Dr.

Muhammad Bin Zulfiqar

PGR-III FCPS SIMS/SHL

IMAGING IN SMALL BOWEL

TUMORS

Special thanks to RA
Imaging Modalities

 USG
 Barium Meal & FollowThrough
 Conventional Enteroclysis
 Conventional CT abdomen with I/VContrast
 CT Enteroclysis
 MR Enteroclysis
 PET Scan
CT & MR ENTEROCLYSIS IS BEST

 TECHNIQUE OF MR ENTEROCLYSIS:
 For MR enterography and enteroclysis fluid
(water or methylcellulose) is the enteric
contrast media
 low signal on T1-weighted images
 high signal on T2-weighted images
coronalT2W-image coronal T1W-image with fatsat.
CT ENTEROCLYSIS

 Water and Methyl Cellulose is used as

Contrast Media

 Bowel Luminal Distension > 2cm

 Bowel Wall Thickness > 3mm always abnormalfor
this level of dilatation.
AIMS:

 Most common tumors

 Metastatic depostion
 Mimics
Most Common

 Bowel tumors are relatively rare and accounts

for 3-6 % tumors
 Adenocarcinoma
 Lymphoma
 Carcinoid
 Gastrointestinal Stromal Tumor
Adenocarcinoma

 25-40 of small bowel neoplasm

 50 % more common
 50 % occur in duodenum, 2nd most common
site is jejunum
Adenocarcinoma

 Risk factors:
 HNPCC - hereditary nonpolyposis colorectal
cancer.
 Familial adenomatous polyposis.
 Peutz-Jeghers.
 Celiac disease.
 Crohn's disease - occurrence in the ileum is often
related to Crohn's disease.
Typical Features:

 focal unilocular
 circumferential mass with shouldering of the
margins and obstruction.
 Ulceration is a quite common feature.
 Extraluminal infiltration can present as fat
stranding.
 Less frequently adenocarcinoma present as an
intraluminal polypoid mass, which can lead to
intussusception.
 Stenotic lesion in the duodenum as a result of an
adenocarcinoma (yellow arrow).
 Not possible to separate from the pancreas (red arrow).
 Pre-stenotic dilatation of the duodenum.
 Coronal MR T2 WI demonstrates irregular
wall thickening in the distal duodenum
(arrows)--Duodenal carcinoma presenting
 Adenocarcinomas often show moderate enhancement,
while carcinoid tumors show bright enhancement.
 Metastases to the liver and peritoneum occur frequently.
 CT images show a circumferential mass with shouldering of
the margins.
 an irregular mass in the
proximal jejunum.
Although it is a large
circumferential growing
mass, the lumen is not
obstructed.
 There is a large
conglomerate of hypodense
lymph nodes in the adjacent
mesentery, consistent with
necrotic lumph node
metastases (lower image).
 This proved to be an
adenocarcinoma, but these
findings could very well
represent a lymphoma.
 Axial and coronal CT images show extensive wall thickening
of the proximal jejunum with aneurysmatic dilatation.
 On top of our differential diagnostic list would be a
lymphoma, but this proved to be an adenocarcinoma.
DD Aenocarcinoma and Lymphoma

 Features that favor adenocarcinoma are fat

stranding due to mesenteric fat infiltration
and lymph node metastases.
 In lymphoma fat stranding is uncommon, but
lymph node metastases do occur and are
usually more bulky.
 CT images show a short obstructing circular mass in
the jejunum (yellow arrow) with enlarged lymph
node (red arrow).
This proved to be an adenocarcinoma.
 Post-contrast T1W-image with fatsat (left)
and T2W-image (right) show an obstructing
mass in the jejunum with shouldering (arrow).
There is prestenotic dilatation.
 Top images show a circular mass in the proximal jejunum
with FDG uptake (yellow arrows).
 Lower MR-images show the same jejunal mass with
shouldered borders consistent with adenocarcinoma.
 Obstructing lesion in the ileum with
shouldering leading to small bowel
obstruction (yellow arrow).
 Here an adenocarcinoma in the proximal jejunum.
The mass is better depicted with MRI than with CT.
 Occurrence in the ileum is often related to Crohn's disease
 There is a thickened wall of the ileum with adjacent
mesenteric infiltration with foci of extraluminal air
indicating perforation.
 Crohn's Disease with noAdenocarcinoma
 Diffuse wall thickening in the distal ileum.
 Comb sign: hypervascularity in the adjacent
mesentery.
 There are multiple
lymph nodes (red
arrow) and there is
fat stranding (yellow
arrows).
 It should not be
mistaken for
mesenteric
panniculitis as these
large necrotic lymph
nodes are
pathologic.
Lymphoma

