N Crohn disease of the terminal ileum

- Clinicalfeatures: diarrhea, pain in the right lower quadrant of the abdomen, elevated ESR; possible iron deficiency anemia, steatorrhea, vitamin B12 deficiency, bile acid loss syndrome with chologenic diarrhea

• Possible complications:

- Stenosis

- Fistula formation: Fistulae may be enterocutaneous, enterovesical, entero-mesenteric, or enterouterine

! Caution: Fistulae may also occur with intestinal tumors.

- Hypoechoic inflammatory mesenteric reaction

- Abscess formation

- Bowel obstruction

• Sonographic findings (Figs. 532-534):

- Thickening of the terminal ileal wall to > 4 mm (for severity of inflammation, see Table 64)

- Increased intraluminal fluid with wall thickening (fluid due to decreased absorption, unlike the secretory fluid collection in viral or bacterial enteritis)

- Rigid bowel loop with absent or decreased peristalsis

- Polypous inner wall with a "cobblestone" appearance

Crohn Stenosis
Fig. 532a, b Crohn disease of the terminal ileum (TI), highly active form with stenosis. a B-mode image: very hypoechoic, swollen bowel walls (BW) with obliterated wall layers. CE = cecum. b CDS: marked inflammatory vascularity

Fig. 533a, b Crohn disease: markedly thickened wall of the terminal ileum (cursors) with an echogenic middle layer (isoechoic to submucosa) and luminal narrowing. a Lower abdominal longitudinal scan, b transverse scan. BW = bowel wall 363

Fig. 533a, b Crohn disease: markedly thickened wall of the terminal ileum (cursors) with an echogenic middle layer (isoechoic to submucosa) and luminal narrowing. a Lower abdominal longitudinal scan, b transverse scan. BW = bowel wall 363

Fig. 534 Crohn disease of the terminal ileum: hypoechoic wall swelling (TI). Fistulous tracts (F), some terminating blindly, pass through the peritoneum (P) to the anterior abdominal wall (AW)

Table 64 ■ Relationship of sonographic wall structure to the severity of inflammation in Crohn's disease

Wall structure Degree of inflammation

Accentuated Mild inflammation

Echogenic layering with a broadened middle layer Moderate inflammation

Hypoechoic wall with obliterated layers Severe inflammation

- Frequent accompanying mesenteritis

- Signs of partial bowel obstruction

- Possible free fluid, lymphadenopathy

- CDS: color flow signals indicating inflammatory hyperperfusion (Fig. 532b) n Acute febrile enteritis (enterocolitis):

• Clinical features: shows a predilection for the ileum but may also affect the jejunum. Acute right lower quadrant pain resembling appendicitis

• Causative organisms: viruses (especially rotaviruses), Yersinia, Campylobacter, staphylococci, salmonellae (invasive microbial pathogens such as Shigella in the colon)

• Sonographic criteria (Fig. 535; see also Fig. 544, p. 369):

- Thickened wall with alternating hypoechoic, hyperechoic, and hypoechoic layers; often shows "gyration" and concomitant involvement ofthe cecal pole

- Local tenderness to bowel compression

- Local free fluid

Mesenteric Lymphadenitis
Fig. 535a, b Acute enteritis. a Swollen wall of the terminal ileum (cursors) with a distinct layered structure. b CDS: mesenteric lymph nodes (LN) anterior to the iliac 364 artery and vein (A, V); mesenteric lymphadenitis

- Frequent enlargement of mesenteric lymph nodes ("mesenteric lymphadenitis")

- CDS: inflammatory hypervascularity n Small-bowel hematoma (Fig. 536): may result from anticoagulant medication or a hemorrhagic diathesis

• Thickened bowel walls

• Pronounced, very hypoechoic wall swelling with luminal narrowing ("garden hose" appearance)

Fig. 536 Small-bowel hematoma in a patient on anticoagulant medication. Ultrasound shows intensely hypoechoic swelling of the bowel wall (BW)

n Mesenteric vascular occlusion (see also Fig. 115, p. 85):

• Hypoechoic "standing" small-bowel loop of variable length (hemorrhagic intestinal necrosis, superinfection)

• Loss of layered wall structure

• Signs of partial or complete bowel obstruction (see p. 353)

• Doppler evidence of mesenteric vascular stenosis or occlusion n Amyloidosis: mild thickening involving a long segment of the bowel wall (intestinal amyloidosis may also occur without significant wall thickening)

n Benign tumors: Examples are adenoma, leiomyoma, and neurofibroma. Occasionally the tumor can be directly visualized with ultrasound, based on the findings of contrast radiography. • Polypoid swelling of the bowel wall n Malignant tumors (Figs. 537 and 538): Examples are duodenal carcinoma, small bowel carcinoma, carcinoid, malignant lymphoma, and metastases

Fig. 537a, b Duodenal carcinoma. a Extensive tumor (T) with a prestenotic fluid collection. FL = fluid, LN = lymph node metastases. b Massive luminal widening of the duodenal bulb and antrum caused by the stenosis. PY = pylorus 365

noid: The metastasis (T) is infiltrating and destroying the superior mesenteric artery (SMA). b Diffuse mesenteric metastasis (T) with small-bowel wall thickening (BW) in a patient with rectal carcinoma. Cursors: normal wall thickness

• Circumferential, infiltrative wall thickening with a target sign and clinical manifestations of stenosis

• Detectable metastases may be present (Fig. 538)

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