Downloaded from www.ajronline.org by 202.62.16.132 on 04/17/15 from IP address 202.62.16.132. Copyright ARRS.

For personal use only; all rights reserved

Review
CT of Bowel Wall Thickening: Significance and Pitfalls of
Interpretation
Michael Macari 1 and Emil J. Balthazar

T has become the most important

imaging technique for evaluating
the abdomen and pelvis. CT is used
to examine patients with acute abdominal complaints, known or suspected malignancy, abdominal and pelvic trauma, and inflammatory
conditions. When CT images of the abdomen
and pelvis are interpreted, the focus is often
placed on the peritoneal cavity, the mesentery,
and the parenchymal organs. A common misconception is that CT provides only limited information with respect to the gastrointestinal tract.
In fact, recent technologic advances and accumulated experience in image interpretation
suggest that substantial information regarding
gastrointestinal tract disorders can be obtained.
Normal variantsas well as abnormal conditionsmay cause thickening of the bowel
wall. In this review, the normal CT appearance
of the bowel wall and the different causes of
bowel wall thickening will be described.
The various criteria that allow one to differentiate normal variants and abnormal conditions are reviewed, including attenuation
pattern of bowel wall thickening; degree of
bowel wall thickening; circumferential symmetric thickening versus asymmetric thickening; focal, segmental, or diffuse involvement;
and associated perienteric abnormalities.
Normal Gastrointestinal Tract

The normal small-bowel wall is thin, measuring between 1 and 2 mm when the lumen is
well distended (Fig. 1). However, the thickness

of the normal small-bowel wall varies slightly

depending on the degree of luminal distention.
As a result, different criteria have been used to
diagnose small-bowel wall thickening [16].
When the lumen of the small bowel is distended, the wall is often not seen. If the bowel
is partially collapsed, the wall measures between 2 and 3 mm and is of symmetric thickness. In these cases it is important to compare
the degree of thickness of similarly distended
segments to exclude disorders. A measurement
of 23 mm as the upper limit of normal thickness has been used by some authors [3, 4].
Others have advocated any perceptible thickening to indicate disorders [5, 6]. However, potential pitfalls exist with this latter approach.
We have observed that when the normal small
bowel is filled with water, its wall may appear
thicker (Fig. 2). In case of uncertainty regarding the presence of a disease process, a smallbowel series should be performed.

The normal thickness of the colonic wall

varies greatly depending on the degree of distention. When the colon is distended, the wall
should measure less than 3 mm; it is often
imperceptible [7]. Frequently, because of fecal contents, fluid, or colonic redundancy, the
true thickness is difficult to ascertain. Carefully following the colonic wall to a region
where the colon is well distended with gas
will often reveal the true thickness (Fig. 3).
The normal bowel wall enhances after an
adequate bolus of IV contrast material (Fig. 1).
The enhancement is often more easily identified in patients who have been given water as
an oral contrast agent. In these cases, the enhancing bowel wall is well depicted adjacent
to the low-attenuation fluid in the lumen. Enhancement is usually greater on the mucosal
aspect of the bowel wall. This enhancement
should not be mistaken for a disease process.
Recognizing that the wall is not thickened and

Fig. 1.Normal enhancement and appearance of small bowel in 77-year-old

woman. Axial CT scan obtained at level
of kidneys with IV contrast material and
water as oral contrast agent shows enhancement of normal bowel wall. Note
thinly enhancing valvulae conniventes
(arrow ). This finding is often better seen
when water alone is given as oral contrast agent. Enhancement may be obscured with positive contrast in lumen.

Received June 27, 2000; accepted after revision November 1, 2000.

1

Both authors: Department of Radiology, NYU Medical Center, Tisch Hospital, 560 First Ave., Ste. HW 207, New York, NY 10016. Address correspondence to M. Macari.

AJR 2001;176:11051116 0361803X/01/17651105 American Roentgen Ray Society

AJR:176, May 2001

1105

Downloaded from www.ajronline.org by 202.62.16.132 on 04/17/15 from IP address 202.62.16.132. Copyright ARRS. For personal use only; all rights reserved

Macari and Balthazar

Fig. 2.Perceived pitfall in interpretation of bowel wall thickening caused
by mixing of water and oral contrast
material in 47-year-old man with history of lymphoma.
A, Axial CT scan through upper abdomen shows apparent homogeneous circumferential thickening of
wall of jejunum loops (arrow ), a
finding suspicious for lymphoma.
B, Radiograph from upper gastrointestinal series performed 2 days after A
shows normal small bowel (arrow ).

A
that no perienteric inflammation is present will
allow one to differentiate normal enhancement
from a disease process.

ease. The CT findings that need to be analyzed

when assessing thickened bowel include pattern of attenuation; degree of thickening; symmetric versus asymmetric thickening; focal,
segmental, or diffuse involvement; and associated perienteric abnormalities. Evaluation of
these parameters, which are reviewed in the
following text, will lead to a more accurate differential diagnosis.

Bowel Wall Thickening

Bowel wall thickening may be related to a

number of entities, including normal variants,
inflammatory conditions, and neoplastic dis-

Fig. 3.Normal colonic wall thickness in 81-year-old

woman with breast cancer. Contrast-enhanced axial
CT scan of cecum suggests bowel wall thickening
with target appearance (arrow ). However, ventral
wall is thin, without target appearance (arrowhead ).
Occasionally, residual fluid in bowel can mimic submucosal edema and bowel wall thickening, as in this
case. Identifying focal area of distention without adjacent fluid will clarify wall thickness.