 Lymphomas make up about 20 % of all small

bowel tumors.
 The distal ileum is the most common site
 Risk factors:
 Celiac disease
 Crohn's disease
 SLE
 immunocompromised state
 a history of chemotherapy or extra-intestinal
lymphoma.
Imaging Features:

 The typical presentation of a small bowel

lymphoma
 Thick walled infiltrating mass With Aneurysmal
dilatation without obstruction
 Bulky mesenteric or retroperitoneal
lymphadenopathy and splenomegaly
 A less common presentation is as an intraluminal
polypoid mass or a large eccentric mass with
extension into the surrounding soft tissues with
possible ulceration and formation of fistulas.
 There is irregular wall thickening of the
terminal ileum with aneurysmatic dilatation.
 Here a typical lymphoma presenting as a large
thick walled mass in the proximal jejunum with
FDG uptake.
Dilated lumen at the site of the mass and
prestenotic dilatation of the duodenum (red
arrow)
 Reversed fold pattern indicating celiac disease
 Ileal-ileal intussusception (yellow arrow), in a patient with
multifocal small bowel lymphoma (not all lesions shown here).
 Mesenteric lymphadenopathy (red arrows).
Enteropathy Associate T cell
Lymphoma

 There is an irregular mass in the jejunum with luminal

dilatation.
 There is infiltration of the mesentery.
 Pathology showed a T-cell lymphoma in celiac disease.
 There is an irregular mass in the jejunum
 There is infiltration of the mesentery
 FDG PET shows marked tracer uptake
Carcinoid Tumors

 Carcinoid tumors are rare neuroendocrine

tumors.
 Well-differentiated - also known as carcinoid
 Poorly differentiated - small or large cell
neuroendocrine carcinoma.
 Carcinoid tumors constitute 2% of all
gastrointestinal tumors.
Carcinoid Tumors

 The most common location of a carcinoid is

the appendix
 The second most common location is the
distal ileum.
 Small bowel carcinoids are multiple in about
one third of cases.
 There is an association with multiple
endocrine neoplasia type I (MEN I).
 CT Images Small intraluminal mass in the
ileum (yellow arrow). Associated spiculated
mesenteric mass with adjacent desmoplastic
reaction in small bowel carcinoid.
 Here a typical carcinoid presenting as a large
mesenteric mass with desmoplastic reaction
and retraction of adjacent small bowel loops
with wall thickening (arrows).
Carcinoid Metastasis:
 Related to size of primary tumor
 > 2 cm High likelihood of metastasis upto 80 % to
liver and adjacent lymph nodes.
Same patient.
 Four years after the initial CT multiple liver
metastases are seen.
 Shows hypervascular enhancement pattern
in the late arterial phase.
Carcinoid Syndrome:

 The carcinoid syndrome occurs in approximately

5% of carcinoid tumors.
 commonly occurs in patients who have liver
metastases.
Symptoms
 flushing
 diarrhea and
 less frequently
 bronchospasm and
 heart failure.
 CT Axial & Coronal images show a carcinoid
tumor presenting as a hypervascular mass (red
arrow) with desmoplastic reaction (yellow
arrow).
Carcinoid presenting as hyperenhancing lesion
in the late arterial phase
Gastrointestinal Stromal Tumors:

 Gastrointestinal stromal tumors are mesenchymal tumors

and represent 9% of all small bowel tumors.
 most frequently occur in the stomach, followed by jejunum
and ileum.

 About 20-30 % of GIST's are malignant at presentation.

