BARIUM IMAGING IN SMALL BOWEL ILEUM.pptx

Contrast Radiography

1. BARIUM IMAGING IN SMALL BOWEL MODERATOR : DR M M PATIL PRESENTER : DR NARENDRA G S

2. Introduction : The small intestine measures approximately 5 m in length and extends from the duodenojejunal flexure to the ileocaecal valve. It is attached by its mesentery to the posterior abdominal wall and this allows its mobility. The proximal two-fifths constitute the jejunum and the distal three-fifths the ileum. The jejunum lies mainly in the left upper and lower quadrants and the ileum in the lower abdomen and the right iliac fossa.

3. The valvulae conniventes have a circular configuration and are about 2 mm thick in the distended jejunum, becoming more spiral shaped and about 1 mm thick in the ileum. They may be absent in the distended terminal ileum, resulting in a rather featureless outline. Jejunal diameter should not exceed 3.5 cm on barium Follow-through & 4.5 cm on enteroclysis.

4. BARIUM STUDIES Single/double contrast - BMFT Enteroclysis. Peroral pneumocolon. Ileostomy enema.

5. Indications Pain Diarrhoea Anaemia/gastrointestinal bleeding Partial obstruction Malabsorption Abdominal mass Failed small bowel enema.

6. Contraindications Complete obstruction Suspected perforation (unless a water-soluble contrast medium is used).

7. Contrast medium 100% w/v 300 ml (150 ml if performed immediately after a barium meal) barium. The transit time through the small bowel is reduced by the addition of 10 ml of Gastrografin to the barium. In children, 3-4 ml kg -1 is a suitable volume. In situations where barium is contraindicated, non-ionic water-soluble solutions have been used .

8. Patient preparation Metoclopramide 20 mg orally may be given 20 min before the examination. Preliminary film : Plain abdominal film.

9. Technique The aim is to deliver a single column of barium into the small bowel. This is achieved by lying the patient on the right side after the barium has been ingested. Metoclopramide enhances the rate of gastric emptying. If the transit time through the small bowel is found to be slow, a dry meal may help to speed it up. If a follow-through examination is combined with a barium meal, glucagon is used for the duodenal cap views rather than Buscopan because it has a short length of action and does not interfere with the small-bowel transit time.

10. Films Prone PA films of the abdomen are taken every 20 min during the first hour, and subsequently every 30 min until the colon is reached. The prone position is used because the pressure on the abdomen helps to separate the loops of small bowel. Spot films of the terminal ileum are taken supine. A compression pad is used to displace any overlying loops of small bowel that are obscuring the terminal ileum.

11. Additional films 1. To separate loops of small bowel: a. obliques b. with X-ray tube angled into the pelvis c. with the patient tilted head down. 2. To demonstrate diverticula: a. erect - this position will reveal any fluid levels caused by contrast medium retained within the diverticula.

12. Complications : Leakage of barium from an unsuspected perforation. Aspiration of stomach contents due to the Buscopan . Conversion of a partial large bowel obstruction into a complete obstruction by the impaction of barium. Barium appendicitis, if barium impacts in the appendix.

13. Small bowel enema/ enteroclysis : Advantages :This procedure gives better visualization of the small bowel because rapid infusion of a large, continuous column of contrast medium directly into the jejunum which avoids segmentation of the barium column and does not allow time for flocculation to occur. Disadvantages : 1. Intubation may be unpleasant for the patient, and may occasionally prove difficult. 2. It is more time-consuming for the radiologist. 3. There is a higher radiation dose to the patient (screening the tube into position)

14. Contrast medium 70% w/v barium. This is diluted with water to give a 20% solution (total volume 1500 ml). The reduced viscosity produces better mucosal coating, and the reduced density permits the visualization of bowel loops which may have been obscured by a denser contrast medium in an overlying loop. An alternative way to gain a double contrast effect is to use 600 ml of 0.5% methylcellulose after 500 ml of 70% w/v barium. Even with these modifications, it may still be difficult to obtain good distension and double contrast effect of the distal small bowel and terminal ileum.