B
Attenuation of the Thickened Bowel Wall

The attenuation pattern of a thickened segment of bowel wall is an important criteria for
establishing a differential diagnosis. In most
cases, the attenuation pattern of a thickened
bowel wall is directly related to the administration of IV contrast material (Fig. 4). If IV contrast material is not administered, most cases
of bowel wall thickening will show homogeneous attenuation. Two notable exceptions to
this are the presence of central fat deposition
and intestinal pneumatosis (Figs. 5 and 6). In
these cases, variations in attenuation of the
bowel wall can be depicted on CT without IV
contrast material because of the marked differences in tissue attenuation.
The presence or absence of enhancement
can be evaluated in a number of ways, including comparing the attenuation of the thickened
segment with other segments of bowel, comparing unenhanced and contrast-enhanced
scans, or, if unenhanced images are not available, obtaining delayed images. After IV contrast material administration, there are two
Fig. 4.Target sign detected only after IV contrast administration in 64-yearold man with pain and bloody diarrhea.
A, CT scan obtained without IV contrast material shows moderate circumferential thickening of sigmoid
colon (arrow ). Attenuation of bowel
wall is homogeneous. Without IV
contrast material, further characterization is not possible.
B, Contrast-enhanced axial CT image
obtained 48 hr after A at same level
shows thickened sigmoid with target
configuration (arrow ). Findings suggest
inflammation or ischemia. Endoscopy
and biopsy confirmed ischemic colitis.

A
1106

AJR:176, May 2001

Downloaded from www.ajronline.org by 202.62.16.132 on 04/17/15 from IP address 202.62.16.132. Copyright ARRS. For personal use only; all rights reserved

CT of Bowel Wall Thickening

Fig. 5.Deposition of fat in submucosa producing target sign in 85-year-old man with history of chronic ulcerative colitis. Contrast-enhanced axial CT scan of
rectum shows target configuration with central low attenuation in submucosa (arrow ). Central low attenuation
is same density (80 H) as surrounding perirectal fat, indicating submucosal fat deposition. Patient was asymptomatic at time of examination.

distinct patterns of bowel wall attenuation: homogeneous and heterogeneous (Appendix 1).
Homogeneous Attenuation

The differential diagnosis of a thickened bowel

wall that shows homogenous attenuation on CT
includes submucosal hemorrhage or hematoma
[8, 9], infarcted bowel [10, 11], neoplasm [12
15], chronic Crohns disease [3], radiation injury
[10], and pseudothickening related to incomplete
distention and residual fluid [1].
Submucosal hemorrhage.The diagnosis of
submucosal intestinal hemorrhage is usually
made when CT depicts circumferential and sym-

metric bowel wall thickening in patients who are

undergoing anticoagulation therapy or who have
an underlying bleeding diathesis (Fig. 7). On CT,
most cases of submucosal hemorrhage show homogeneous high attenuation of the thickened
segment and lack of enhancement [8, 9]. Patients
often have a history of coagulopathy and, in
most cases, the small bowel is affected in a segmental distribution [9]. In patients with suspected submucosal hemorrhage, an unenhanced
CT examination is often helpful in establishing
the diagnosis by showing high attenuation in the
thickened segment [8, 9]. The high attenuation is
due to acute bleeding in the bowel wall.
Ischemia and infarction.The appearance
of the gastrointestinal wall varies on IV
contrast-enhanced CT as the bowel wall
progresses from ischemia to infarction. When
the wall is ischemic, it is often circumferentially thickened and may contain a target or
halo configuration of attenuation [9, 10] (Fig.
8). In other cases of ischemic bowel, the wall
is thickened and no enhancement is identified
[10, 11]. In these cases, homogeneous attenuation of the bowel wall will be seen. Detecting lack of enhancement can be difficult, but
comparing adjacent loops helps to show this
finding [11] (Fig. 9). In our experience, complete lack of enhancement is rarely identified
in these patients. Etiologies of ischemia and
infarction include thromboembolism, low
flow (related to poor cardiac output), and
strangulation obstruction [10].
Chronic Crohns disease and chronic radiation changes.Chronic Crohns disease and

chronic radiation enteritis may show homogenous attenuation on contrast-enhanced CT [3,

10]. In patients with long-standing Crohns
disease or radiation injury, transmural fibrosis
develops. In the chronic phase, the typical
findings on IV contrastenhanced CT of a target appearance are no longer present [3, 10].
Neoplasm.Gastrointestinal neoplasms can
present with homogeneous attenuation of the
thickened segment on contrast-enhanced CT
[1214]. In these instances, other criteria (degree, symmetry, length of involved segment,
and associated perienteric abnormalities) are
important in establishing the correct diagnosis.
In cases of neoplasm, homogeneous attenuation correlates with size of the tumor [15].
Smaller tumors present either as circumferential areas of bowel wall thickening or as asymmetric areas of bowel wall thickening with
homogeneous enhancement (Fig. 10).
Small-bowel lymphoma is often depicted
on CT as a segmental area of circumferential
thickening with homogeneous attenuation
and enhancement [12, 14]. A recent study
found that in 33 (72%) of 46 patients with
small-bowel lymphoma, the involved bowel
showed single or multiple focal areas of
gross circumferential wall thickening with
homogeneous attenuation [14] (Fig. 11).
Pitfalls.Residual fluid within the lumen
coating the mucosa of the bowel wall may be
perceived as a thickened segment without enhancement (Fig. 2). In these cases, a disease process may be difficult to exclude, and correlation
with a small-bowel series may be needed [1].

Fig. 6.Improved detection and evaluation of intramural air with wide window and low level settings in 34-year-old woman with AIDS and diarrhea.
A, Contrast-enhanced axial CT scan (window width and level, 420 and 30 H) at level of cecum shows gas surrounding cecum (arrow ).
B, Same CT slice as A (window width and level, 1550 and 460 H, respectively) better shows that central low attenuation (gas) is in wall (arrow ) of cecum, which is compatible with pneumatosis. Patient was treated with antibiotics, improved within a week, and did not require colectomy.

AJR:176, May 2001

1107

Downloaded from www.ajronline.org by 202.62.16.132 on 04/17/15 from IP address 202.62.16.132. Copyright ARRS. For personal use only; all rights reserved

Macari and Balthazar

Fig. 7.Intramural hemorrhage in 64-year-old man

with bowel wall thickening (homogeneous attenuation). Contrast-enhanced axial CT scan of abdomen
shows segmental circumferential thickening with homogeneous attenuation of a loop of jejunum (arrow ).
Differential diagnosis includes hemorrhage, ischemia,
and lymphoma. Because of history of anticoagulation
therapy and abrupt onset, hemorrhage is most likely.
Unenhanced study can better define high attenuation.