 In the small bowel they are more often malignant than in
the stomach.
 Tumors smaller than 2 cm are usually benign, whereas
masses larger than 5 cm are often malignant.
 Malignant GIST's predominantly grow extraluminally and
can show necrosis, hemorrhage, calcification (post therapy)
and fistula formation.
Gastrointestinal Stromal Tumors:

 Features:
 GIST is a well defined and exophytic mass with
heterogeneous enhancement and a clear
delineation from the mesentery.
 Unlike carcinoid tumors, the primary lesion in a
GIST is large.
 Liver metastases are usually hypervascular
 Despite radical surgical resection, 40-90 % of
patients have recurrence of disease in liver or
mesentery.
 Typical GIST in the ileum presenting as an
exophytic tumor.
 CT Axial, Coronal And MRT1 Fat Sat image
shows an exophystic mass lesion near
duodenojejunal flexure
Disease recurrence in resected GIST showing
hypodense liver metastases and a large
heterogeneous peritoneal metastasis.
 Adenocarcinoma Lymphoma Carcinoid GIST

HNPCC Celiac Disease

FamilialAdenomatosis Crohn’s Disease
Risk Factors polyposis SLE
Peutz Jeghers Immunodeficiency
Celiac Disease states
Crohn’sDisease Extra intestinal
Lymphoma
Post radiation

Duodenum>Jejunum>Ilium Terminal ilium Appendix, Stomach>> Smallbowel

Distal Ilium
Location
Focal circumferentialmass Thick walled Transmural Well defined exophyticmass
with shouldered borders infiltrating mass hypervascularmass
Key Features with aneurysmal Thick bowel wall
dilatation Desmoplastic
reaction
Mesenteric mass

Moderate and Homogeneous Hypervascular Heterogeneous

Heterogeneous
Enhancement
Splenomegaly, Carcinoid syndrome< Hypervascular livermets
Mesenteric and 10% No L/N Mets
Associated Features retroperitoneal Liver Mets Mesenteric Mets recurrent
lymphadenopathy disease

Large Lymphoma Large Sclerosing Lymphoma

Adenocarcinoma mesenteritis
Diff. Diagnosis
Differential Diagnosis

 The most common small bowel tumors are

metastases
 The differential diagnosis of small bowel
tumors includes many infectious and
inflammatory diseases, that all present with
focal bowel wall thickening.
Metastasis

 Spread of metastases to the small bowel

 Intraperitoneal
 Hematogenous,
 Lymphatic
 Direct extension.
 Most common (50%) is “Intraperitoneal seeding”.
 Most CommonSites:
 Ovary
 Appendix
 Colon
 Hematogenous metastases usually occur in breast
carcinoma, melanoma and renal cell carcinoma.
 Multiple Luminal Metastasis in a patient with
melanoma
 small bowel metastasis.
This patient had a history of colon- and
esophaguscarcinoma.
 This patient has multiple intraluminal small bowel
masses (yellow arrows), which appeared to be
metastases from an unknown primary.
Also note the intussusception (red arrow) en soft
tissue metastasis in the left gluteus muscle (blue
arrow).
 Crohn’s Disease

 Crohn's disease with

multiple lesions (arrows).
 Active Crohn's disease.
Long segment of ileal
wall thickening with
comb sign and
transmural
enhancement.
Desmoid
Tumors

 Desmoid is a most common primary tumor of the mesentery and

can mimic a malignant bowel- or mesenteric neoplasm.
 Benign locally aggressive mass
 There is often a history of previous abdominal surgery.
 Desmoid tumors do not metastasize, but do tend to recur.
Mesenteric desmoids usually show minimal enhancement.
FEATURES:
 Small bowel or mesenteric vessels can be displaced or encased.
Because these tumors can be very hard, percutaneous biopsy can
be challenging.
Adenomas

 Adenomas are pre-cancerous lesions

 present as polypoid pedunculated masses on a stalk, a sessile mass
(no stalk) or a mural based nodule within the mucosa.
 Lesions show homogeneous enhancement and are usually
nonobstructive.
 Extraserosal extension is suggestive of malignant degeneration.
 MRT2WI shows multiple small bowel polyps, mainly located in
jejunum(patient with Peutz-Jeghers syndrome)
Polyposis Syndrome

 Peutz Jagher Syndrome

 Familial Adenomatous Polyposis(Gardener
Syndrome)
 Multiple Polyps are seen
 Patient with Peutz-Jeghers syndrome with
ileal polyp as leadpoint for intussusception.
Others

 Hemangioma
 Leiomyoma
 Lipoma
 Mesenteric Ischemia
 Typhilitis
Referrences
 by Rinze Reinhard and Gerdien Kramer Radiology department of the VU medical
centre, Amsterdam, the Netherlands Publicationdate May 21, 2014

MRI of the small-bowel: how to differentiate primary neoplasms and mimickers.G.
Masselli, M.C. Colaiacomo, G. Marcelli et al.
Br J Radiol 2012; 85: 824-837
Thank You