15. Equipment 1. Bilbao-Dotter tube with a guide-wire (the tube is longer than the wire so that there is reduced risk of perforation when introducing the wire). 2. Silk tube: 140-cm long tube with a tungsten-filled guide-tip. It is made of polyurethane and the stylet and the internal lumen of the tube are coated with a water-activated lubricant to facilitate the smooth removal of the stylet after insertion.

16. Patient preparation: 1. A low-residue diet for 2 days prior to the examination. 2. If the patient is taking any antispasmodic drugs, they must be stopped 1 day prior to the examination. 3. Amethocaine lozenge 30 mg, 30 min before the examination. Immediately before the examination , 4.the pharynx is anaesthetized with lignocaine spray.

17. Technique The patient sits on the edge of the X-ray table. The pharynx is thoroughly anaesthetized with lignocaine spray. patency of the nasal passages is checked by asking the patient to sniff with one nostril occluded. The Silk tube should be passed with the guide-wire pre- lubricatcd and fully within the tube, whereas for the Bilbao-Dotter tube it may be more comfortable to introduce the guide-wire after the tube tip is in the stomach. The tube is then passed through the nose or the mouth, and brief lateral screening of the neck may be helpful in negotiating the epiglottic region. The patient is asked to swallow as the tube is passed through the pharynx. The tube is then advanced into the antrum.

18. The patient then lies down and the tube is passed into the duodenum. Various manoeuvres may be used alone or in combination, to help this part of the procedure, which may be difficult. a. Lie the patient on- the left side so that the gastric air bubble rises to the antrum, thus straightening out the stomach. b. Advance the tube whilst applying clockwise rotational motion . c. In the case of the Bilbao-Dotter tube, introduce the guide-wire. d. In the case of the Silk tube, lie the patient on the right side, as the tube has a tungsten-weighted guide-tip which will then tend to fall towards the antrum. e. Get the patient to sit up, to try to overcome the tendency of the tube to coil in the fundus of the stomach. f. Metoclopramide (20 mg i.v.) may help.

19. When the tip of the tube has been passed through the pylorus, the guide-wire tip is maintained at the pylorus as the tube is passed over it along the duodenum to the level of the ligament of Treitz. Clockwise torque applied to the tube may again help in getting past the junction of the first and second parts of the duodenum. The tube is passed as far as the duodenojejunal flexure to diminish the risk of aspiration due to reflux of barium into the stomach. Barium is then run in quickly, and spot films are taken of the barium column and its leading edge at the regions of interest, until the colon is reached. If methylcellulose is used, it is infused continuously, after an initial bolus of 500 ml of barium, until the barium has reached the colon.

20. The tube is then withdrawn, aspirating any residual fluid in the stomach. Again, this is to decrease the risk of aspiration. Finally, prone and supine abdominal films are taken Aftercare 1. Nil orally for 5 h after the procedure. 2. The patient should be warned that diarrhoea may occur as a result of the large volume of fluid given. Complications 1. Aspiration 2. Perforation of the bowel owing to manipulation of the guide-wire.

21. Barium- Enteroclysis

22. ENTEROCLYSIS v/s BMFT Contrast administered at desired rate, Pylorus bypassed Distension of bowel can be assessed Bowel proximal to stenosis dilates-stands out Time taken 20 to 30 min Direct rapid infusion produce hypotonia Reliability high superior Critically ill,elderly No discomfort Transit time assesed Overlapping & poor distension of bowel loops Prolonged study

23. PERORAL PNEUMOCOLON Mainly to evaluate distal ileum and IC junciton Air insufflated after barium reaches transverse colon

24. Ileostomy enema : Symptoms following ileostomy may be due to recurrent disease, for example Crohn's, adhesions related to the procedure, or a stomal hernia. A Foley catheter is inserted into the stoma, its balloon inflated just deep to the anterior abdominal wall, and barium suspension injected via a syringe, followed by some air for a double-contrast effect. The procedure is the same but water-soluble contrast is used.