Heterogeneous (Stratified) Attenuation

Heterogeneous attenuation is the second

pattern that may be depicted in a thickened
segment of bowel wall. When the attenuation
of a thickened bowel wall is heterogeneous,
the wall may display a stratified pattern or a
mixed pattern of attenuation.
Recognizing alternating (stratified) layers of
attenuation in a thickened segment of bowel
wall helps in the differential diagnosis. The

stratified pattern may be in the form of a double halo or a target configuration. The double
halo sign consists of an inner low-attenuation
(edema) ring surrounded by an outer higher attenuation ring. In the target sign, inner and
outer layers of high attenuation surround a
central area of decreased (edema) attenuation
[1]. These signs are best visualized during the
late arterial and early portal venous phases of
IV contrast material enhancement [1]. On unenhanced or delayed (>2 min) IV contrastenhanced CT, these signs may not be visualized
(Fig. 4). The high attenuation present with
these signs is related to hyperemia [1].
Inflammation and ischemia.The double
halo and target signs have similar significance in that they usually indicate an acute
inflammatory or ischemic condition. The
double halo sign was first reported by Frager
et al. [16] in patients with Crohns disease. In
addition to Crohns disease, this pattern of
attenuation may be present in ulcerative colitis, infectious enterocolitis, radiation enteritis, vasculitis, lupus erythematosus, and
bowel edema in patients with cirrhosis [1, 3,
1639] (Figs. 1214). The finding of stratified attenuation in a thickened segment, although nonspecific, is used mainly to
exclude malignant conditions. Correlation
with clinical history and associated findings
on CT related specifically to the bowel wall
and the surrounding mesentery may allow
one to narrow the differential diagnosis.

Fig. 8.Ischemic bowel with mural thickening and target configuration of attenuation in 71-year-old woman.
A, Contrast-enhanced axial CT scan at level of terminal ileum shows circumferential small-bowel wall
thickening with target configuration (arrow ).
B, Contrast-enhanced axial CT scan at level of superior mesenteric artery shows intraluminal filling defect
(arrow ) consistent with mural thrombus. Thrombus was confirmed at follow-up angiography.

1108

Neoplasm.A notable exception to this accepted general rule (target sign = inflammation) is the rare occurrence of this sign in
infiltrating scirrhous carcinoma of the stomach
and colon. Rigidity (after attempted air insufflation), severe luminal narrowing, abrupt transition, and regional lymphadenopathy usually
help in establishing the correct diagnosis.
Pitfalls.A potential pitfall may arise when
residual fluid and oral contrast material fill the
bowel lumen to mimic a target sign [2]. Seeing
that the bowel is partially filled with fluid and
that adjacent areas of the bowel are well distended with gas will usually allow these pitfalls
to be recognized (Fig. 3). Moreover, usually no
perienteric disease is associated with these
fluid-filled segments, which also tends to exclude an acute inflammatory process.
The deposition of submucosal fat in the large
and small bowels has been documented in patients with both acute and chronic inflammatory
disorders of the bowel [40, 41]. One study
found submucosal fat deposition in 61% of patients with ulcerative colitis but in only 8% of
patients with Crohns disease [23]. Although a
stratified pattern of attenuation is present with
submucosal fat deposition, recognizing the very
low attenuation (negative Hounsfield unit value)
of the submucosa will allow an accurate diagnosis to be established (Fig. 5).
Finally, pneumatosis may present as a striated
pattern of attenuation [42]. Occasionally, small
amounts of gas may be overlooked when CT

Fig. 9.Closed-loop small-bowel obstruction with ischemic

bowel in 83-year-old woman. Contrast-enhanced axial CT image at level of pelvis shows typical configuration of closedloop obstruction with dilated small-bowel loops in radial
distribution, minimal to no mural thickening, and homogeneous attenuation (open arrows ). Note loops in closed-loop
obstruction do not enhance to same degree as loops not in
closed loop (solid arrow ), suggesting ischemia. Ischemic
bowel with infarction was present at subsequent surgery.

AJR:176, May 2001

Downloaded from www.ajronline.org by 202.62.16.132 on 04/17/15 from IP address 202.62.16.132. Copyright ARRS. For personal use only; all rights reserved

CT of Bowel Wall Thickening

Fig. 10.Well-differentiated adenocarcinoma in 26-year-old man with bowel obstruction. Contrast-enhanced axial CT scan at level of cecum shows homogeneous attenuation (enhancement) of circumferentially thickened cecum (straight arrows ). Small amount of fluid is seen in
lumen (arrowhead ). Note multiple obstructed loops of small bowel with airfluid levels (curved
arrow ). Surgery revealed well-differentiated adenocarcinoma of cecum.

Fig. 12.Target sign in 35-year-old woman with history of ulcerative colitis. Contrast-enhanced axial CT image of rectum shows mild wall thickening with classic
target appearance and inner enhancement of mucosa (short white arrow ) and
outer enhancement of muscular layer (long white arrow ) surrounding low-attenuation edematous submucosa (black arrow ).

scans are viewed at standard abdominal window

and level settings (Fig. 6). In these cases, viewing the scans at wider window and lower level
settings facilitates visualization of the gas. Air
trapped between the bowel wall and residual
fluid in the lumen may mimic pneumatosis (Fig.
15), which usually occurs in the cecum or stomach. In these cases, the perceived pneumatosis
will be seen on the dependent aspect of the
bowel where the residual fluid is present. Recognizing that the more ventral aspect of the bowel
wall does not show the appearance will usually
allow this pitfall to be avoided.

AJR:176, May 2001

Fig. 11.Lymphoma of small bowel in 30-year-old man. Contrast-enhanced axial CT image of mid abdomen shows homogeneous attenuation (enhancement) of markedly thickened small bowel (arrows ).
Thickening involves a short segment of small bowel. Despite smallbowel thickening, mild dilatation of lumen is seen. Findings are strongly
suggestive of small-bowel lymphoma. Note retroperitoneal lymphadenopathy (arrowhead ). Biopsy revealed non-Hodgkins lymphoma.

