen; rule out other causes of obstruction
• Dilated sigmoid colon in inverted U configuration;
absent haustra; "beaking"; "whirl" sign
• Air-fluid levels observed, but no peristalsis
• No colonic obstruction
Functional megacolon
• Gross constipation without organic cause
• Markedly dilated, ahaustral, air or stool-filled colon
• Ogilvie Syndrome - non-obstructive dilation of cecum
5
Distal colon obstruction
63
• Change in stool caliber over several months
• Gas-filled intestinal loops proximal to obstruction; no
gas seen distally
• Abrupt transition at site of obstruction
• Malignancy
o Most common (55%) cause of colonic obstruction
o Insidious in onset
o Weakness, weight loss and anorexia
o "Apple-core" configuration with destruction of
mucosa
o Positive fecal occult blood test is highly suggestive of
colon cancer
• Stricture secondary to diverticulitis
o Second most common (12%) cause of colonic
obstruction
o History of recurrent attacks of diverticulitis
o Other diverticula are present
I PATHOLOGY
General Features
• Etiology
o Major predisposing factors for colonic volvulus
• Redundant segment of bowel that is freely
moveable within the peritoneal cavity
• Close approximation of points of bowel fixation
o Sigmoid volvulus
• Diet: 1 Fiber - 1 bulk of stool and elongates colon
• Chronic constipation and obtundation from
medications - gaseous distension
• Degree of rotation relative to chance of
nonsurgical decompression: 180°:35%; 360°:50%;
540°:10%
 SIGMOID VOLVULUS
o Cecal volvulus
• Congenital defect in attachment
• Postpartum ligamentous laxity and mobile cecum
• Colon distension (pseudo-obstruction; distal
tumor, endoscopy, enema or postoperative ileus)
o Transverse colon volvulus
• Failure of normal fixation of mesentery ~ 1
mobility of right colon and hepatic flexure
o Splenic flexure volvulus
• Postoperative adhesions
• Congenital or surgical removal of normal
attachments to abdominal wall
o Compound volvulus
• Also known as ileosigmoid knot
• Hyperactive ileum winding around narrow pedicle
of a passive sigmoid colon
o Etiology in children
• Malrotation and other mesenteric attachment
abnormalities
• Constipation (mental retardation, Hirschsprung's
disease, cystic fibrosis or aerophagia)
• Epidemiology
o Third most common (10%) cause of colonic
obstruction
o Incidence of colonic volvulus
• U.S. and other western countries: 1-4% of
intestinal obstructions
5 • Africa and Asia: 20-25% of intestinal obstructions
o Incidence of sigmoid volvulus
64 • U.S.: 1-2% of intestinal obstructions
• Increased incidence in elderly men and residents
of nursing homes and mental hospitals
(constipation and obtundation)
• Increased significantly in Scuth America and
Africa (1 fiber in diet)
o Colonic volvulus in children
• Mean is 7 years of age
• Boys to girls: 2-3:1
• Associated abnormalities
o Comorbid disease in sigmoid volvulus
• 30% with psychiatric disease; 13% are
institutionalized at time of diagnosis
Gross Pathologic & Surgical Features
• Twisted narrow segment with marked proximally
dilated bowel loop
Microscopic Features
• Localized thickening of mucosal folds; ischemic and
necrotic changes
I CLINICAL ISSUES
Presentation
• Most common signs/symptoms
o Acute or insidious in onset
o Abdominal pain « 33%), vomiting and distension
o Transverse colon volvulus
• Severe vomiting (compression of duodenojejunal
junction at root of mesentery)
o Compound volvulus
• Rapid deterioration (greater than other colonic
volvulus)
• Pain out of proportion to physical findings and
absolute constipation
o Diagnosis
• Sigmoid volvulus and cecal volvulus: Diagnosed
by radiography (75%)
• Transverse colon and splenic flexure volvulus:
Diagnosed by fluoroscopic-guided water-soluble
contrast enema
Demographics
• Age
o Sigmoid volvulus: 60-70 years of age
o Cecal volvulus: Younger age than sigmoid
Natural History & Prognosis
• Complications
o Closed loop obstruction ~ strangulation
o Ischemia, necrosis (15-20%) and perforation
o Ileosigmoid knot ~ strangulation and gangrene of
small bowel within hours
• Prognosis
o Uncomplicated: Good; complicated: Poor
o Colonic volvulus
• 8% mortality (from gangrenous bowel)
o Sigmoid volvulus
• 40-50% recurrence after non operative reduction
• 3% recurrence after nonoperative and operative
reduction
o Transverse colon volvulus: Up to 33% mortality
Treatment
• Sigmoid volvulus
o Nonoperative: Proctoscopic or colonoscopic
decompression of obstruction ± stabilization by
inserting rectal tube (successful 70-80% of attempts)
o Nonoperative and operative: Decompression,
mechanical cleansing and elective sigmoid resection
• Complicated cases: Surgical emergency
• Follow-up
o Sigmoid volvulus: Fluoroscopic-guided water-soluble
contrast enema to rule out underlying colon cancer
I DIAGNOSTIC CHECKLIST
Consider
• Acute abdomen; rule out other causes of obstruction
Image Interpretation Pearls
• Dilated sigmoid colon in inverted U configuration;
absent haustra; "beaking"; "whirl" sign
I SELECTED REFERENCES
1. Moore C] et al: CT of cecal volvulus: unraveling the image.
A]R Am] Roentgenol. 177(1):95-8, 2001
2. Lee SH et al: The ileosigmoid knot: CT findings. A]RAm]
Roentgenol. 174(3):685-7,2000
3. Dulger M et al: Management of sigmoid colon volvulus.
Hepatogastroenterology. 47(35):1280-3, 2000
4. ]avors BR et al: The northern exposure sign: A newly
described finding in sigmoid volvulus. A]R 173:571-574,
1999
S. Catalano 0: Computed tomographic appearance of
sigmoid volvulus. Abdominal Imaging 21:314-317, 1996
 SIGMOID VOLVULUS
I IMAGE GALLERY
Typical
(Left) Supine radiograph
shows dilated colon. The
apex of the sigmoid colon
(arrow) is above the
transverse colon, the
"northern exposure" sign of
sigmoid volvulus. (Right)
Single contrast BE shows a
smooth tapered beak
obstructing the lumen of the
sigmoid colon.