25. Normal Findings Small bowel gradually tapers in diameter from the duodenojejunal junction to the terminal ileum, so the jejunum (up to 3 cm in luminal diameter) 4-7folds per inch & the ileum (up to 2cm) (2-4 folds per inch) , changes in enteroclysis. The folds are composed of mucosa and submucosa , whereas individual villi lining the folds are composed only of mucosa and lamina propria .

26. Frontal spot image from enteroclysis shows normal folds in distal jejunum as thin (1–2- mm-thick) delicate structures perpendicular to longitudinal axis of bowel. There are normally four to seven folds per inch of jejunum.

27. CONGENITAL LESIONS : Malrotation: Intestinal malrotation can be broadly defined as any deviation from the normal 270° counterclockwise rotation of the midgut during embryologic development.  Duplication: Cystic or tubular. Intramural duplications may cause obstruction, The typical triradiate fold configuration of the diverticulum is infrequently visualised on contrast studies. Inverted Meckel‘s diverticulum is a rare but well- recognised cause of intestinal obstruction. Congenital stenoses and atresias also occur, usually because of incomplete canalisation , with the duodenum the most common site.

28. Meckel diverticulum as tubular outpouching from distal ileum. No folds are seen in the diverticulum.

29. BMFT revealing large meckel’s diverticulum

30. Small bowel obstruction: Mechanical intestinal obstruction accounts for approximately 20% of surgical admissions. Causes may be generally divided into extrinsic and intrinsic groups. Extrinsic causes include Adhesions (following surgery or peritoneal inflammation), Hernias (inguinal, femoral or internal, particularly paraduodenal) Masses, most notably disseminated peritoneal malignancy. Congenital malrotation or peritoneal (Ladd's) bands are rarer extrinsic causes.

31. . adhesive band

32. small bowel adhesion

33. Intrinsic mural disease may be due to inflammatory strictures, notably due to Crohn's disease or radiation enteritis, ischaemia , or rarely primary small-bowel tumours (which may also he accompanied by intussusception). Intraluminal obstruction may be due to gallstones or foreign bodies. Non-steroidal tablets may cause intestinal membranes, resulting in obstruction.

34. ).

35. adhesions.

36. Water-soluble studies are often requested by surgeons to diagnose acute obstruction. These are likely to he less useful than CT for diagnosis of the level and cause, predominantly because of slow transit & coupled with distal contrast dilution. Patients settled on conservative treatment if contrast had entered the colon but laparotomy was likely if it had not These features are best sought using enteroclysis, although compression during follow-through techniques can be useful by demonstrating loop fixity and abrupt angulation

37. Prestenotic dilatation suggests a degree of functional obstruction but the distensibility of a strictured segment is best assessed using enteroclysis due to infusion pressure. Massive small-bowel dilatation secondary to chronic strictures can occur and may be complicated by bacterial overgrowth.

38. ILEUS & PSEUDO OBSTRUCTION Causes of paralytic ileus, are often needs to be differentiated from mechanical obstruction, Both small and large bowel may be dilated. The commonest etiologies are laparotomy ,peritonitis , electrolyte imbalance , may also be implicated. Constitutional disease, for example scleroderma (systemic sclerosis) Some may be associated with a gut myopathy or neuropathy which gives rise to the clinical picture of intestinal pseudo-obstruction. The cardinal radiological feature of scleroderma is duodenal and jejunal dilatation associated with fold crowding and slow transit due to collagen replacement of intestinal smooth muscle.

