23

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Review Article

:;... ,, ,. ,.., .., .

CT of the Gastrointestinal Tract: Principles and

Interpretation
Emil J. Balthazar1

The experience accumulated in daily abdominal CT scanning such as phlegmons, abscesses, and perforations. Conven-
and CT evaluation of gastrointestinal lesions has generated help- tional barium examinations remain superior to CT for evalu-
ful technical guidelines and some reliable principles of interpre- ating intraluminal and mucosal disease, but CT is far more
tatlon. These general principles are briefly discussed in this
accurate for evaluating the intramural and extraintestinal com-
review, and the importance of performing a CT examination that
ponents, including involvement of the mesentery, peritoneal
is adequate for the detection and evaluation of gastrointestinal
lesions is stressed. CT features useful in difterentiating benign cavity, retroperitoneum, and solid organs. CT therefore should
from malignant lesions, limitations and pftfalls in CT interprets- not be regarded as competing with, but as complementing,
tion, overlap in the CT appearance, and classical CT features barium examinations of the gastrointestinal tract. Contrast
leading to specific diagnoses are described and illustrated. examinations should be performed in all patients in whom the
Although CT is established as one of the most important presence, origin, or nature of the abnormality is unknown or
techniques for imaging the gastrointestinal tract, it should be uncertain at the time of the CT examination. Conversely, CT
used selectively and only in the context of appropriate clinical examinations are often required to elucidate and evaluate
and conventional radiologic examination. CT should not be re- gastrointestinal abnormalities detected or suspected on con-
garded as competing with, but as complementing, barium exam-
ventional examinations.
ination of the gastrointestinal tract.
The purpose of this review is to emphasize principles of
performing adequate CT examinations and formulate general
Technological advances in CT have changed the practice
rules of interpretation and differential diagnosis of gastroin-
of gastrointestinal radiology. With the development of high-
testinal lesions. Common pitfalls in CT interpretation, limita-
resolution scanners, technical refinements in obtaining better
tions in the diagnosis, and the characteristic CT appearance
quality studies, and the accumulated clinical experience lead-
of some of the primary gastrointestinal lesions are discussed
ing to better interpretation, the role, indications, and accuracy
and illustrated.
of CT of the gastrointestinal tract have dramatically enlarged
and improved. Technical Considerations
Today the indications for gastrointestinal examinations en-
compass a steadily expanding list of abnormalities based on Routine CT examinations of the abdomen usually result in
CT’s usefulness for (1) diagnosing or suggesting the presence the inadequate evaluation of most primary gastrointestinal
of primary gut disease; (2) evaluating the nature and extent lesions, unless a special effort is made to enhance their
of disease in patients with known gastrointestinal lesions; and visualization. Techniques used to achieve this objective vary
(3) determining the presence, location, and severity of com- and have been described in the literature [1]. The goal of
plications associated with primary gastrointestinal lesions obtaining a high-resolution study can be accomplished only

, Received May 29, 1990; accepted June 26, 1990.

, Department of Radiology, New York University-Bellevue Medical Center, 550 First Ave., New York, NY 10016. Address reprint requests to E. J. Balthazar.

AJR 156:23-32, January 1991 0361-803X/90/1561-0023 C) American Roentgen Ray Society