Fig. 13.Target sign in 37-year-old man with history of acute Crohns disease.
Contrast-enhanced axial CT image shows marked circumferential thickening of terminal ileum. Target appearance is present, with enhancement of mucosa (short
arrow ) and outer enhancement of muscular layer (long arrow ) surrounding low-attenuation edematous submucosa (arrowhead ).

Heterogeneous (Mixed) Attenuation

The final category of attenuation pattern in

thickened bowel is mixed attenuation. In these
cases, the grossly thickened bowel wall shows
several irregular zones of lower attenuation haphazardly located adjacent to areas of higher attenuation. The findings are related to ischemia
and necrosis and are seen in high-grade, poorly
differentiated gastrointestinal neoplasms such
as adenocarcinoma and stromal cell tumors.
Larger tumors frequently undergo central necrosis and will show heterogeneous enhancement on contrast-enhanced scans. This

heterogeneous enhancement is seen in large tumors and is related to rapid growth, ischemia,
and necrosis. Mucinous adenocarcinomas often
contain poorly defined central areas of low attenuation related to intracellular tumor mucin
deposition and may show heterogeneous attenuation after contrast administration (Fig. 16).
Degree of Bowel Wall Thickening

The second variable that aids in establishing

a differential diagnosis when evaluating bowel
wall thickening is the degree of thickening
(Appendix 2). Entities that cause mild bowel

1109

Macari and Balthazar

in patients with ulcerative colitis [23] (Figs.
12 and 13). In most cases of intestinal infection involving the small bowel, the wall is either normal or mildly thickened.
Downloaded from www.ajronline.org by 202.62.16.132 on 04/17/15 from IP address 202.62.16.132. Copyright ARRS. For personal use only; all rights reserved

Marked Thickening

Fig. 14.Target sign in 37-year-old woman with history of lupus erythematosus. Contrast-enhanced axial CT image
at level of mid abdomen shows diffuse marked circumferential thickening of colon. Target appearance is present, with
enhancement of mucosa (short white arrow ) and outer enhancement of muscular layer and serosa (long white arrow )
surrounding low-attenuation edematous submucosa. Small amount of ascites is present (arrowhead ).

wall thickening (12 cm) often overlap and include inflammatory conditions and neoplasms.
In general, benign conditions result in bowel
wall thickening of less than 2 cm, whereas
wall thickening greater than 3 cm is usually
present in neoplastic conditions [1, 12, 14, 43].
Mild Thickening

In cases of mild bowel wall thickening, a

nonneoplastic (inflammatory or infectious)

condition is usually present. Two of the more

common inflammatory conditions of the
bowel are ulcerative colitis and Crohns disease. Because the disease process is limited
to the mucosa in patients with ulcerative
colitis and is often transmural in Crohns disease, bowel wall thickening is usually greater
in Crohns disease. One study found the
mean thickness of the colon wall in Crohns
disease was 11.0 mm compared with 7.8 mm

Fig. 15.Intraluminal air mimicking pneumatosis in 58-year-old man. Unenhanced

axial CT scan at level of stomach shows gas (arrow ) between wall of stomach and
residual gastric fluid mimicking pneumatosis. Note pneumobilia (arrowhead ) from
previous procedure.

1110

Infection and inflammation.With severe infections of the colon, the wall may become
markedly thickened by edematous haustral
folds (up to 2 cm or even greater) (Fig. 17). On
CT, the finding of barium trapped between these
folds is known as the accordion sign [24]
(Fig. 18). The accordion sign has been detected
in 419% of patients with documented
Clostridium difficile colitis and has been considered specific [2426]. However, other causes,
especially cytomegalovirus in AIDS patients, as
well as a variety of other infectious and inflammatory conditions, have shown massive colonic
wall thickening and a similar mucosal pattern to
that shown by the accordion sign [27, 28] (Fig.
14). The usefulness of the accordion sign relates
to the depiction of severe submucosal edema in
a segmental or diffuse colitis caused by either an
infection or ischemia.
Neoplasm.Primary intestinal neoplasms
often present as short segments of bowel wall
thickening (Fig. 10). Sarcoma (gastrointestinal
stromal tumors) usually presents as a bulky
exophytic mass with heterogeneous attenuation (Fig. 19). Small-bowel lymphoma rarely
obstructs the lumen, and it often presents as a

Fig. 16.Heterogeneous low-attenuation enhancement in mucinous adenocarcinoma with irregular circumferential bowel wall thickening in 64year-old man with abdominal pain. Contrast-enhanced axial CT image of
splenic flexure shows irregular wall thickening (arrows ) with heterogeneous areas of low attenuation in colon wall (arrowhead ). Large mucinous adenocarcinoma was found at surgery.

AJR:176, May 2001

Downloaded from www.ajronline.org by 202.62.16.132 on 04/17/15 from IP address 202.62.16.132. Copyright ARRS. For personal use only; all rights reserved

CT of Bowel Wall Thickening

Fig. 17.Diffuse marked colonic thickening with target appearance in pseudomembranous colitis in 18-year-old woman with diarrhea. Contrast-enhanced axial CT image
of mid abdomen shows diffuse marked circumferential wall thickening of cecum and
descending colon with target appearance (arrows ). Findings are consistent with inflammatory colitis; stool was positive for Clostridium difficile cytotoxin.

markedly thickened segment ranging from 1.5

to 7 cm (mean, 2.6 cm) [14] (Fig. 11).
Symmetric Versus Asymmetric Thickening

Another feature to evaluate in cases of bowel

wall thickening is whether the involved segments are symmetrically or asymmetrically
thickened (Appendix 3). Symmetric thickening
is present when the involved segment shows the
same degree of thickening throughout the circumference of the abnormal segment. Asymmetric thickening relates to different degrees of
eccentric thickening around the circumference
of the involved segment.
Symmetric thickening is seen in intestinal
inflammatory conditions, infections, bowel
edema, and ischemia [1] (Figs. 1214). In
addition, the bowel is usually symmetrically
thickened in cases of submucosal hemor-

Fig. 19.Exophytic intestinal mass

in 84-year-old man with bowel obstruction. Contrast enhanced axial
CT image shows large bulky exophytic mass extending from jejunum
with heterogeneous attenuation
(white arrows ). Small bubble of gas
is present in mass (black arrow ),
suggesting fistula in bowel. Surgery
revealed malignant gastrointestinal
stromal tumor.

