1. GI Barium Cases 26-50

2. Case directory 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

3. Case 26

4. Duodenal hematoma Diffuse thickening of the duodenal folds DDX:
Case directory
Duodenal hematoma
Diffuse thickening of the duodenal folds
DDX:
Lymphoma

5. Case 27

6. Gastric bezoar Complication of subtotal gastrectomy and vagotomy
Case directory
Gastric bezoar
Complication of subtotal gastrectomy and vagotomy
Poorly chewed fibrous foods, lack of gastric peristalsis, absence of hydrochloric acid

7. Case 28

8. Gastric carcinoma
Sharply circumscribed constricting lesion (arrows) in proximal body
Mucosa is irregular and there are shoulders at the lesion's margins
Segment involved by the tumor is rigid and non-distensible

9. Gastric (ulcerative) carcinoma
Ulcerated lesion in the body of the stomach with irregularly thickened folds around it
Ulcer crater (black) is rectangular in shape
Surface pattern of the adjacent mucosa (white) is nodular
Nodules are of different sizes and more irregular than the usual areae gastricae pattern

10. Gastric carcinoma Diagnosis: gastric carcinoma, linitus plastica
Body and antrum of the stomach are narrowed, rigid
No peristalsis was seen

11. Gastric carcinoma
Diagnosis: ulcerating carcinoma of cardia, with extension into lower esophagus
Irregular shaped ulcer crater (arrows) in gastric cardia
Folds radiating towards the ulcer crater are of uneven thickness, and most do not reach the crater edge
Distal esophagus is narrowed, secondary to proximal extension of the tumor (arrowhead)

12. Gastric carcinoma Mass in the cardia with thickened folds (arrows)
Case directory
Gastric carcinoma
Mass in the cardia with thickened folds (arrows)
Normal cardiac rosette is obliterated
Mucosa is coarsely nodular in some areas

13. Case 29

14. Gastrointestinal stromal tumor
Case findings:
Well- circumscribed, smooth-surfaced 3 cm mass in gastric antrum
Barium-filled ulcer crater is centrally located

15. Ectopic pancreatic rest
Single, smooth-surfaced, relatively flat, polypoid lesion (arrow) on the greater curvature of the distal gastric antrum

16. Gastrointestinal stromal tumor
Case directory
Gastrointestinal stromal tumor
Large smooth broad-based polypoid lesion (arrows) along distal lesser curvature
Lesion has abrupt margins (arrowheads) with the luminal contour  submucosal mass
Large, solitary submucosal masses of the stomach  MC GIST and lymphoma (about 50% are ulcerated)
DDX: lymphoma

17. Case 30

18. Gastric lymphoma
Loss of the normal gastric rugal pattern, with multiple, large ulcers (large arrows)
Stomach is diffusely narrowed, which is the result of diffuse infiltration by lymphomatous tissue
Well demarcated line (small arrows) in fundus, suggesting that the barium is being displaced by a mass effect exerted by the tumor

19. Case directory
Gastric lymphoma
MC NHL of B-cell origin, arising in the mucosa-associated lymphoid tissue of the stomach (MALT)
Associated H pylori gastritis
Features:
MC appearance an infiltrating lesion
May be focal or diffuse, nodular or smooth thickening of the rugal folds
Gastric wall may either be rigid mimicking scirrhous carcinoma or be pliable due to the soft nature of the lymphomatous infiltrate
Multiple ulcers are often present
Ulcerated submucosal mass
Ulcerating mass with a nodular surface

20. Case 31

21. Carcinoid
Smooth-surfaced, broad-based, sessile polypoid lesion (arrows) in the ileum
Wall opposite the tumor is mildly in-bowed (arrowhead)

22. Carcinoid DDX sessile polypoid lesion in ileum:
Gastrointestinal stromal tumor (GIST)
Lipoma: soft and change size or shape
DDX ileal submucosal lesion:
Metastasis
Disseminated lymphoma
Kaposi's sarcoma
Carcinoid tumor

23. Carcinoid
Polypoid lesion in the terminal ileum (black arrowhead), carcinoid lesion
Ileal diverticula (white arrowheads) and the smooth-surfaced submucosal mass (black arrows) at the entrance of the appendix into the cecum (mucinous cystadenoma of the appendix)

24. Carcinoid (annular) Mucosal folds are shown to be preserved (arrow)
Case directory
Carcinoid (annular)
Mucosal folds are shown to be preserved (arrow)