 24 BALTHAZAR AJA:156, January 1991

by a determined attempt to follow several general principles location of the lesion is known or clinically suspected, the
of CT examination: technique can be appropriately tailored, and the examination
1 . Visualization of the intestinal lumen and its mucosal must be monitored before it is considered completed. For a
surface and evaluation of the true thickness of the intestinal pelvic lesion, for instance, one can start with a bolus of 50 ml
wall require the gastrointestinal tract to be empty and clean of 43% contrast material at 1 .5 mI/sec at the level of the
and its lumen to be opacified and distended. Patients should diaphragm followed by 75 ml at 0.8 mI/sec. Delay the second
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fast, and adequate preparation of the colon is essential, bolus for 60 sec and again inject 75 ml of contrast material at
particularly in patients in whom colonic disease is suspected 1 .5 mI/sec while scanning over the pelvis. This technique
or known to be present. Visualization of intestinal lumen is allows imaging of the intestinal lesion at the peak of contrast
achieved by the oral administration of 700-800 ml of 2% enhancement, while permitting excellent visualization of the
diluted barium or Gastrografin (diatrizoate meglumine, entire region during the arterial and venous return phase. The
Squibb, Princeton, NJ) at least 1 hr before scanning. The presence, degree, and pattern of enhancement are some of
terminal ileal loops and cecum should be filled with contrast the important criteria used in the differential diagnosis of
material in all patients because the right lower quadrant is a primary gastrointestinal lesions and should always be consid-
common site for primary intestinal disease. This can be facil- ered in the CT evaluation.
itated by the oral administration of 1 0 mg of Metoclopramide 3. The successful acquisition of high-resolution images
or, when necessary, by a second pelvic examination 15-30 requires the liberal use of thin (5-mm) sections over the area
mm later. Stomach and colon may be filled with diluted barium suspected or known to be pathologically involved. This can
or Gastrografin. We prefer, however, the use of air (EZ gas be done, during the initial scanning, when the location of the
for the stomach and air insufflation for the colon) because the lesion is known, or during repeated scanning at the end of
procedure can be achieved easily and rapidly, it is well toler- the examination, when an abnormality is suspected but is
ated by the patients, and air provides an excellent CT contrast inadequately imaged. At this time, 1 mg IV glucagon to inhibit
medium [1 ]. Detection of subtle gastric, duodenal, or colonic peristalsis, additional barium or air in the stomach or colon,
lesions can be enhanced by repeated scans obtained with the and proper positioning of the patient should be considered
patient prone or in the left or right lateral decubitus positions, before repeated thin (5-mm) sections over the area of interest
depending on the location of the lesion, and by using well- are obtained.
established guidelines for fluoroscopic examination of the
gastrointestinal tract [1].
2. Imaging of a primary gastrointestinal lesion should be Common Pitfalls in CT Interpretation
done, whenever possible, during the arterial phase of a bolus
IV injection of iodinated contrast material by using the se- Most of the pitfalls in the CT detection and evaluation of
quential incremental table movement technique. With a rapid gastrointestinal lesions are related to technical failures.
2-sec scanner, this objective can be achieved with the help Among them, inadequate contrast filling of the intestinal lumen
of an automatic power injector with a 22-gauge angiocath, and incomplete intestinal distension during CT scanning are
and by injecting 50 ml of 43% diatrizoate at a rate of 1.5 ml/ the most common. Empty, collapsed intestinal loops or fluid-
sec followed by 140 ml at a rate of 0.8 mI/sec. When the filled bowel can present as soft-tissue density mimicking

Fig. 1.-CT scan of pseudotumor (PT) in left Fig. 2.-Correlation of bowel thickness with degree of luminal distension on CT.
upper abdomen produced by nonopacified, fluid- A, Collapsed stomach (S) located posterior to transverse colon (C) shows 1.8-cm-thick gastric
filled jejunal loops. Homogeneous appearance and wall (arrows). Note perfect symmetry and homogeneous density.
higher density of intestinal contents mimics soft- B, After luminal distension with air, stomach (S) shows a gastric wall thickness of only 1-2 mm
tissue tumor. (arrows).
 AJR:156, January 1991 CT OF GASTROINTESTINAL TRACT 25

mesenteric tumor (Fig. 1 ). Although they usually involve prox- CT Assessment of Gastrointestinal Lesions
imal jejunal loops, these pseudotumors may be located
Once a gastrointestinal lesion is detected, its radiologic
throughout the intestinal tract depending on the amount and/
features are analyzed by using criteria employed in conven-
or timing of oral contrast administration before the CT ex-
tional radiology as well as observations specific to CT imag-
amination. Furthermore, partial filling of the intestinal lumen
ing. Important considerations are location, size, and length of
can lead to false-positive or false-negative examinations be-
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involvement. It is particularly important to define the abnor-