AJR:176, May 2001

Fig. 18.Accordion sign in 44-year-old man with diarrhea and Clostridium

difficile colitis. Contrast-enhanced axial CT image of mid abdomen shows
marked thickening of haustra (arrowheads ). Barium (arrow ) trapped between
thickened haustra mimic appearance of accordion.

rhage [8, 9] (Fig. 7). Some neoplasms may

also display symmetric thickening, especially scirrhous carcinoma and, occasionally,
lymphoma [1, 14] (Fig. 11).
Asymmetric or eccentric bowel thickening
is mainly seen with malignant conditions. An
exception to this is cases of long-standing
Crohns disease in which the bowel may be
asymmetrically thickened. Usually, associated
mesenteric findings will help establish the diagnosis of Crohns disease in these cases.
Most neoplasms present with asymmetric
thickening, including stromal tumors, adenocarcinoma, carcinoids, metastases, and, occasionally, lymphoma. A bulky exophytic mass
is usually present in patients with gastrointestinal stromal tumors, metastases, and, occasionally, lymphoma. Irregular short asymmetric
lesions with abrupt margins are the hallmark

of primary intestinal adenocarcinoma and metastatic disease [12] (Fig. 20).

Focal, Segmental, or Diffuse Bowel Wall
Thickening and Location

The extent and location of bowel wall involvement should be evaluated. It is important
to determine if the bowel wall thickening is focal (a few centimeters), segmental (1030 cm),
or diffuse (involving most of the small bowel
or colon). Although inflammatory or neoplastic conditions may overlap in the length of involvement, the analysis helps in narrowing the
differential diagnosis (Appendix 4). With few
exceptions, long segments of involvement are
seen in benign conditions.
Focal Involvement

Focal thickening is seen in both benign and

malignant processes. Most neoplasms of the gastrointestinal tract present as a focal area of bowel
wall thickening (Figs. 10 and 20). Inflammatory
processes that may present as focal areas of
bowel wall thickening include diverticulitis, appendicitis, and, occasionally, tuberculosis.
Segmental Involvement

A segmental distribution of involvement is usually caused by an inflammatory process. Conditions associated with segmental involvement
include Crohns disease, infectious ileitis, radiation
enteritis, and ischemia [1, 38]. Other considerations for segmental involvement include intramural hemorrhage and lymphoma (Figs. 7 and 11).

1111

Macari and Balthazar

Downloaded from www.ajronline.org by 202.62.16.132 on 04/17/15 from IP address 202.62.16.132. Copyright ARRS. For personal use only; all rights reserved

Diffuse Involvement

Diffuse thickening of the bowel wall is

seen with a variety of inflammatory conditions, including ulcerative colitis, infectious enteritis, edema from low-protein
states, portal hypertension associated with

cirrhosis, and low-flow ischemia [30, 32,

33, 39] (Fig. 21). Segmental or diffuse
thickening may be seen in patients with
small-bowel vasculitis, as often occurs in
systemic lupus erythematosus [3537]
(Fig 12).

Associated Abnormalities

Last, a major advantage of CT over endoscopy or barium studies is the ability of CT to

show extraintestinal manifestations of disease. These associated findings include
lymph nodes; mesenteric stranding and calcification; abscess, sinus tracts, and fistulas;
proliferation of fat; vascular occlusion; and
solid organ abnormalities.
Lymph Nodes

Fig. 20.CT scans of focal asymmetric thickening in 59-year-old man show importance of rectal distention.
A, Axial scan at level of rectum shows lack of distention (arrow ), which limits the examination.
B, Axial scan at same level as A performed after administration of rectal air shows focal asymmetrically thickened ulcerated mass (arrow ) on nondependent wall of rectum. Biopsy revealed rectal adenocarcinoma.

Fig. 21.Diffuse mild colonic wall

thickening in 35-year-old woman. Contrast-enhanced axial CT image shows
mild circumferential wall thickening of
ascending and descending colons
(arrows ). Diffuse mild colitis suggests
infection or ulcerative colitis. Endoscopy revealed ulcerative colitis.

The number, size, location, and attenuation of lymph nodes in the abdominal and
pelvic cavities are important associated findings when examining patients with thickened
bowel [4346].
Attenuation.The attenuation of lymph
nodes and the presence or absence of calcification should be evaluated [45, 46]. Low-attenuation lymph nodes with a rim of contrast
enhancement or calcified lymph nodes should
alert one to the possibility of tuberculosis,
other mycobacterial infections, or histoplasmosis (Fig. 22). In a patient with AIDS, the
presence of high-attenuation lymph nodes suggests the possibility of Kaposis sarcoma. In
this condition, the lymph nodes are hyperemic
and will show enhancement during CT performed with IV contrast material.
Neoplasm.On CT, focal colonic wall
thickening may present a challenge in the differential diagnosis. When present, especially
in the sigmoid or descending colon, the main
differential diagnosis is adenocarcinoma versus diverticulitis (Fig. 23). A recent study
found that pericolonic lymph nodes adjacent to
the focal area of colonic thickening are more
commonly seen in patients with colon cancer.
Pericolonic inflammatory changes are more
commonly seen in diverticulitis [43].
In addition to low-attenuation lymph
nodes caused by tuberculosis, metastatic
lymphadenopathy from mucinous tumors of

Fig. 22.42-year-old woman with

low-attenuation caseating lymph
nodes in intestinal tuberculosis.
A, Contrast-enhanced axial CT image
of cecum shows irregular focal thickening (arrow ) with associated small
regional lymph nodes (arrowhead ).
Findings mimic cecal carcinoma.
B, Contrast-enhanced axial CT image 1 cm cephalad to A shows larger
lymph node with central low attenuation (arrow ). Endoscopy and biopsy
revealed cecal tuberculosis.