25. Case 32

26. Crohn’s
Ulcer (black arrowheads) on the mesenteric border of the distal ileum
Radiolucent collar of edema (arrows) parallels the barium-filled groove
Aphthoid ulcers (white arrowheads)

27. Crohn’s
More extensive along the mesenteric side of the small intestine, and extends along vessels and lymphatics entering the small bowel mesentery
Linear mesenteric border ulcer:
Associated with fibrosis and shortening of mesenteric side
Whenever flattening of a mesenteric border is seen in a Crohn's, suspect mesenteric border ulceration
Look on antimesenteric side for sacculations

28. Crohn’s
Mesenteric border ulcer (arrowhead)  folds radiate toward the ulcer
Opposite wall (antimesenteric border) is mildly sacculated (arrows), which is the result of the folds radiating toward the ulcer, and is associated shortening of the mesenteric border

29. Case directory
Crohn’s
With progressive luminal narrowing and fibrosis of the wall, some of the antimesenteric sacculations survive as diverticula-like outpouchings (arrows)

30. Case 33

31. Crohn’s DDX of small bowel stricture:
Ischemia: MC solitary, smooth surfaced narrowing, with gradually tapering margins
Radiation: smooth, thick folds perpendicular to the longitudinal axis
If very long-standing, radiation strictures may be smooth circumferential tubular narrowing
Neoplasm: annular constricting tumors (primary or metastatic) are sharply demarcated with shoulder formation
Ulcerative colitis: rare, chronic stage of UC with short annular constrictions separating dilated segments are present

32. Case directory
Crohn’s
Stricture of the terminal ileum (string sign)

33. Case 34

34. Crohn’s Ileosigmoid fistula due to terminal ileal Crohn's disease
Case directory
Crohn’s
Ileosigmoid fistula due to terminal ileal Crohn's disease
BE: shows reflux of barium into the TI, and a strictured TI

35. Case 35

36. Small bowel ischemia
Intramural hemorrhage: identical on SBFT  submucosal edema or blood causes thumbprinting, with thickened but straight folds
Barium trapped between the thick folds produces interspace spikes
CT target sign = barium thumbprinting
Etiology of intramural hemorrhage/ischemia:
Low flow states
Emboli or atherosclerosis
Vasculitis: SLE, RA, Behçet's, HSP
Bleeding from hemophilia, ITP, anticoagulation, or intrinsic coagulopathies
Radiation enteropathy

37. Case directory
Small bowel ischemia

38. Case 36

39. Primary small bowel lymphoma
Grow first by submucosal infiltration longitudinally resulting in thickened valvulae conniventes
Then extends through the thickness of the wall with effacement of valvulae conniventes
Lumen can be mildly narrowed by submucosal lymphoma, but obstruction is uncommon
If the smooth muscle of the wall is destroyed, the lumen can expand (aneurysmal dilatation)

40. Primary small bowel lymphoma
Features:
MC type is infiltrative
2nd MC type is cavitary (ulcerating)
DDX:
Malignant GIST
Metastatic melanoma
Rarely primary adenocarcinoma

41. Primary small bowel lymphoma
May infiltrate short segment of small bowel
Segment of annular narrowing (arrowhead) of the distal jejunum
Borders are abrupt (arrows), but not shelf-like
Normal folds are absent
NOTE: lack of obstruction and relative mild luminal narrowing favor primary lymphoma a over primary adenocarcinoma

42. Primary small bowel lymphoma
Case directory
Primary small bowel lymphoma
Large cavity (white arrows) extends into the small bowel mesentery
Surface of cavity is nodular
Folds of the SB are thick (black arrows)
Large tumor nodules (arrowheads) are seen on the mesenteric border

43. Case 37

44. Meckel’s diverticulum
Case findings:
Smooth-contoured saccular outpouching from the antimesenteric wall of a RLQ ileal loop
No folds are seen in the outpouching
Occurs at obliterated omphalomesenteric duct
Contains all layers of the bowel wall
Ectopic gastric mucosa may be present (hemorrhage)
Pertechnetate scan

45. Meckel’s diverticulum
Case directory
Meckel’s diverticulum
Junction of the diverticulum with the antimesenteric border of the distal ileum is a narrow neck (arrows)

46. Case 38

47. Scleroderma Dilated duodenum and jejunum
Despite the massive dilatation, there are 7-8 folds per inch in the first jejunal loop

48. Scleroderma
Hidebound bowel: crowding of small bowel folds despite luminal dilatation
Asymmetric scarring leads to sacculation of the wall opposite the scarring (MC seen in colon)

