Springer-Verlag France S.A.R.L

Pierre Bret, Christine Cuche and Gerard Schmutz

Radiology of the small intestine Preface by Igor Laufer

Foreword by Henri N ahum

With 550 illustrations

Springer-Verlag France S.A.R.L

Pierre Bret 2, quai Augagneur 69003 Lyon France

Christine Cuche 28, avenue Foch 07300 Toumon France

Gerard Schmutz Hospices civils de Strasbourg Service de Radiologie - Clinique medicale B 1, place de I'H6pitai 67091 Strasbourg Cedex France

Translation supervised by Alan Barkun

All translation, reproduction and adaptation rights reserved for all countries.

The law of March 11, 1957 forbids copies or reproductions intended for collective use. Any representation, partial or integral reproduction made by any process whatsoever without the consent of the author or his executors os illicit and constitutes a fraud dealt with by Articles 425 and following of the Penal Code.

© Springer-Verlag France 1989 Originally published by Springer-Verlag France, Paris In 1989 Softcover reprint of the hardcover 1st edition 1989

The use of registred names, trademarks, etc. in this publications does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product Liability ; The publisher can give no guarantee for information about drug dosage and application there of contained in this book. In every individual case the respective user must check its accuracy by consultinf other pharmaceutical literature.

2918/3917/543210 - Printed on Acid-free paper.

ISBN 978-2-8178-0893-2 ISBN 978-2-8178-0891-8 (eBook) DOI 10.1007/978-2-8178-0891-8

Preface

There is a tradition behind the current radiologic examination of the small bowel. Many of the great names in gastrointestinal radiology have established their reputations on the basis of their work in the small bowel. This is an area which is assuming ever greater importance for radiologists as its mucosal surface continues to elude the endos­copist. Moreover, it is an aspect of radiology which calls for the greatest technical and interpretative skill.

It is a great pleasure to welcome the English language version of this beautiful work on Radiology of the Small Intestine. English­speaking physicians are frequently not as familiar with the large body of work published in French as they should be. Tant pis ! Dr. Bret and his co-workers have been pioneers in the pursuit of excellence in gastrointestinal radiology. During all the years that I have been involved in this field, I have admired their work.

This volume on the small bowel is typical of their approach to gastrointestinal radiology. It combines the best elements of radiological art and science. It is a pleasure to leaf through this book just to glance at the pictures. The text is also clear and gives much valuable advice regarding the diagnosis of diseases in the small bowel. I am sure that all physicians will find this book of value since it relies not on any single technique but on the entire range of imaging modalities that apply to the small bowel. Never­theless, the emphasis is clearly on barium studies and I am sure that this volume will serve as an inspiration to all physicians who work in this area.

Igor Laufer, M.D.

Foreword

Gastrointestinal radiology has been at the forefront of French Radiology for decades: the technical perfection of the examinations and the sophisticated precision of their analysis are part of our heritage. Endoscopy first challenged and quickly, it must be said, replaced the radiological examination.

But the radiologists stand firm and double-contrast techniques have since continued to improve the performance of conventional Radiology; we must realise though that today, in the late 1980 s, this effort has yielded only a moral victory.

Y et one area remains unchallenged: the small bowel. Up to now, this mass of innumerable superimposed loops had remained an enigma for contrast Radiology. Unfamiliar with the organ's pathology and uncomfortable with the imaging techniques required, the radiologists had long abandoned this field, thus limiting its diagnostic work-up to physiological testing.

All the credit belongs to Pierre Bret for having deciphered this riddle. Pierre Bret is a complete radiologist, both conventional and innovative, he is a practicioner and a teacher. Technically demanding, analytically rigorous and clinically superb, he is one of the great masters of gastrointestinal Radiology.

He was the first in France to use double contrast techniques, to opacify directly the biliary ducts, and perform radiologically guided biopsies. He is today the undisputed nationalleader in digestive Radiology.

Limiting hirnself to the practical and the useful, Pierre Bret has fathered a simple and reproducible technique of examination of the small bowel. He has perfected an analytical model which is easily learned. From the constellation of signs he describes, stems a reliable and brilliant diagnostic precision based on a rigorous methodology.

This book is both the product and the essence of a man and his School.

Translated from Henri Nahum's preface to the French version of this textbook

Introduction

The small intestine is the Iongest part of the gastrointestinal tract. It ensures digestion and absorption of food and plays an important part in immunity. Direct endoscopic exploration is confined to its extremities. The small bowel is the privileged domain of Radiology. It provides the only technique that allows for the morphological study of all its loops. Complementary studies include ultrasound, computed tomography and angiography.