A
1112

AJR:176, May 2001

Downloaded from www.ajronline.org by 202.62.16.132 on 04/17/15 from IP address 202.62.16.132. Copyright ARRS. For personal use only; all rights reserved

CT of Bowel Wall Thickening

Fig. 23.Benign versus malignant colonic lesion: importance of lymphadenopathy.
A, Contrast-enhanced axial CT scan of descending colon in 43-year-old man shows mild bowel wall thickening (straight arrow ) with fluid in adjacent paracolic
gutter (arrowhead ). Small diverticulum is present
(curved arrow ). Findings are consistent with mild focal
diverticulitis, which resolved after antibiotic therapy.
B, 66-year-old man with left-sided abdominal pain.
Contrast-enhanced axial CT image at level of descending colon shows mild thickening (long arrow )
with fluid and stranding in adjacent paracolic gutter
(arrowhead ). In addition, cluster of small lymph nodes
is seen in adjacent pericolonic fat (short arrow ). This
finding (lymphadenopathy) is more commonly present
in focal adenocarcinoma than in diverticulitis. Surgery
revealed adenocarcinoma, and seven of nine lymph
nodes tested positive for lymphadenopathy.

Fig. 24.Mesenteric mass with calcification and adjacent desmoplastic reaction in 80-year-old woman with abdominal pain.
Contrast-enhanced axial CT image of abdomen shows soft-tissue mass with small calcifications (black arrow ) in mesentery
(straight white arrow ). Note desmoplastic response with stranding of adjacent fat and associated bowel wall thickening (curved
arrow ). Surgery revealed carcinoid tumor.

Fig. 25.Abscess in Crohns disease in 21-year-old man. Contrast-enhanced axial

CT image of pelvis shows segmental distal ileal thickening with target sign (white
arrow ) and abscess in right iliopsoas muscle (black arrow ).

AJR:176, May 2001

Fig. 26.Colonic edema in cirrhosis in 50-year-old man. Contrast-enhanced axial

CT image of right colon shows mild circumferential wall thickening in right colon
and target appearance consistent with edema (arrow ). Patient did not have pain or
diarrhea. CT of liver (not shown) showed findings consistent with cirrhosis.

1113

Downloaded from www.ajronline.org by 202.62.16.132 on 04/17/15 from IP address 202.62.16.132. Copyright ARRS. For personal use only; all rights reserved

Macari and Balthazar

the colon will often be of low attenuation.
When large bulky retroperitoneal lymph
nodes are present adjacent to or in areas removed from a region of bowel wall thickening, a diagnosis of lymphoma is suggested
(Fig. 11).
Mesenteric Stranding and Calcification

Stranding.When stranding of the perienteric fat is present adjacent to a thickened segment of bowel, an inflammatory process should
be suspected. When this finding is not present,
the differential diagnosis includes lymphoma
and hemorrhage (Figs. 7 and 11). A frequent
pitfall when interpreting CT with apparent
bowel wall thickening is differentiating a disease process from pitfalls related to residual
fluid. When the perienteric fat is normal adjacent to a thickened segment of bowel, an acute
inflammatory condition is less likely (Fig. 2).
Calcification.Mesenteric calcifications
are seen in benign and malignant conditions.
Benign mesenteric calcifications may be
present in granulomatous processes such as
tuberculosis, sarcoidosis, or, rarely, fungus.
These calcifications may be present in mesenteric lymph nodes or solid organs such as
the liver or spleen. The presence of mesenteric calcification does not imply that the abnormal bowel wall thickening is related to a
granulomatous disease; it merely suggests
that these conditions should be considered in
the differential diagnosis.
Malignant neoplasms may present on CT
with calcifications in the mesentery, which is
occasionally seen in patients with treated lymphoma. Calcified foci in the mesentery can
also be seen in mucinous metastases from
ovarian or gastrointestinal neoplasms. Another neoplastic process that can present with a
calcified soft-tissue mass in the mesentery is
carcinoid tumor [12]. In these cases, a significant desmoplastic process in the mesentery is
sometimes present, tethering adjacent loops of
small bowel toward the calcified central mass
(Fig. 24). The small bowel is often thickened,
which is likely related to the peptides secreted
by the carcinoid tumor and secondary edematous changes.
Abscess, Sinus Tracts, and Fistulas

CT findings of mild, symmetric bowel

wall thickening with or without a target configuration in the distal ileum lead to a differential diagnosis of infectious enteritis,
Crohns disease, vasculitis, and radiation enteritis. Secondary findings that help establish
the diagnosis of Crohns disease include fis-

1114

tulas, sinus tracts, perienteric abscess, and fibrofatty proliferation [3, 20] (Fig. 25).

4.

Fibrofatty Proliferation

Intestinal tuberculosis is particularly difficult to distinguish from Crohns disease [21,

22]. Important clues in differentiating the
cause of the abnormal bowel are fibrofatty
proliferation or marked lymphadenopathy.
Marked low-attenuation lymphadenopathy in
abdominal tuberculosis is often the cause of
displacement of small-bowel loops on barium studies, whereas fibrofatty proliferation
is usually the cause of bowel displacement in
Crohns disease [22].
Solid Organs

When evaluating diffuse or segmental bowel

wall thickening, findings in the parenchymal organs can be helpful in establishing the differential diagnosis. Focal or segmental bowel wall
thickening with associated splenomegaly suggests the diagnosis of lymphoma.
The differential diagnosis for diffuse colonic
edema is infectious, idiopathic (ulcerative), or
ischemic colitis. However, patients with cirrhosis may also develop intestinal edema. The
edema most often occurs in the small bowel and
occasionally in the stomach and colon, especially the right colon [6, 39] (Fig. 26).
Conclusion

Bowel wall thickening revealed on CT is

seen as normal variants, inflammatory conditions, and gastrointestinal neoplasms. A careful analysis of several parameters described in
this reviewpattern of attenuation and enhancement; degree, symmetry, and extent of
thickening; and associated abnormalities
will avoid most pitfalls, indicate a diagnosis of
primary intestinal lesions, or offer a pertinent
differential diagnosis. Although none of the
solitary CT findings is by itself specific, the association of several abnormal parameters will
lead to a correct diagnosis or will narrow the
differential diagnosis in most cases. When
confusing or overlapping CT parameters are
encountered or uncertainties persist, barium
examinations should be liberally used as complementary diagnostic studies.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.
19.