49. Scleroderma
Although the number of folds/inch remains is normal (5-6/inch), there are too many folds for the massive luminal dilatation

50. Scleroderma Lumen is dilated
Case directory
Scleroderma
Lumen is dilated
Folds radiate toward the mesenteric border (arrows) due to asymmetric scarring
Antimesenteric border shows broad-based sacculations (arrowheads)
Classic appearance:
Luminal dilatation
Tethered, crowded folds
Broad based sacculations opposite these folds

51. Case 39

52. Familial adenomatous polyposis
Case directory
Familial adenomatous polyposis
Hamartomatous polyps:
Cowden (multiple hamartoma syndrome): associated with breast and thyroid cancer
Peutz-Jeghers
Multiple hamartomas  MC stomach
Mucocutaneous hyperpigmentation
Adenomatous polyps:
Familial polyposis coli
Turcot: associated with brain tumors (GBM, medulloblastoma)
Gardner’s syndrome: colonic polyps, osteomas (frontal sinus, mandible), ST tumors (desmoid tumors, epidermoid inclusion cysts, fibroma, lipoma, leiomyoma)
Juvenile polyps:
Juvenile polyposis coli
Cronkite-Canada: inflammatory juvenile polyps

53. Case 40

54. Ulcerative colitis Early ulcerative colitis:
Colonic mucosa replaced by a diffusely granular appearance
Corresponds to edema and hyperemia, and may precede actual ulceration

55. Ulcerative colitis Rectum shows diffuse narrowing
Case directory
Ulcerative colitis
Rectum shows diffuse narrowing
Widened presacral space

56. Case 41

57. Crohn’s Case findings: DDX terminal ileum fold thickening:
Case directory
Crohn’s
Case findings:
Distal ileum fold thickening and cobble-stoning
Mild transient spasm of this portion of bowel indicating acute inflammation at this site
No skip lesions, obstructions, leaks, or masses
DDX terminal ileum fold thickening:
Crohn's disease
Yersinia infection
Mycobacterium tuberculosis ileitis
Adjacent appendiceal abscess

58. Case 42

60. Mucinous cystadenoma of appendix
Case directory
Mucinous cystadenoma of appendix
Case findings:
BE:
Smooth, sharply outlined, broad based extramucosal mass impressing the apex of the cecum
CT:
Sharply defined round mass in RLQ
Central part has low attenuation
Wall of the lesion is thickened
Peripheral calcification

61. Case 43

62. Crohn’s Case findings (SBFT): Early findings: Late findings:
20cm segment of the terminal ileum is narrowed and non-distensible
Within the right mid abdomen, there is a shorter, approximately 10cm segment of similar narrowing
Early findings:
Aphthoid ulcer: shallow pinpoint mucosal erosions surrounded by an edematous mound
Late findings:
Cobblestone pattern: ulcerations grow and fuse together, forming linear confluent deep ulcerations separated by edematous mucosa

63. Crohn’s Thickened and distorted folds
Case directory
Crohn’s
Thickened and distorted folds
String sign: progressive narrowing of the lumen (MC in terminal ileum)
Rigid, featureless bowel, strictures and obstruction, and foreshortening of bowel
Asymmetric involvement of bowel wall both longitudinally and circumferentially  lesions MC on mesenteric side of intestine
Sinus tract and fistula formation, originating in deep ulcers or fissures
Creeping fat: inflamed mesenteric fat (stranding) accumulate on serosal surfaces

64. Case 44

66. Cecal bascule Case findings: DDX: cecal volvulus BE: CT:
Contrast flowed to the level of what initially appeared to represent the cecum
However, the hugely distended loop of bowel located in the pelvis and extending into the mid-abdomen did not fill with contrast
No “birds beak” sign was demonstrated
CT:
Markedly distended bowel loop in the pelvis
DDX: cecal volvulus

67. Cecal bascule Case directory
Form of volvulus in which the cecum folds anteromedially in front of the ascending colon, producing a flap-valve occlusion at the site of flexion
Torsion in the transverse plane
Cecum usually falls into the pelvis, resting centrally
Birds beak sign: not present with bascule because there is no true twist
Axial torsion: classic cecal volvulus
Rotation occurs in the longitudinal plane
Cecum turns upward and usually lies in an ectopic location (MC LUQ)
Classic “kidney-bean” appearance
Bascules represent up to 1/3rd of cecal volvuli
Two forms of cecal volvuli have similar presentations and treatments

68. Case 45