Typical
(Left) Axial CECT of sigmoid
volvulus shows a diffuse
dilation of colon. There is a
swirl of sigmoid mesocolic
blood vessels that converge
at the site of volvulus
5
(arrow). (Right) Axial CECT
65
shows swirl of mesocolic
vessels at the base of the
volvulus (arrow).

(Left) Supine radiograph

shows dilated, inverted "U"
shaped sigmoid colon.
(Right) Single contrast BE
shows twist + beak at point
of volvulus with dilated
colon beyond the twist.
 CECAL VOLVULUS

Graphic shows twist (volvulus) of ascending colon, Upright abdominal radiograph shows dilated cecum
obstructing lumen and blood supply. Cecum, on a with air-fluidlevel pointing toward left upper quadrant.
mesentery dilated + displaced toward left upper Remainder of c%n collapsed.
quadrant.

o Markedly distended gas or fluid-filled small bowel;

ITERMINOLOGY little gas in distal colon
Abbreviations and Synonyms • Fluoroscopic-guided water-soluble contrast enema
• Volvulus of cecum, ascending colon o "Bird's beak" sign: Point of torsion at mid-ascending
5 Definitions
colon
CT Findings
66 • Rotational twist of the right colon on its axis;
associated with folding of the right colon • CECT
o Progressive tapering of afferent and efferent limbs
leading into the twist or "beaking"
o "Whirl" sign: Tightly twisted mesentery and bowel
I IMAGING FINDINGS at right mid-abdomen or RUQ
General Features
Imaging Recommendations
• Best diagnostic clue: Dilated, twisted cecum with tip
• Best imaging tool: Fluoroscopic-guided water-soluble
pointing to left upper quadrant
contrast enema
• Location
o Twist is distal to ileocecal valve (term is a misnomer)
o Cecum is located in mid-abdomen or LUQ
o Terminal ileum swings around the dilated bowels
I DIFFERENTIAL DIAGNOSIS
Radiographic Findings Sigmoid volvulus
• Dilated, ahaustral sigmoid loop with inverted U
• Radiography
o Dilated air-filled cecum in an ectopic location configuration
o Single, long air-fluid level • Dilated proximal colon; Gas-less distally
o Cecal apex at LUQ Acute ileus
o Medially placed ileocecal valve produces soft tissue • Dilated colon to rectum with haustra pattern
indentation ~ kidney or coffee bean-shaped
gas-filled cecum Distal colon obstruction
o One or two haustral markings usually seen • Gas and stool-filled colon

