CLASSIC SIGNS IN GASTROINTESTINAL RADIOLOGY

NO SIGNS DISEASE PICTURES

1 Bird’s beak sign Achalasia – failure of LES to relax
Primary achalasia, the more common
etiology, is idiopathic. The lack of lower
esophageal sphincter relaxation is likely
due to a loss of inhibitory neurons in the
esophageal myenteric plexus. Proposed
causes include neuronal degeneration,
viral infection, genetic inheritance, and
autoimmune disease.

Secondary achalasia affects patients

much less commonly and can be caused
by entities such as esophageal
carcinoma and Chagas disease.

2 Corkscrew sign Diffuse esophageal spasm –

esophageal motility disorder
The “corkscrew” sign is the visual
manifestation of lumen-obliterating,
simultaneous, nonperistaltic
contractions within the esophagus.

3 Double-barrel The term “double-barrel esophagus”

esophagus classically refers to the radiographic
appearance of a dissection between
the esophageal mucosa and
submucosa without perforation.

Intramural esophageal dissection is

most commonly seen in middle-aged
or elderly women.
4 Bull’s eye lesions Kaposi’s sarcoma and carcinoid
tumors
Lesions within the stomach forming
central collections of oral contrast
within ulcerated intramural masses
can produce a target or bull’s eye
appearance.

5 Ram’s horn Chron’s disease

Crohn’s disease of the stomach leads
to gastric deformity, causing a
tubular shape, conical narrowing,
and limited distensibility of the
stomach.
These changes may give the stomach
an unusual shape resembling the
horn of a ram
6 Leather bottle Linitis Plastica
stiff, nondistensible wall gives the
stomach a leather bottle appearance

7 Windsock sign Intraluminal duodenal diverticulum

This windsock appearance is most
commonly located in the second
portion of the duodenum and
consists of the barium-filled
diverticulum that lies entirely within
the duodenum
8 Double bubble Duodenal Atresia
sign The double bubble sign indicates the
presence of duodenal obstruction
that can be caused by a number of
intrinsic or extrinsic etiologies.The
intrinsic causes include duodenal
webs, duodenal atresia, and
duodenal stenosis. The extrinsic
etiologies include a preduodenal
portal vein, malrotation of the gut
with a midgut volvulus or by Ladd
bands, or an annular pancreas

9 Whirpool sign Midgut Volvulus

The whirlpool appearance
represents the swirling pattern of
the gut and the superior mesenteric
vein as they wrap around the
superior mesenteric artery (SMA) in
a clockwise rotation

10 String of pearls Small-bowel obstruction

11 Stack of coins Small-bowel hematoma

12 String sign Crohn’s disease – Bowel wall
thickening
The string sign represents the
marked narrowing of the terminal
ileum lumen secondary to
symmetric, transmural
granulomatous inflammation and
subsequent fibrotic thickening of the
bowel wall
13 Ribbon sign Graft-Versus-Host-Disease
fold thickening, luminal narrowing,
separation of folds, and ultimately
complete effacement of the valvulae
conniventes.

14 Comb sign Crohn’s disease

The teeth of the comb in this
instance represent engorged small
arteries, the vasa recta, perfusing
the small bowel

The presence of the comb sign

suggests an acute exacerbation of
Crohn’s disease
15 Target sign Crohn’s disease
The target-like appearance is formed
when a thickened bowel wall
demonstrates alternating degrees of
attenuation, with an inner and outer
layer of higher attenuation and a
middle layer of lower attenuation

16 Coiled spring Intussusception

These ring shadows represent
contrast reflux within the lumen
between the walls of the
intussusceptum and intussuscipiens
17 Arrowhead Acute Appendicitis
This perceived arrowhead shape is
secondary to focal, symmetric
thickening of the cecal wall
secondary to spreading
inflammation from appendicitis.

18 Thumbprint sign Ischemic Colitis

These nodular densities represent
edema and hemorrhage into the wall
of the colon most commonly
secondary to ischemia

19 Cobblestone Crohn’s Disease – active

The cobblestone appearance of the
bowel wall is due to a combination
of extensive, broad, linear transverse
and longitudinal ulcerations within
an inflamed mucosal surface. Only
scattered islands of normal mucosa
remain in this setting

20 Bowler hat Intraluminal Polyp and Diverticulum

An intraluminal polyp will result in a
bowler-hat sign with its dome
pointed inward toward the lumen,
while a diverticulum will produce a
bowler hat sign pointed outward.
21 Mexican hat Pedunculated colonic polyps

22 Collar button active ulcerative colitis

“Collar button ulcers” are
manifestations of inflammatory
processes within the bowel.

23 Apple core Colon Carcinoma

The apple core appearance is the
visual manifestation of an annular
lesion of the bowel with irregular
overhanging edges and shouldered
margins

24 Accordion sign Pseudomembranous Colitis

This sign describes the appearance
of alternating, edematous haustral
folds that are due to transmural
edema and are separated by
transverse mucosal clefts filled with
oral contrast

The accordion sign has also been

observed with colonic edema
secondary to cirrhosis and in Crohn’s
 disease, ischemic colitis, lupus
vasculitis, and infectious colitis
25 Lead pipe Ulcerative Colitis
The lead pipe appearance likely
represents the visual manifestation
of multiple pathophysiological
processes.

26 Coffee bean sign Sigmoid Volvulus

The appearance of the coffee bean is
created by the dilated lateral walls of
the sigmoid colon forming the outer
walls of the coffee bean and the
closely apposed medial walls forming
the cleft of the coffee bean

A cecal volvulus can appear very

similar to a sigmoid volvulus;
however, a cecal volvulus should
have only one air-fluid level,
whereas a sigmoid volvulus may
demonstrate two air-fluid levels.