39. Primary visceral myopathy.

40. Scleroderma

41. CROHN’S DISEASE Idiopathic inflammatory disease which may affect any part of the luminal gastrointestinal tract from mouth to anus. Characterised by discontinuous transmural ulceration, fistulation and spontaneous abscess formation. Most patients (60-80 %)will have small bowel disease, with the terminal ileum most commonly affected (55 % of all patients). Approximately 25% overall will have colonic disease only.

42. Villous oedema and blunting are the earliest detectable radiological change, manifest as a granular pattern on high-quality contrast studies ,the `grains' are due to individual filling defects produced by the enlarged and inflamed vili and are best appreciated on compression studies. Ulceration becomes linear and deeper, with typical transmural penetration accompanied by mural thickening. Mucosal oedema and inflammation intervenes between these ulcers to cause the characteristic 'cobblestone' appearance.

43. Crohn's disease. intense mucosal granularity,

44. Crohn’s disease. Fold thickening.

45. Crohn's disease. Fat suppressed T2-weighed MR scan shows thickened ileal loops (curved arrows) and also reveals a parastomal abscess (straight arrow).

46. Ulceration is frequently discontinuous and patchy and also asymmetrical along the bowel circumference; indrawing at the site of ulceration may he accompanied by ballooning of the contralateral wall, creating a characteristic pseudodiverticlar appearance. Advanced disease may also he complicated by strictures, fistulation , abscess formation and, rarely, by tumour . Strictures are generally easy to demonstrate using contrast studies

47. multiple aphthoid ulcers as punctate collections of barium surrounded by radiolucent mounds of edema

48. Cobblestoning of the terminal ileum, thickening of the wall of the terminal ileum, and an enlarged ileocaecal valve in Crohn's disease

49. Crohn disease shows cobblestoning in distal ileum due to intersecting linear and transverse ulcers. separation of diseased loops from adjacent small bowel by fibrofatty proliferation in mesentery

50. pseudodiverticulae aphthous ulcers background granularity caused by villous oedema .

51. ileocecal fistulas with narrowing of terminal ileum near ileocecal valve.

52. barium enema examination (with reflux into terminal ileum) in patient with Crohn disease shows classic string sign with marked narrowing of terminal ileum due to severe edema and spasm.

53. Long stricture in Crohn's disease. A long segment of narrowing is seen in the ileum just proximal to the site of an ileocolic anastomosis in a patient who had undergone a previous resection for Crohn's disease.

54. PRIMARY SMALL BOWEL TUMORS Primary small-bowel tumours are rare and frequently difficult to diagnose because findings are non-specific and the diagnosis is often not considered, which often leading to late presentation and possibly poor prognosis.

55. BENIGN TUMORS Adenomas & stromal tumors. Benign stromal tumours (leiomyomas), the commonest benign small-bowel tumour , arise from the smooth muscle of the muscularis propria. They are usually jejunal and may have endoluminal and exolmninal components. They are usually easy to demonstrate on contrast studies once large enough to cause obstruction or intussusception

56. Adenomas are similar to their colonic counterparts both morphologically and histologically and are classified in a similar fashion: tubular, villous, tubulovillous. Lipomas may be recognized by their characteristic low attenuation on CT. Most are ileal) and asymptomatic. When seen on contrast studies they are smooth and easily compressible. Haemangiomas may be capillary or cavernous. Most are too small to produce a filling defect but frequently present with anaemia due to haemorrhage .

57. Benign stromal tumour , Barium follow-through reveals an intraluminal mass .,,The tumour is also visible on CT

58. MALIGNANT TUMORS. In contrast to the large bowel, adenocarcinoma is remarkably uncommon outside of a polyposis syndrome. There are well-documented associations with Crohn's and coeliac disease and the morphology is essentially similar to that seen in the colon . an annular, shouldered, apple-core-type lesion

59. Small bowel adenocarcinoma

60. B-cell non-Hodgkin lymphoma as a giant cavitated lesion in distal ileum, with displacement of adjacent small-bowel loops by the surrounding mass.