DDx: Marked Colonic Distention

Sigmoid Volvulus Acute Ileus Colon Cancer Olgilvie Syndrome

 CECAL VOLVULUS

Key Facts
Imaging Findings Top Differential Diagnoses
• Best diagnostic clue: Dilated, twisted cecum with tip • Sigmoid volvulus
pointing to left upper quadrant
• Single, long air-fluid level Clinical Issues
• Medially placed ileocecal valve produces soft tissue • Acute or insidious onset
indentation - kidney or coffee bean-shaped gas-filled • Abdominal pain, distension and vomiting
cecum Diagnostic Checklist
• Markedly distended gas or fluid-filled small bowel;
• Rule out ileus and Ogilvie syndrome
little gas in distal colon

• Diagnosis: 75% by radiography

Functional megacolon
• Gross constipation without organic cause Demographics
• Markedly dilated, ahaustral, air or stool-filled colon • Age: Younger patients than sigmoid volvulus
Ogilvie syndrome Natural History & Prognosis
• Colonic pseudo-obstruction without mechanical cause • Complications
o Ischemia, necrosis (15-20%) and perforation
• Prognosis
I PATHOLOGY o Uncomplicated: Good; Complicated: Poor

General Features Treatment

• General path comments • Colon oscopy to reduce volvulus (higher risk of
o Cecal bascule perforation than sigmoid volvulus)
• Anterior folding (not twisting) of cecum
positioned at mid-abdomen
• Complicated cases: Surgical emergency
• Surgical options: Cecopexy, cecostomy and resection
5
• Possibly due to adhesive band from previous 67
abdominal surgery
o Embryology-Anatomy I DIAGNOSTIC CHECKLIST
• Right colon is incompletely fused to posterior
parietal peritoneum (10-37% adults) Consider
• Etiology • Rule out ileus and Ogilvie syndrome
o Congenital defect in attachment of right colon
Image Interpretation Pearls
o Postpartum ligamentous laxity and a mobile cecum
• Massively dilated cecum at mid-abdomen, distended
o Colon distension (pseudo-obstruction, distal tumor,
loops of small bowel, "bird's beak" sign
endoscopy, enema, or postoperative ileus)
o Chronic constipation and laxative use
• Epidemiology
o One-third of all cases of colonic volvulus
I SELECTED REFERENCES
o 2-3% of colonic obstructions 1. Moore CJ et al: CT of cecal volvulus. AJR. 177:95-98, 2001
o 22-33% of colonic volvulus; second to sigmoid 2. Hemingway AP: Cecal volvulus: A new twist to the barium
• Associated abnormalities enema. British Journal Radiol. 53:806-807, 1980
o One third of patients have concomitant partially
obstructing lesion located more distally in the colon
o Malrotation and long mesentery [IMAGE GALLERY
Gross Pathologic & Surgical Features
• Twisted, markedly dilated segment with moderate
dilation of small intestine
Microscopic Features
• Localized thickening of mucosal folds; ischemic and
necrotic changes

ICLINICAL ISSUES
Presentation
• Most common signs/symptoms (Left) Supine radiograph shows dilated cecum in mid-abdomen,
o Acute or insidious onset pointed toward left upper quadrant. (Right) Cecal bascule. Enema
o Abdominal pain, distension and vomiting fills markedly dilated cecum (ascending colon) which is folded
acutely + displaced. Note ilea-cecal valve (arrow).