cause of inability to determine the true thickness of the
mality as focal, segmental, or diffusely affecting an entire
intestinal wall. On CT, the normal thickness of the gastroin-
intestinal segment (i.e., stomach, colon, or small bowel). CT
testinal wall varies greatly with the degree of luminal disten-
features include degree of thickening of intestinal wall, sym-
sion. The wall is barely perceptible and no more than 1 -2 mm
metry of involvement, smooth vs irregular or lobulated inner
thick in a distended segment and appears thicker (3-4 mm)
or outer contour, and pattern of enhancement. Associated
when the intestine is collapsed or partially distended. This is
findings such as exophytic component, lymphadenopathy,
particularly true in the stomach, where the wall thickness
distal metastases, adjacent mesenteric inflammatory re-
varies considerably between 1 mm when distended to as
sponse, phlegmon, or abscess are additional important fea-
much as 2 cm when it is collapsed (Fig. 2). If the wall is
tures that are helpful in the differential diagnosis.
perceived to be evenly, concentrically, and symmetrically
thickened and it is homogeneously enhancing, the clinical
significance of this finding should be cautiously interpreted
Benign Intestinal Disease
and related to the degree of distension of the gastrointestinal
segment analyzed. The hallmark of the CT appearance of a benign intestinal
lesion is the circumferential and symmetric thickening of the
bowel wall, usually not exceeding 1 cm from the luminal to
the serosal surface (Fig. 3). The process is usually segmental
or diffusely involves the entire colon or small bowel, and
adjacent inflammatory reaction manifesting as thickened mes-
enteric fat with a streaky higher density appearance is com-
mon. Depending on the cause and the severity of the abnor-
mality, the intestinal wall may occasionally be thicker (1-2cm).
However the circumferential involvement, relative symmetry,
and segmental distribution are maintained. The involved
bowel wall has a homogeneous soft-tissue density (Fig. 4) or
exhibits alternate rings of low and high attenuation referred
to as a “double halo” (two rings) or “target” (three rings) sign
Benign Malignant (Figs. 5 and 6).

Fig. 3.-Cross section of abnormal bowel on CT. Benign disease shows

Double Halo and Target Sign
mild (0.3-1.0 cm), circumferential, and symmetric wall thickening and
adjacent mesenteric inflammatory response. Neoplastic disease exhibits
thicker bowel wall (<2 cm), asymmetric Involvement, lobulated contour, This CT appearance has been shown to be associated with
and narrowing of intestinal lumen. submucosal edema, inflammation, and/or fat deposition [2J,

Fig. 4.-CT of Crohn disease affecting termi-

nal ileum with associated mesenteric lymphade-
nopathy.
A, Segmental involvement of distal ileum with
mild, circumferential, and symmetric wall thick-
ening showing a homogeneous density (arrows).
B, Unusual regional mesenteric lymphadenop-
athy (long arrows) adjacent to thick-walled intes-
tine (short arrows). Crohn disease and large
inflammatory nodes were proved at surgery.
 26 BALTHAZAR AJR:156, January 1991
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Fig. 6.-Cross section of benign intestinal disease. Involved segment

may exhibit a homogeneous enhancing soft-tissue density, two concentric
rings of low and high attenuation (double halo sign), or three concentric
rings of high, low, and high density (target sign). Presence of two or three
concentric rings has a similar clinical significance. Degree of density
Fig. 5.-CT scan of ischemic enteritis showing alternate rings of high, difference is related to severity of mucosal hyperemia, submucosal edema,
Inflammation, or fat deposition and to quality of CT examination.
low, and high attenuation in a symmetrical, circumferential, and slightly
thickened bowel wall (arrows). Distribution is segmental, and there is
associated Intraperitoneal hemorrhagic fluid (F).
TABLE 1: Double Halo and Target Sign