61. Lymphoma is non-Hodgkin's in origin and is the commonest primary small bowel malignant tumour in some series. Again, there is an association with coeliac and Crohn's disease. There may be diffuse, regular fold thickening without any obvious, localised tumour mass .In contrast, other cases exhibit marked focal mural thickening with fistulation , Non-obstructing stricturing is common. Aneurysmal dilatation, which is highly characteristic and due to cavitating necrosis, often following effective treatment.

62. cavitated lesion in mid– small bowel with displacement of adjacent smallbowel loops by mass. This patient had malignant gastrointestinal stromal tumor.

63. irregular-segmental thickening of folds in loop of mid–small bowel, with markedly thickened, lobulated folds This patient had primary non-Hodgkin small bowel lymphoma.

64. innumerable nodules in distal ileum due to smallbowel lymphoma. nodules are less uniform in size and larger than typical lymphoid follicles. In subtotal colectomy with ileosigmoid anastomosis .

65. Lymphoma. Diffuse fold thickening and nodularity.

66. Carcinoid the majority are in the distal ileum. Tumours larger than 2 cm are frequently malignant, defined by metastasis. An intense desmoplastic response to the primary tumour is highly characteristic and is well demonstrated by CT. Carcinoid syndrome may occur when significant liver metastasis prevents metabolism of secreted vasoactive serotonin and bradykinin, allowing them to reach the systemic circulation, and is characterised by episodic flushing and diarrhoea.

67. barium enema examination (with reflux into terminal ileum) shows carcinoid tumor as smooth, sessile, 1.5-cm-diameter polyp (black arrows) in terminal ileum. Also note multiple ileal diverticula (white arrows).

68. patient with carcinoid tumor shows mass effect, angulation , and tethering of ileal loops due to marked desmoplastic reaction incited by tumor in mesentery.

69. Polypoid Lesions MUCOSAL SUB MUCOSAL Adenomas Hamartomas Familial adenomatous polyposis Peutz jegher’s syndrome Carcinoids . Hematogenous metastases Malignant melanoma Lymphoma Multiple carcinoid tumors Neurofibromas Kapossi’s sarcoma Lipoma. Inverted meckel’s diverticulum

70. POLYPOSIS SYNDROME Adenomas in familial adenomatous polyposis (FAP) tend to cluster around the duodenal ampulla. The larger the polyp, the greater the possibility of malignancy and there is also an association with ampullary carcinoma. FAP is also strongly associated with desmoid diseas e. Peutz-Jeghers syndrome is an autosomal dominant disease characterized by mucocutaneous pigmentation, often perioral, and gastrointestinal hamartomas.

71. Cowden’s disease also describes small intestinal hamartomas (and also adenomas, hyperplastic polyps & adenomas.) Diffuse intestinal inflammatory polyposis cronkhite-canada syndrome is associated with neuroectodermal change, manifests as nail dystrophy , alopecia & mal absorption.

72. Barium follow through reveal ileal hamartoma in peutz jeghers syndrome

73. barium enema examination (with reflux into terminal ileum) shows lipoma as smooth, ovoid, submucosal mass in distal ileum.

74. multiple smooth-surfaced hemispheric submucosal masses in small bowel; other lesions have bull’s-eye appearance due to central ulceration. The patient had malignant melanoma with hematogenous metastases to small bowel.

75. metastatic melanoma shows intussuscepting mass (black arrows) with telescoping of small bowel ( intussusceptum ,) into adjacent loop ( intussuscipiens ). A “coil spring” appearance results from barium coating folds of intussuscipiens

76. smooth elongated mass in distal ileum with telescoping of small bowel ( intussusceptum , white arrow) into adjacent lumen ( intussuscipiens ), producing coil spring appearance This patient had inverted Meckel diverticulum acting as lead point for intussusception.

