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CT Evaluation of Small Bowel Wall Lesions |
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Pushan Kumar Sharma, Devidas B Dahiphale, Asmita Suryawanshi, Abhang Apte, Saurabh Choudhari, Raj Deore 1. Junior Resident, Department of Radiology MGM Medical College, Aurangabad, Maharashtra, India. 2. Associate Professor, Department of Radiology, MGM Medical College, Aurangabad, Maharashtra, India. 3. Assistant Professor, Department of Radiology, MGM Medical College, Aurangabad, Maharashtra, India. 4. Associate Professor, Department of Radiology, MGM Medical College, Aurangabad, Maharashtra, India. 5. Junior Resident, Department of Radiology MGM Medical College, Aurangabad, Maharashtra, India. 6. Junior Resident, Department of Radiology MGM Medical College, Aurangabad, Maharashtra, India. |
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Correspondence Address : Dr. Devidas B Dahiphale, Associate Professor, Department of Radiology, MGM Medical College, Aurangabad-431003, Maharashtra, India. E-mail: drdbdahiphale@gmail.com |
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| ABSTRACT |  | |||||||||||||||||||||||||||||||||||||||||||||||||
: Introduction: MDCT has lead to vast improvement in depiction and characterisation of small bowel wall lesions especially differentiation of benign and malignant lesions. Aim: To evaluate the role of MDCT in suspected small bowel lesions in patients referred to Radiology Department of a Tertiary Care Centre at Aurangabad district of Maharashtra in India. Materials and Methods: Present observational study was done on 49 patients of suspected small bowel lesions referred for MDCT during November 2014-2016. Patients presenting with symptoms related to altered bowel habits, positive small bowel wall findings on plain CT, small bowel lesions detected on ultrasound, history of trauma undergoing CT-scan with small bowel wall thickening on USG/CT were included. Patients were followed up to therapeutic/biopsy/operative diagnosis. Histopathological reports helped in retrospective confirmation of provisional diagnosis on MDCT. Results: Duodenum was most common location for malignant lesions. Ileum (43.5%) was the most common location for benign lesions. The malignant lesions showed heterogeneous mixed attenuation (100%), marked thickening (66.7%) and asymmetric thickening (100%). Benign lesions showed homogenous attenuation (89.1%), mild thickening (93.5%) and symmetrical thickening (97.8%). Focal thickening was seen in most of the malignant lesions (66.7%) while segmental involvement was seen in most of benign lesions (93.5%). All malignant lesions were associated with adjacent fat stranding. Amongst benign lesions, surrounding fat stranding was absent in 71.7% cases. Conclusion: MDCT imaging findings can provide very useful help in diagnosis of small bowel lesions along with clinical correlation especially for identification of benign or malignant nature of small bowel lesions. | ||||||||||||||||||||||||||||||||||||||||||||||||||
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| Keywords : Attenuation, Neoplasm, Small bowel wall thickening | ||||||||||||||||||||||||||||||||||||||||||||||||||
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DOI and Others :
DOI: 10.7860/IJARS/2018/32057:2415
Date of Online Ahead of Print: May 29, 2018 Date of Publishing: Jul 01, 2018 Financial OR OTHER COMPETING INTERESTS: None. |
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| INTRODUCTION |
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Early detection of the neoplasm of small bowel is a highly desirable but a very challenging task for the clinicians as well as radiologists. Multidetector Computed Tomography (MDCT) has lead to a vast improvement in the depiction as well as characterisation of the small bowel wall lesions especially differentiation of benign and malignant lesions. Thickening of the bowel wall may present as a focal, segmental or diffuse thickening. Differential diagnosis of cases with focal thickening is narrowed down by the assessment of degree and symmetry of the bowel wall thickening and study of perienteric abnormalities. Malignant lesions are usually associated with focal thickening which is heterogeneous and asymmetric, whereas benign conditions and well differentiated tumours are usually associated with symmetric regular and homogeneous thickening (1),(2),(3). | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Material and Methods |
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This observational study was conducted in the Department of Radiology at a Tertiary Care Centre in Aurangabad district of Maharashtra, India, between the period of November 2014-2016. A total of 49 patients of suspected small bowel lesions referred to the department were included in the study. Institutional Ethics Committee approved the study protocol and written informed consent was taken from all the study participants. Inclusion criteria for the study were: (a) Patients presenting with symptoms related to altered bowel habits/abdomen; (b) Patients with positive small bowel wall findings on plain CT; (c) Patients with small bowel lesions detected on ultrasound; and (d) Patients with history of trauma undergoing CT-scan with small bowel wall thickening on USG/CT. Pregnant females and patients with deranged renal function were excluded from the study. Formal sample size calculation was not done. All patients attending the hospital during the study period and fulfilling the inclusion and exclusion criteria and willing to give consent were enrolled in the study. Age and sex distribution of cases, clinical presentation, location of lesions, presence of attenuation, degree, symmetry and extent of bowel wall thickening, presence of fat stranding, lymphadenopathy, obstruction and metastasis were the features studied and described. Procedure and CT protocol for bowel imaging: Toshiba Aquillion CT scanner (16 slice) was used. Colon cleaning preparation was orally administered 12 hours prior to procedure and 1-1.5L of water/oral contrast was given shortly before scanning with or without rectal contrast (SOS). Standard CT scout imaging was used to assess the degree of distension of bowel. The criterion for the acceptability of image was the visualisation of all the colonic segments and in a well distended state (4). Statistical data was presented in the form of percentages for malignant and benign lesions. | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Results |