1 . lschernic ententis
and it is helpful in the differential diagnosis of benign vs 2. Crohn disease
malignant disease. The different ring densities are better 3. Ulcerative colitis
appreciated during the arterial phase of enhancement and 4. Infectious colitis
5. Radiation enteritis
may be totally absent on examinations performed without IV
6. ShOnlein-Henoch purpura
contrast material or with slow, low-volume drip infusions. 7. Bowel edema associated with portal hypertension
Although originally reported in Crohn disease [3], it has since
been observed in other benign entities (Table 1) and is there-
fore not specific. In our experience it is more commonly
present in ischemic disease, but its significance should be the colonic wall, altered or absent haustral pattern, deep
judged in the context of the clinical presentation and the transmural ulcerations, and significant pericolic inflammatory
associated intestinal and mesenteric CT findings. Further- changes (Fig. 7). We have found CT to be particularly valuable
more, the detection of this sign does not signify active disease in the initial diagnosis of pseudomembranous colitis affecting
because it may occur in a burned-out inflammatory or is- debilitated persons on broad-spectrum antibiotic therapy and
chemic process in asymptomatic persons. cytomegalovirus colitis in AIDS patients [6, 7]. These patients
are often referred for examination because of sepsis and
nonspecific abdominal complaints with the diagnosis unsus-
Inflammatory Disease pected at the time of CT scanning.
The CT prototype of a typical inflammatory lesion is Crohn
disease. Because mucosal disease cannot be detected on
Intramural Hemorrhage and Intestinal lsChemia
CT, conventional barium studies remain the procedures of
choice for the initial diagnosis of Crohn disease. With CT, Intramural hemorrhage and intestinal ischemia have CT
however, this entity often can be diagnosed on the basis of features similar to those of Crohn disease as far as their
the symmetric thickening of the bowel wall (Fig. 4), segmental segmental distribution and the symmetrical, circumferential
distal ileal distribution, skipped areas of involvement, fistulas, thickening of the affected bowel wall (Fig. 5).
and other commonly associated mesenteric abnormalities Intramural hemorrhage due to anticoagulant therapy, bleed-
[4, 5]. Fibrofatty proliferation of the mesenteric fat is seen in ing diathesis, or trauma can be reliably visualized with CT.
about 40% of patients with various degrees of streakiness, The high-density wall thickening usually involves a more prox-
poorly defined heterogenous mesenteric densities (phleg- imal intestinal segment, and small amounts of mesentenc
mons), and/or well-marginated collections of fluid sometimes and/or free intraperitoneal blood may be present (Fig. 8). In
containing bubbles of air representing abscesses. Small re- the context of a proper history, these findings are character-
gional mesenteric nodes are present in about 20% of patients istic of intramural hemorrhage. Furthermore, follow-up CT
(Fig. 4). It is in the evaluation and management of these examination in these patients shows the typical and rapid
complications that CT has had the greatest impact [5]. resolution with return to a normal configuration in 7-1 4 days
Mild inflammatory colitides such as ulcerative and infectious [8]. Because of its high sensitivity, noninvasiveness, and
colitis affect only the colonic mucosa and are not optimally ability to image the entire peritoneal cavity, pelvis, and retro-
evaluated or diagnosed with CT. Forms of severe colitis, on peritoneum, CT has become the imaging technique of choice
the other hand, are easily recognized. They are characterized in patients with abnormal clotting factors who develop acute
by their diffuse distribution, marked concentric thickening of abdominal symptoms or a sudden decrease in hematocrit.
 AJR:156, January 1991 CT OF GASTROINTESTINAL TRACT 27

Fig. 7.-Pseudomembranous colitis

affecting of trans-
entire colon. CT scan
verse colon shows circumferential wall
thickening, distortion of haustral pat-
tern, and pericolic inflammation (ar-
rows). Findings are consistent with a
severe form of universal colitis but are
not etlologically specific.
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Fig. 8.-Intramural hemorrhage as-

sociated with anticoagulant therapy.
CT scan of jejunal segment in left upper
abdomen shows concentric wall thick-
ening (arrowheads) and high-density
fluid (blood, B) in adjacent mesentery.