Today's radiologists can use a reliable technique based on the conti­nuous opacification and palpation of all intestinal loops under fluoroscopic monitoring. The films thus obtained must be studied methodically. This book contains the description of technical requirements and of a method of analysis needed to obtain and interpret the films. They are followed by radiological descriptions of small bowel pathology. Wehave thus attempted to include all the elements needed to carry out and interpret the radiological examination of the small intestine. Webase this work on our personal experience as well as the published literature. As the bibliography of such a book cannot be complete, we have had to choose the references we found most useful and have listed them at the end of each chapter.

The authors wish to thank:

- Alain Chayvialle, who reviewed the «clinical notes» in this book,

- Pierre Bensimon, who reviewed the anatomicopathological notes in this book,

- all our colleagues who contributed to illustrating this book: Jean-Pierre Barbut, Fran\=oise Berger, Michel Bretagnolle, Alain Fond, Denis Gauthier, Gerard Gay, Guy Jeannot, Jean-Pierre Moiroud, Jean-Marie Pouillaude,

- the members of GERMAD (research group on the radiological study of digestive pathology): Jean-Michel Bigot, Patrice Bret, Jean-Michel Bruel, Jean-Baptiste Carcy, Jean De Toeuf, Louis Engelholm, Christian Garcin, Claude Guien, Louis Jourde, Claude L'hermine, Pierre Mahieu, Yves Menu, Maurice Piante, Jacques Pringot, Denis Regent, Pierre-Jean Valette

- Alan Barkurr for his help with the english version of this textbook.

References works

Dünndarmradiologie : Einführung und Atlas (1988) Antes G, Eggemann F. Springer-Verlag Berlin

Gastro-enterologie (1986) Bernier JJ. Flammarion, Paris

Gastroenterolgy (1985) Bockus H. Saunders, Philadelphie (4e edition)

Radiologie de l'intestin grele et du colon : technique et semiologie (1981) Bret P. SIMEP, Lyon

L'intestin grele normal et pathologique (etude clinique et radio­logique) (1957) Cherigie E, Hillemand P, Proux CH, Bourdon R. Expansion scientifique fran<_;aise, Paris

Precis des maladies du tube digestif (1977) Sous la direction de CH Debray et Y Geffroy. Masson, Paris

Encyclopedie medico-chirurgicale (1988) Editions Seguier' Paris

Radiologie examination of the small intestine (1959) Golden R. Lippincott, Philadelphie (2e edition)

Double cantrast gastro-intestinal radiology (1979) Laufer I. Saunders , Philadelphie

Alimentary Tract Roentgenology (1973) Margulis AR, Burhenne HJ. Mosby

Radiology of the small intestine (1976) Marshak RH, Lindner AE. Saunders, Philadelphie

Traite de radiodiagnostic (1982) : - Tarne IV- Urgences abdominales, grele et colon Nahum

H, Geindre M, Bigot JM, Monnier JM, Sterin P. Masson, Paris

- Tarne XVIII - Radiopediatrie : appareil digestif et urinaire Lefebvre S, Faure C, Sauvegrain J, Nahum H, Portier­BeauHeu M, Hassan M. Masson, Paris

Radiologie clinique de l'intestin grele (1954) Poreher P, Buffard P, Sauvegrain J. Masson, Paris

Radiology of the small bowel. Modern enteroclysis - Technique and atlas (1982) Sellink JL, Miller RE. Martinus Nijhoff

Contents

Preface V

Foreword ....... ... ....... ... ....... ... .. ... .. ..... ... .. ..... ... .. ... ............. ... ..... ... ... VII

Introduction . ... .. ... ..... .. ..... .... ... ..... ... .. ..... ..... ........ ..... ... ... .. ... ... ... .. ... . IX

Clinical and technical aspects ....................................................... . General review ............................................................................ .