77. OUTPOUCHINGS : JEJUNAL DIVERTICULOSIS SACCULATIONS

78. diverticula in duodenum and jejunum as smooth rounded outpouchings of varying sizes

79. Frontal overhead radiograph from enteroclysis shows massive jejunal diverticulosis Paradoxically, this degree of diverticulosis can be more difficult to detect on barium studies, because diverticula are easily mistaken for overlapping loops of small bowel.

80. patient with scleroderma shows markedly dilated duodenum and proximal jejunum, with increased number of small-bowel folds crowded together ,producing the “hidebound” sign. Also note multiple outpouchings (arrows) due to asymmetric fibrosis with sacculation of opposite wall of bowel.

81. INFECTIOUS ENTERITIS Salmonella, Campylobacter and Staphylococcus are all possible causative agents. Radiology has no role to play but appearances may be dramatic if patients are examined during an attack, with dilatation, ulceration and nodularity. In case of chronic infection fold thickening & mild dilatation may occur. Intestinal tuberculosis usually affects the ileocaecal area. Terminal ileal ulceration in association with a funnelled , contracted caecum are characteristic. Ulcers tend to be discrete and transverse or star-shaped.

82. FLEISCHNER’S SIGN (INVERTED UMBRELLA SIGN) TB Most common in terminal ileum because of… The increased physiological stasis, Increased rate of fluid and electrolyte absorption, Minimal digestive activity and An abundance of lymphoid tissue at this site .

83. Stierlin’s sign

84. Conical caecum

85. Ascaris lumbricoides is a large roundworm which is extremely common. Cause small-bowel obstruction. Their appearance on contrast studies is characteristic once the worms have swallowed contrast themselves; barium is seen within their intestinal tract. non-specific findings of fold thickening, nodularity, mild dilatation and flocculation on contrast studies can be elicited. Whipple's disease may also be considered an intestinal infection because of its association with the bacilli Tropheryrna whippelii. Contrast studies typically reveal a micronodular mucosal pattern.

86. SBFT in patient with Whipple disease shows thickened irregular folds in jejunum and proximal ileum due to accumulation of Whipple bacilli.

87. patient with AIDS shows thickened irregular folds in jejunum due to opportunistic infection by cryptosporidiosis.

88. NON INFECTIOUS ENTERITIS The small bowel is often unavoidably irradiated as a consequence of radiotherapy to abdominopelvic tumours . An acute radiation enteritis is followed by fibrotic healing which may precipitate an strictures, notably colonic, and often suffer from short-bowel endarteritis obliterans. This causes ischaemia and the subsequent fibrosis & stricture that is characteristic of chronic radiation enteritis.

89. Pt on warfarin sodium shows straightsegmental thickening of folds (arrows) due to localized submucosal hemorrhage from anticoagulation. Small-bowel ischemia may produce similar findings

90. straight-segmental thickening of folds in loop of ileum due to localized submucosal edema and hemorrhage.

91. There may he abrupt margination between affected bowel and normal adjacent bowel excluded from the radiation field. Initially the valvulae are thickened but may eventually become completely effaced. Extensive adhesions between the anti mesenteric aspects of adjacent loops results in the phenomenon of `mucosal tacking' and a ' picketfence ’ appearance. Superficial ulceration, stenosis and obstructive dilatation are common .

92. patient with prior radiation therapy to pelvis shows straight-segmental thickening of folds in pelvic loops of ileum with narrowing, angulation and lowgrade obstruction due to radiation serositis

93. Barium follow-through in a patient with extensive radiation enteritis reveals strictures, dilatation & picket fence appearance

94. Eosinophillic gastroenteritis is a rare condition caused by widespread eosinophillic infiltration, which may be revealed on endoscopic biopsy. Peripheral blood eosinophilia may also be associated. The gastric antrum and small bowel are most frequently affected and nodular antral fold thickening is characteristic. Nodular forms also exist. Necrotising enteritis affects premature infants, especially those with additional problems such as respiratory distress. Plain films reveal gastric and small-bowel dilatation. Intramural pneumatosis is a characteristic but late finding, as is portal vein gas

95. Patient with eosinophilic gastroenteritis shows straight- and irregular-diffuse thickening of folds in small bowel due to infiltration of small bowel wall by eosinophils.