Similar findings of mild (0.5-1 .0 cm), circumferential, and because of patchy irregular areas of lower densities related
symmetric thickening, with segmental distribution and homo- to zones of decreased blood supply and tumor necrosis
geneous or “double halo” density, is often seen in ischemic [12].
bowel disease (Fig. 5). Free intraperitoneal blood, when pres-
ent, is extremely useful in the differential diagnosis from
inflammatory disease and in securing an early diagnosis. The
Primary AdenoCarCinoma
sensitivity of CT in ischemic bowel disease is unknown but Carcinoma is by far the most common tumor affecting
appears to be limited to the more severe forms of involvement mainly the colon and stomach. In the small bowel, it is more
[9-1 1]. The role of CT in this entity is still emerging and common in the proximal duodenojejunal segment, often as-
remains somewhat controversial. Although original reports sociated with proximal intestinal obstruction. The tumor usu-
were very encouraging, later clinical investigations have ally involves only a short intestinal segment (3-5 cm) and on
shown that nonspecific abnormalities (small-bowel dilatation, CT presents as an eccentric focal mass or as a circumferential
congestive changes in mesentery) are present in 50-56%, asymmetric and irregular thickening of the bowel wall (Fig. 9).
whereas a specific diagnosis can be made in only 26-39% of Larger lesions, when examined during the bolus arterial phase
patients [9-1 1]. On good-quality examinations, CT can some- and imaged with narrow windows, show the characteristic
times establish the cause of ischemia by showing arterial patchy areas of low density representing tumor ischemia. The
occlusion or thrombosis in the superior mesenteric or portal sensitivity of CT in detecting primary adenocarcinoma varies
vein. greatly depending on the size of the lesion and the quality of
Advanced cases of ischemia in which bowel infarction has the examination. In the colon, it was reported to be 68% on
already developed are more reliably diagnosed by the detec- routine CT examination and 95% on examinations performed
tion of air in the wall of bowel (pneumatosis) associated with on clean and air-distended colons [1 2J. CT cannot be used
air in the regional mesenteric venous branches and/or intra- as a primary technique in diagnosing adenocarcinoma; how-
hepatic portal veins.
Radiation enteritis has CT features very similar to inflam-
matory and ischemic disease and can be diagnosed mainly in
the context of a proper history. The disease, in addition, has
a characteristic distribution in most persons, with involvement
of the pelvic structures including rectosigmoid and low-lying
pelvic small-bowel loops.

NeoplastiC Intestinal Disease

The hallmark of a malignant lesion on CT is eccentric or
asymmetric thickening of the bowel wall, the irregular and
Iobulated inner and outer contour, and/or the focal soft-tissue
mass usually exceeding 2 cm from the luminal to serosal
surface (Fig. 3). The area of involvement varies in size. There
is abrupt transition, luminal narrowing, and sometimes a
spiculated outer contour. Regional adenopathy and distal
mesenteric, retroperitoneal, and liver metastases, when pres-
ent, confirm the neoplastic nature of the primary lesion. The Fig. 9.-Adenocarcinoma of sigmoid colon. Magnified CT scan shows
narrowed irregular sigmoid lumen and circumferential infiltration by a
contrast-enhanced soft-tissue mass may have a homoge- lobulated and asymmetric soft-tissue mass (arrows). Colonic tumor (1) Is
neous density or, with certain lesions, appears heterogeneous compressing uterus (U), and expected intermediary fat plane is obliterated.
 28 BALTHAZAR AJR:156, January 1991

ever, in our experience it has been useful in detecting tumors sive regional and distal retroperitoneal and/or mesenteric
that were clinically unsuspected and in patients with nonspe- adenopathy [1 3]. Intestinal obstruction is unusual, but large
cific abdominal complaints. ulcerations filled with contrast material and air may be present.
Small incipient gastrointestinal lesions cannot be differen-
tiated from adenocarcinoma.
Lymphosarcoma
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In most patients, at the time of the examination, gastroin-

Leiomyosarcoma
testinal lymphosarcoma presents as a large infiltrating sub-
mucosal tumor. In these cases, two CT features allow a highly Gastrointestinal leiomyosarcoma is a bulky tumor arising
reliable preoperative diagnosis (Fig. 1 0). First, there is striking from the wall of bowel and developing into a large, lobulated,
mural soft-tissue thickening concentrically infiltrating a seg- exophytic soft-tissue mass. The characteristic CT features
ment of bowel. The segment involved is longer than most are unusually large size and very common central necrosis
adenocarcinomas (5-15 cm). The tumor may be lobulated but and liquefaction (Fig. 1 0). A large irregular central zone of
sharply defined, and as a rule, it has a homogeneous density lower attenuation and fluid/fluid levels are detected with CT
throughout (Fig. 11). Second, in most persons there is mas- (Fig. 1 2). The tumor has an oval or round configuration, and
when totally liquefied, it appears as a fluid-filled cyst with a
slightly thickened and irregular outer wall attached to an
intestinal segment [1 4]. If the site of attachment is not de-
tected, the lesion may be misdiagnosed as pancreatic pseu-
docyst or mesenteric or ovarian cyst (Fig. 1 2). Lymphadenop-
athy is not seen in patients with leiomyosarcoma because
this neoplasm spreads locally and by hematogeneous dissem-
ination and not by lymphatic permeation.