20.

21.

References
1. Balthazar EJ. CT of the gastrointestinal tract: principles and interpretation. AJR 1991;156:2332
2. Shirkhoda A. Diagnostic pitfalls in abdominal
CT. RadioGraphics 1991;11:9691002
3. Gore RM, Balthazar EJ, Ghahremani GG, Miller

22.
23.

FH. CT features of ulcerative colitis and Crohns

disease. AJR 1996;167:315
James S, Balfe DM, Lee JKY, Picus D. Smallbowel disease: categorization by CT examination.
AJR 1987;148:863868
Scanlon MH, Blumberg ML, Ostrum BJ. Computed tomographic recognition of gastrointestinal
pathology. RadioGraphics 1983;3:201227
Karahan OI, Dodd GD III, Chintapalli KN, Rhim
H, Chopra S. Gastrointestinal wall thickening in patients with cirrhosis: frequency and patterns at contrast-enhanced CT. Radiology 2000;215:103107
Horton KM, Corl FM, Fishman EK. CT evaluation of the colon: inflammatory disease. RadioGraphics 2000;20:399418
Lane MJ, Katz DS, Mindelzun RE, Jeffrey RB Jr.
Spontaneous intramural small bowel hemorrhage:
importance of non-contrast CT. Clin Radiol
1997;52:378380
Balthazar EJ, Hulnick D, Megibow AJ, Opulencia
JF. Computed tomography of intramural intestinal hemorrhage and bowel ischemia. J Comput
Assist Tomogr 1987;11:6772
Rha SE, Ha HK, Lee SH, et al. CT and MR imaging features of bowel ischemia from various primary causes. RadioGraphics 2000;20:2942
Zalcman M, Van Gansbeke D, Lalmand B, Braude P,
Closset J, Struyven J. Delayed enhancement of the
bowel wall: a new CT sign of small bowel strangulation. J Comput Assist Tomogr 1996;20:379381
Buckley JA, Fishman EK. CT of small bowel
neoplasms: spectrum of disease. RadioGraphics
1998;18:379392
DiSario JA, Burt RW, Vargas H, McWhorter WP.
Small bowel cancer: epidemiological and clinical
characteristics from a population-based registry.
Am J Gastroenterol 1994;89:699701
Balthazar EJ, Noordhoorn M, Megibow AJ, Gordon RB. CT of small-bowel lymphoma in immunocompetent patients and patients with AIDS:
comparison of findings. AJR 1997;168:675680
Horton KM, Abrams RA, Fishman EK. Spiral CT
of colon cancer: imaging features and role in
management. RadioGraphics 2000;20:419430
Frager DH, Goldman M, Beneventano TC. Computed tomography in Crohn disease. J Comput
Assist Tomogr 1983;7:819824
Jacobs JE, Birnbaum BA. CT of inflammatory
disease of the colon. Semin Ultrasound CT MR
1995;16:91101
Wills JS, Lobis IF, Denstman FJ. Crohn disease:
state of the art. Radiology 1997;202:597610
Ros PR, Buetow PC, Pantograg-Brown L, Forsmark CE, Sobin LH. Pseudomembranous colitis.
Radiology 1996;198:19
Herlinger H, Furth EE, Rubesin SE. Fibrofatty
proliferation of the mesentery in Crohn disease.
Abdom Imaging 1998;23:446448
Baoudiaf M, Zidi SH, Soyer P, et al. Tuberculous
colitis mimicking Crohns disease: utility of computed tomography in the differentiation. Eur Radiol 1998;8:12211223
Makanjuola D. Is it Crohns disease or intestinal tuberculosis? CT analysis. Eur J Radiol 1998;1:5561
Philpotts LE, Heiken JP, Wescott MA, Gore RM.
Colitis: use of CT findings in differential diagnosis. Radiology 1994;190:445449

AJR:176, May 2001

Downloaded from www.ajronline.org by 202.62.16.132 on 04/17/15 from IP address 202.62.16.132. Copyright ARRS. For personal use only; all rights reserved

CT of Bowel Wall Thickening

24. OSullivan SG. The accordion sign. Radiology
1998;206:177178
25. Boland GW, Lee MJ, Cats AM, Ferraro MJ, Matthia AR, Mueller PR. Clostridium difficile colitis:
correlation of CT findings with severity of clinical disease. Clin Radiol 1995;50:153156
26. Fishman EK, Kavuru M, Jones B, et al.
Pseudomembranous colitis: CT evaluation of 26
cases. Radiology 1991;180:5760
27. Balthazar EJ, Megibow AJ, Fazzini E, Opulencia
JF, Engel I. Cytomegalovirus colitis in AIDS: radiographic findings in 11 patients. Radiology
1985;155:585589
28. Macari M, Balthazar EJ, Megibow AJ. The accordion sign on CT: a nonspecific finding in patients
with colonic edema. Radiology 1999;211:743746
29. Horton KM, Corl FM, Fishman EK. CT of nonneoplastic diseases of the small bowel. J Comput
Assist Tomogr 1999;23:417428
30. Taourel PG, Deneuville M, Pradel JA, Regent D,
Bruel JM. Acute mesenteric ischemia: diagnosis with
contrast-enhanced CT. Radiology 1996;199:623626
31. Balthazar EJ, Liebskind ME, Macari M. Intestinal ischemia in patients in whom small bowel obstruction is suspected: evaluation of accuracy,

32.