96. MALABSORPTION : Impaired absorption of normal dietary constituents, namely protein, carbohydrates, fats, minerals and proteins. Due to luminal disease, mucosal disease, bowel wall disease, and diseases outside the gastrointestinal tract, including drugs. many of the infective and non-infective enteritides may cause malabsorption, as can extensive tumours and endocrine disorders (diabetes, Zollinger-Ellison syndrome). Many findings are non-specific and dilatation, oedematous fold thickening and impaired motility generally occur.

97. patient with advanced gastric carcinoma shows areas of mass effect, angulation , and tethering on concave border of distal ileum due to intraperitoneal-seeded metastases.

98. Coeliac disease: The classical radiological feature is ileal ` jejunisation '. Jejunal folds are either widely separated or absent altogether and this feature is accompanied by a paradoxical increase in ileal folds. Iuminal dilatation ,Fold thickening may also occur, because of oedema secondary to hypoalbuminaemia . Transient intusception . Complications such as ulcerations , T cell lymphoma. Tropical sprue : non specific.

99. patient with celiac disease shows markedly decreased number of folds per inch of jejunum with increased number of ileal folds , producing a “flip-flop” pattern.

100. patient with bone marrow transplant shows thickened and effaced folds (arrows) in several loops of distal ileum due to graft-versus-host disease.

101. Amyloidosis:non -specific dilatation, fold thickening and impaired motility, suggesting pseudo-obstruction , Localised deposition is less common but results in filling defects, either macro- or micronodular Cystic fibrosis :non-specific small-bowel dilatation and fold thickening, duodenal sacculation is said to be characteristic and viscid secretions adhering to villi may produce a coarse reticular pattern.

102. VASCULAR DISEASE : Acute superior mesenteric artery (SMA) occlusion, usually due to atheromatous thrombus or embolus, will result in small bowel and right colonic ischaemia . Small-bowel collaterals are more developed than in the colon and healing will ensue if these are adequate, sometimes with subsequent fibrotic stricture. Multiple, gas-filled, dilated small-bowel loops. Pain is intermittent and classically follows eating in cases of chronic angina .

103. tubular narrowing of multiple loops of distal ileum (with complete obliteration of folds) due to chronic small-bowel ischemia.

104. Mesenteric vein thrombosis most often follows abdominal surgery but is associated with trauma, portal hypertension and hypercoagulative states. There is bleeding into affected loops, with associated oedema , gas-filled loops with associated mural thickening (thumb-printing if marked), Intra mural hemorrhage : isolated segment of mural thickening with high attenuation. Occurs in cases of trauma. Vasculitides :There is small bowel mucosal and submucosal haemorrhage in approximately 50%. Contrast examinations will reveal fold thickening in affected areas and CT will show the extent of mural haemorrhage

105. Small-bowel thickening, causing a 'target' sign, in a young woman with Henoch-Schonlein purpura Gross intramural jejunal haemorrhage revealed by CT in a young man taking oral anticoagulants

106. Nodular lymphoid hyperplasia: Nodular filling defects 2-3 mm in size. Pneumatosis intestinalis describes gas in the bowel wall. This may be primary or secondary, due to infection, ischaemia or trauma.

107. Terminal ileum nodular lymphoid hyperplasia.

108. enlarged lymphoid follicles as small round nodules (arrows) separated by normal mucosa in terminal ileum.

109. Plain films showing pneumatosis intestinalis evidenced by(arrows). innumerable air-filled cysts.

110.  T hank you 

111. ntestinal lymphangiectasia shows tiny nodules in jejunum (arrows) due to dilated lacteal vessels in lamina propria