Limitations in the CT Diagnosis of Gastrointestinal

Lesions
Lymphosarcoma Leiomyosarcoma The CT characteristics of benign and malignant intestinal
lesions heretofore described are helpful in the differential
Fig. 10.-Difterential diagnosis of lymphosarcoma vs Ieiornyosarcoma. diagnosis of the majority of cases encountered in clinical
Lymphosarcoma shows focal or circumferential massive wall thickening practice. There remains, however, a good number of gastroin-
(5-10 cm), homogeneous enhancement, and extensive regional and distal testinal lesions in which the atypical CT appearance, similari-
lymphadenopathy. Leiomyosarcoma presents as a bulky, exophytlc mass
with large central zones of low density (ischemia, necrosis), or total ties and overlap in the CT presentation, and technical failures
liquefaction. There l no associated lymphadenopathy. in CT performance and interpretation lead to an erroneous

A B

Fig. 11.-Distal ileal lymphosarcoma (L). CT Fig. 12.-Gastric lelomyosarcoma presenting as a large encapsulated cystic mass.
scan shows an infiltrating circumferential, asym- A, CT scan of stomach (5) shows a deep ulcer (arrow) along proximal greater curvature posterior
metric soft-tissue mass of homogeneous density wall. Attached to wall and surrounding ulcer is a lobulated soft-tissue tumor (7) exhibIting irregular
(arrows) compressing and displacing sigmold co- patchy areas of necrosis (n). Tumor extends to anterior edge of spleen (5).
Ion (C). Barium-filled intestinal lumen is slightly B, Midabdominal CT scan shows large cystic component of tumor (T), with liquefaction, fluid-fluid
distended and featureless, and bowel is not ob- level (open arrows), and a slightly thickened irregular wall (solId arrows).
structed.
 AJA:156, January 1991 CT OF GASTROINTESTINAL TRACT 29

diagnosis. Among some of the more common and most halo sign, and particularly the presence of significant associ-
important entities leading to potential pitfalls in the CT diag- ated adenopathy are clues leading to the correct diagnosis
noses are the following: (Fig. 14).
1 . Infiltrating scirrhous carcinoma (linitis plastica), presents 3. The differential diagnosis of diverticulitis vs sigmoid
as a plaquelike or circumferential wall thickening that mimics carcinoma remains an important, common, and controversial
benign disease (Fig. 1 3). The bowel wall is 3-1 0 mm thick, clinical problem. Even in the presence of diverticula and
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the segment involved is long (1 0-1 5 cm) without abrupt pericolic inflammation, the configuration and degree of wall
transition, and the wall’s inner and outer contour is smooth thickening remain the Crucial CT indicators of the nature of
and symmetric. Despite its benign appearance, this lesion is the abnormality. The true thickness and configuration of the
easily recognized in the stomach because of its common abnormal sigmoid segment can be assessed only when the
involvement of this organ. When it involves the distal colon bowel lumen is clearly visualized and well distended, and
(rectosigmoid), it may be misdiagnosed as a form of segmen- often only with thin (5 mm) sections obtained in the middle of
tal colitis or diverticulitis (Fig. 1 3). In most instances, however, the suspected lesion (Fig. 15).
rigidity with significant narrowing of the intestinal lumen oc- The diagnosis of diverticulitis on CT can be made by
curs, and regional adenopathy and/or distal metastases se- demonstrating mild wall thickening (3-5 mm), symmetry of
cure the correct diagnosis. involvement, short segment (4-5 cm), colonic diverticula, and
2. Lymphosarcoma can have protean CT manifestations. especially pericolic inflammation, phlegmon, or abscess [15,
It appears as a focal intraluminal lesion (Fig. 1 4) or as an 16] (Fig. 1 6). In about 1 0% of patients, however, there is
infiltrating segmental intestinal lesion leading to slight circum- significant overlap in colonic wall thickness in diverticulitis and
ferential wall thickening (Fig. 1 4). When focal, it can be mis- carcinoma, particularly with lesions between 1 and 3 cm in
interpreted as a mesenchymal tumor or as adenocarcinoma. thickness [1 7]. In diverticulitis the wall thickening is seen
It can be mistaken for an inflammatory or ischemic lesion mainly in chronic, long-standing disease, and it is the result
when its involvement is segmental. In most cases however, of muscle hypertrophy, fibrosis, edema, intramural inflamma-
the slight asymmetry in wall thickening, absence of the double tion, or organized intramural inflammatory mass (Fig. 17). In