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Age group of the subjects was from 10 to 70 years. Malignant lesions were mostly seen in later decades of life (51-70 years) and benign lesions were mostly seen in 21-40 years age group (Table/Fig 1). Out of 49 patients, 29 were males and 20 were females (Table/Fig 2). Abdominal pain, bleeding per rectum and weight loss was the most common presentation amongst malignant lesions. Abdominal pain, constipation, vomiting were the most common modes of presentation amongst all the benign lesions (Table/Fig 3). Duodenum was the most common location for malignant lesions. Ileum was the most common location for all the benign lesions followed by jejunum (Table/Fig 4). All of the malignant lesions showed heterogeneous mixed attenuation. Most of the benign lesions 41 (89.1%) showed homogenous attenuation (Table/Fig 5). Marked thickening was seen in most of malignant lesions (66.7%). Mild thickening was seen in most (93.5%) of benign lesions (Table/Fig 6). All of the malignant lesions showed asymmetric thickening while symmetric thickening was seen in most of the benign lesions (97.8%). Focal thickening was seen in most of the malignant lesions (66.7%) while segmental involvement was seen in most of benign lesions (93.5%). All of the malignant lesions were associated with adjacent fat stranding whereas it was noticed in only 28.3% of benign lesions. All of the malignant lesions were associated with enlarged lymph nodes whereas enlarged lymph nodes were noticed in only 19.6% of benign lesions. Obstruction was present in 66.7% malignant cases whereas, it was present in only 4.3% benign cases. Metastasis was present in 66.7% malignant cases and the site of metastasis was liver. (Table/Fig 7) shows CECT axial Image of circumferential bowel wall thickening involving distal ileal loops. | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Discussion |
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In our study, the number of patients with malignancy was low i.e., 3 out of 49 cases studied. All of them showed heterogeneous mixed attenuation whereas, most of the benign lesions showed homogenous attenuation (89.1%). Roccasalva F et al., study (5) and Balthazar EJ, study (6) has also observed that benign disease (infective/inflammatory) presentation on CT is that of homogenous attenuation while the malignant disease presentation on CT is that of heterogeneous attenuation. In our study, asymmetric thickening on MDCT was found in all malignant lesions, while MDCT presentation amongst benign lesions was symmetrical thickening in almost all of the cases (97.8%). Karpagam B et al., have also mentioned in their review of imaging findings of bowel lesions that malignant lesions often presented with focal asymmetric wall thickening (7). Similarly, Desai RK et al., study evaluated CT presentation with respect to symmetry of intestinal wall thickening and reported that malignant lesions often presented with focal asymmetric wall thickening whereas, benign lesions often presented with symmetric thickening (8). Chou CK et al., mentioned in their study that small bowel wall thickening may be caused by a neoplastic or a non neoplastic pathology (9). They further stressed that neoplasms usually present as short (except lymphoma), irregular, and asymmetric on CT. Macari M et al., have also reported that small bowel neoplasms typically present with heterogeneous enhancement and this finding is most commonly associated with adenocarcinoma and malignant gastrointestinal stromal tumours (10). Many authors have highlighted the significance of CT investigation in small bowel tumours and it has been reported that around 90% of tumours of small bowel present with abnormalities demonstrated on CT (11),(12),(14). Wittenburg J et al., have reported that attenuation pattern of intestinal wall lesions on CT can help in differentiation of benign and malignant nature of the tumours (14). Buckley JA and Fishman EK also mentioned that with an extensive differential diagnosis, small bowel tumours still have certain characteristic features on CT that help in arriving at the final diagnosis (15). Mak SY et al., and Qalbani A et al., mentioned in relation to small bowel obstruction due to adenocarcinoma that, at the transition point, the CT imaging findings usually seen is an asymmetric, pronounced and irregular mural thickening (16),(17). Thus, our study adds to the literature on radiological findings in small bowel lesions. It presents the data from our geographical region which has a clinical significance that it will help clinicians in better correlation with clinical findings while interpreting radiological findings among the patients from the region. Limitation Hospital based and observational study design, small sample size especially, very few cases with malignant lesions, among the study group were the limitations of our study. | ||||||||||||||||||||||||||||||||||||||||||||||||||
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