33.
34.
35.

36.

37.
38.

39.

limitations, and clinical implications of CT in diagnosis. Radiology 1997;205:519522

Mirvis SE, Shanmuganathan K, Erb R. Diffuse
small-bowel ischemia in hypotensive adults after
blunt trauma (shock bowel): CT findings and
clinical significance. AJR 1994;163:13751379
Rademaker J. Veno-occlusive disease of the colon: CT findings. Eur Radiol 1998;8:14201421
Balthazar EJ. CT of small-bowel obstruction.
(George W. Holmes lecture) AJR 1994;162:255261
Byun JY, Ha HK, Yu SY, et al. CT features of systemic lupus erythematosus in patients with acute
abdominal pain: emphasis on ischemic bowel disease. Radiology 1999;211:203209
Zizic TM, Classen JN, Stevens MB. Acute abdominal complications of systemic lupus erythematosus and polyarteritis nodosa. Am J Med
1982;73:525531
Ko SF, Cheng TT, Ng SH, et al. CT findings at lupus
mesenteric vasculitis. Acta Radiol 1997;1:115120
Blumeke DA, Fishman EK, Kuhlman JE, Zinreich ES. Complications of radiation therapy: CT
evaluation. RadioGraphics 1991;11:581600
Balthazar EJ, Gade MF. Gastrointestinal edema
in cirrhotics. Gastrointest Radiol 1976;1:215223

40. Jones B, Fishman EK, Hamilton SR, et al. Submucosal accumulation of fat in inflammatory
bowel disease: CT/pathologic correlation. J Comput Assist Tomogr 1986;10:759763
41. Muldowney SM, Balfe DM, Hammerman A,
Wick MR. Acute fat deposition in bowel wall
submucosa: CT appearance. J Comput Assist Tomogr 1995;19:390393
42. Feczko PJ, Mezwa DG, Farah MC, White BD.
Clinical significance of pneumatosis of the bowel
wall. RadioGraphics 1992;12:10691078
43. Chintapalli KN, Chopra S, Ghiatas AA, Esola
CC, Fields SF, Dodd GD III. Diverticulitis versus
colon cancer: differentiation with helical CT findings. Radiology 1999;210:429435
44. Rao PM, Rhea JT, Novelline RA. CT diagnosis of
mesenteric adenitis. Radiology 1997;202:145149
45. Pombo F, Rodriguez E, Mato J, Perez-Fontan J,
Rivera E, Valvuena L. Patterns of contrast enhancement of tuberculous lymph nodes demonstrated by
computed tomography. Clin Radiol 1992;46:1317
46. Yang Z-G, Min P-Q, Sone S, et al. Tuberculosis
versus lymphomas in the abdominal lymph
nodes: evaluation with contrast-enhanced CT.
AJR 1999;172:619623

APPENDIX 1: Patterns of Attenuation in Bowel Wall Thickening

I. Homogeneous
A. Common
1. Submucosal hemorrhage
2. Lymphoma
3. Small adenocarcinoma
B. Uncommon
1. Infarcted bowel
2. Pitfalls related to residual fluid
3. Chronic Crohns disease
4. Chronic radiation injury
II. Heterogeneous
A. Stratified attenuation
1. Common
a. Ischemia
b. Infectious enterocolitis
c. Crohns disease, ulcerative colitis
d. Vasculitis, lupus, Henoch-Schnlein purpura
e. Radiation
f. Bowel edema related to cirrhosis or low-protein state
2. Uncommon
a. Infiltrating scirrhous carcinoma (usually stomach or rectum)
b. Residual fluid and contrast material
c. Submucosal fat deposition
d. Pneumatosis
B. Mixed attenuation, common
1. Large adenocarcinoma
2. Gastrointestinal stromal tumor
3. Mucinous adenocarcinoma
Appendixes 24 are on the next page.

AJR:176, May 2001

1115

Downloaded from www.ajronline.org by 202.62.16.132 on 04/17/15 from IP address 202.62.16.132. Copyright ARRS. For personal use only; all rights reserved

APPENDIX 2: Degree of Bowel Wall Thickening

Macari and Balthazar

I. Mild Thickening (<2 cm)

A. Common
1. Infectious enterocolitis
2. Ulcerative colitis
3. Crohns disease
4. Radiation injury
5. Ischemia
6. Bowel edema in cirrhosis
7. Submucosal hemorrhage
B. Uncommon
1. Adenocarcinoma
2. Lymphoma
II. Marked Thickening (>2 cm)
A. Common
1. Adenocarcinoma, gastrointestinal stromal tumor, metastases, lymphoma
2. Severe colitis
3. Systemic lupus erythematosus
B. Uncommon
1. Crohns disease, tuberculosis, histoplasmosis, cytomegalovirus
2. Submucosal hemorrhage
APPENDIX 3: Symmetry of Bowel Wall Thickening

I. Symmetric
A. Infections of the small and large bowel
B. Ulcerative colitis
C. Crohns disease
D. Radiation injury
E. Ischemia
F. Bowel edema in cirrhosis
G. Lymphoma
H. Submucosal hemorrhage
II. Asymmetric
A. Adenocarcinoma
B. Gastrointestinal stromal tumor
APPENDIX 4: Length of Bowel Wall Thickening

1116

I. Focal (<10 cm)

A. Common
1. Diverticulitis, appendicitis
2. Adenocarcinoma
B. Uncommon
1. Lymphoma
2. Tuberculosis
3. Crohns disease
II. Segmental (1030 cm)
A. Common
1. Lymphoma
2. Crohns disease
3. Infectious ileitis
4. Radiation
5. Submucosal hemorrhage
6. Ischemia
B. Uncommon: systemic lupus erythematosus
III. Diffuse
A. Common
1. Ulcerative colitis
2. Infectious enterocolitis
3. Edema from low protein and cirrhosis
4. Systemic lupus erythematosus
B. Uncommon: ischemia

AJR:176, May 2001