Fig. 13.-Sclrrhous carcinoma exhibiting cir-

cumferential and symmetric wall thickening and
homogeneous density of Intestinal wall on CT.
A, Gastric lumen (S) is narrowed, wallis thick-
ened (solid arrows), and numerous large lymph
nodes are In lesser omentum (open arrows).
B, Sigmoid colon (C) reveals circumferential
wall thickening (arrows) misdiagnosed as In-
flammatory or ischernlc bowel disease.

Fig. 14.-Lymphosarcoma with in-

volvement of small intestine, colon, and
lymph nodes.
A, CT scan of segment of distal
Ileum shows circumferential wall thick-
ening (solid arrows) with slight asym-
metry of involvement. Retroperitoneal
adenopathy Is visible at same level
(open arrow).
B, CT scan of upper pelvis reveals
focal homogeneous soft-tissue mass in
cecum (arrows) and massive retroper-
itoneal lymphadenopathy (LN).
 30 BALTHAZAR AJA:156, January 1991

Fig. 15.-Sigmoid adenocarcinoma optimally

imaged with air distension and thin (5 mm) sec-
ton in middle of lesion.
A, Initial CT scan through sigmoid colon (c)
reveals abnormally narrowed lumen and nonspe-
chic circumferential thickened wall (arrows). Di-
agnosis includes diverticular disease with mus-
cia hypertrophy and adenocarcinoma.
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B, Repeated thin-section (5 mm) CT scan

through sigmoid lumen (c) shows circumferential
inflftrating lesion with overhanging edge and ab-
rupt transition typical of adenocarcinoma (ar-
rows).

Fig. 16.-CT scans of acute diverticulitis of

distal descending colon.
A, Typical appearance with mild circumfer-
ential wall thickening (solid arrow), air-filled di-
verticulum (open arrow), and pericolic inflam-
matory response (I).
B, Adjacent cross section shows fluid-filled
colon (C), pericolic inflammation, and bubbles of
air (arrow) indicating sealed-oft perforation. CT
findings were proved at surgery.

these patients, CT cannot confidently be used to differentiate 1 . Gastrointestinal lipoma may occur throughout the gas-
diverticulitis from colonic carcinoma. Perforated sigmoid car- trointestinal tract. It is commonly seen in the colon and small
cinoma should be suspected when the CT features are atyp- bowel and can be suspected on conventional barium studies
ical, equivocal, or unusual. In our experience, if the colon is because of its intraluminal location, sharply defined contour,
clean, with luminal visualization, air distension, and high- and change in shape with compression. The lesion may be
resolution (5-mm-section) scanning, this differential diagnosis sessile when small (1 -2 cm), or pedunculated when it is larger.
can be made in most instances (Fig. 1 8) [1 8]. In the remaining CT can easily confirm the diagnosis with the demonstration
uncertain cases, however, barium enema should be used of a homogeneous, low-density (-50 to -1 00 H) intraluminal
liberally as an important complementary examination, to avoid defect (Fig. 1 9). With small lesions, thin sections (5 mm) and
potential CT errors. In addition, when the acute abdominal adequate contrast filling of the bowel lumen are required for
findings subside, and if surgical resection is not contemplated, a successful evaluation [19].
sigmoidoscopy or barium enema should be performed to 2. Small-bowel carcinoid. The sensitivity of CT in the de-
confirm the CT diagnosis. tection and diagnosis of gastrointestinal carcinoids is not
known. On the basis of their morphologic features, CT’s
sensitivity should be low for small intramural lesions, and its
Typical CT Appearance of Gastrointestinal Lesions specificity should be unimpressive for the colonic or gastric
lesions. Some of the primary small-bowel lesions, however,
A few primary gastrointestinal lesions present with CT have exhibited characteristic CT features allowing a reliable
features that are virtually pathognomonic. They have no dif- and specific diagnosis to be made. The primary lesion located
ferential diagnosis and do not require endoscopy or barium commonly in the terminal ileum appears as a small, round,
studies for confirmation. In our experience, CT has been very and slightly lobulated soft-tissue mass that may contain cen-
helpful and specific in the diagnosis of the following lesions: tral calcifications (Fig. 20). A radiating soft-tissue pattern
 AJR:156, January 1991 CT OF GASTROINTESTINAL TRACT 31
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Fig. 17.-Sigmoid diverticulitis exhibiting neo- Fig. 18.-CT scans of perforated sigmoid adenocarcinoma.
plastic CT features. Note sIgnIficant circumferen- A, Pelvic CT scan shows poorly encapsulated abscess (A) and asymmetric thickening of adjacent
tIal wall thickening (arrows), narrowed lumen with sigmoid colon (c). Intramural tumor (T) has spread through serosa into adjacent pericolic fat (t).
apparent abrupt transition, and pericolic inflam- B, Bulk of primary sigmoid (C) tumor is better seen on a more caudal pelvic cross section. Pelvic
mation (I). CT was suggestive of adenocarcinoma; abscess (A) is present anterior to sigmoid tumor (T).
barium enema showed diverticulitis.

Fig. 19.-Intussuscepted jejunal lipoma.

A, Barium examination revealed a jejunal in-
tussusception (small arrows) with leading intra-
luminal mass (large arrows) of unknown cause.
B, Thin-section (5 mm) CT scan shows con-
centric layers of intussusception (open arrow)
and a fat-containing intraluminal tumor (solid
arrow) representing jejunal lipoma. Radiologic
findings were proved at surgery.

reminiscent of a sunburst is seen in the periphery of the lesion represents the invaginated intestinal loop (intussusceptum).
and in the adjacent mesenteric fat (Fig. 20). Loops of small Eccentrically and adjacent to it is the invaginated low-density
bowel are displaced and sharply angulated in the vicinity of mesentery. The peripheral outer contour is formed by the
the primary lesion, betraying the dermoplastic mesenteric receiving intestinal loop (intussuscipiens), which is sharply
reaction common in this entity. In our experience, these defined (Fig. 21). Luminal contrast material may be seen
features have been highly reliable for intestinal carcinoids. trapped between the two loops. The underlying neoplasm
3. Intestinal intussusception in adults occurs rarely, but it may or may not be detected on CT depending on its size and
is often associated with a benign or malignant neoplasm density [20]. Although the CT detection of intestinal intussus-
necessitating surgical intervention. In most of these patients, ception is reliable, its cause and clinical significance should
CT can rapidly and reliably establish the diagnosis by showing be evaluated in the context of the clinical presentation and in
a characteristic intestinal complex, targetlike mass [20] (Fig. association with other pertinent CT findings such as small-
21). On cross section, the inner central density of the mass bowel obstruction or metastases.
 32 BALTHAZAR AJR:i56, January 1991
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Fig. 20.-Distal ileal carcinoid tumor with mesenteric spread and desmoplastic reaction.
A, Plain abdominal film reveals ringlike calcification (arrow) in right side of lower abdomen.
B, CT scan shows soft-tissue intestinal tumor containing central calcifications (large arrow) and a radiating pattern resembling sunburst (small arrows).
C, Adjacent cross section reveals striated, radiating mesenteric reaction (arrows) displacing and kinking adjacent intestinal loops.

Fig. 21.-CT scans of ileocolocolic intussus-

ception due to cecal carcinoma.
A, Ascending colon shows two concentric
rings (c) representing intussuscepted colon.
Central loop of small intestine (I) and adjacent
luminal mesenteric fat (f) complete typical-ap-
pearing complex mass (arrows).
B, More cranial section reveals soft-tissue
mass of adenocarcinoma (T) and associated
proximal intussusception (arrows) containing
mesenteric fat (f).

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