Embryology ........................................................................... . Anatomy ................................................................................. 1 Histology . .. ... .. . .. ... .. ..... ... .. ..... ... .. ..... ... .. .. . .. ... .. ..... ... ... .. ..... ... ... 2 Physiology. .. ... ..... ... .. .. ... ... .. .. . .. ... .. .. ... ... .. ..... ... .. ... ..... ... .. ... ... ... 3 Clinical findings .. .. .. ... ... .. .. ... ..... .. ... ..... .. ... ... .. .. ... ... ... .. ... ......... 4 Physiologie testing .. .. .. ... ... .. .. ... ..... .. ... ... .. .. ... ... ... .. ... ............. .. 4 Endoscopic studies ...... ..... ... .. ..... ... .. .. ... ... .. ... ... ..... ..... ... .. ... ... .. 5 Radionuclide scanning ... .. .. ... ... .... ... ..... .. . .. ... .. ... ... ... .. ... ........ .. 5

Plain film of the abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Barium studies of the small intestine . .. .. ... ... ..... ..... ... .. ... ... ... .. ... ... 6

History .................................................................................... 6 Present techniques .. .. ... ... .. .. ... ... ... .. .. ... ..... .. ... .. . .. .. ... .. . .. .. ... ...... 7 Normal radiological images ................................................... 15 Approach to the analysis of abnormal radiological images ... 17 Radiological syndromes ......................................................... 32

Other examinations with barium .. .. ... .. ... .. ... .. ... .. ... .. . .. ... .. .. . .. ... .. .. 36 Barium swallow ..................................................................... 36 Barium enema . .. ... ..... ... .. .. . .. ... .. ... .. . .. .. ... .. ... .. ... ... ... .. .. ... ... .. ... .. 36

Ultrasound ... .. .. ... ... .... ... ..... .. ... .. ... .. ... ..... .. ... ... .. ... ..... ... .. ... ... ....... ... 39 Technique ............................................................................... 39 Ultrasonographie interpretation ... .. .. ... ... .. ..... ... .. ... ... ... .. ... ... ... 40

Computed tomography .. .. .. ..... ... .. .. ... ... .. ........ .. ... ... ... .. ... ..... ..... ... . 41 Technique ............................................................................... 41 Normal appearance ................................................................ 43 Interpretation .......................................................................... 43

Arteriography ... .. ... ...... .. .. ... ..... .. ... .. .. ... .. . .. ... .. ..... .. .. . .. ... .. . . ... ... .. ... . 44 Technique . .. .. ... ... .. ... .. ... .. .. ... .. ... .. ... .. ... .... ... .. . .. .. ... .. . .. .. ... .. ... .. . . 44 Anatomy interpretation . .. ... ... .. ... .. .. . .. ... .. .. ... ... .... ... ... .. .. ... .. . .. .. 44 Interpretation .. .. .. ... .. . .. .. ... .. ... .. ... .. ... .. .. . .. ... .. ... .. ... .. ... .. ... ... .. ..... 44

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 7

XIV Radiology of the small intestine

Congenital pathology. ..................................................................... 51 Stenosis and atresia of the small intestine . . .. .. . .. . . .. . . . .. . .. . . .. .. . . . ..... 51 Segmental dilatation . . . . .. . .. ....... .. . .. .. .. ... .. . .... .. . .. .. . . . . . .. . .. .... .. . .. .. . .. . . 51 Viscera) myopathy and neuropathy ............................................. 51 Hirschsprung's disease ................................................................ 52 Adhesions, hemias, eventration ................................................... 55 Malrotations of the primitive loop ............................................... 55 Diverticula ................................................................................... 55

Diverticulosis ......................................................................... 55 Meckel's diverticulum ........................................................... 56

Dup1ication .. ... ... ... ... . .. . .. ... ... . .. . .. . .. .... ... ... ... . .. ... .. . . ... .. . .. . . .. .. . .. ... ... . 63 Heterotopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Vascu1ar abnormalities .. . .. .......... .. .. .. . .. .. . ... . .. . . . .. . . . .. .. . . . .. . . . . . . . .. . ... . 64 References .. .. ..... .. . .. .. . . .. ... . . . ... . .. . .. .. .. ... ... .. ..... .. .. . .. . . .. . .. . . . ... . .. . .. .. .. .. 65

Neoplasms. ....................................................................................... 69 lntroduction. .. .. .. ... ... ... . .. .. . .. .. .. ... ... .... .. . .. . .. . .. . ... .. . ... .. . .. . .. .. .. .. . .. . . .. .. 69 Benign tumors .. .. .. . .. . . .. . . . .. ....... .. . .. . ... . .. ... ....... .. . .. .. .. .. . .. ... . . . . .. . .. ..... 70

Pathology ............................................................................... 70 Clinical findings .. .. .. . .. . ... . .. ... .. . .. . . .. . .. .... ... .. . .. . . .. .. . .. . .. . .. . .. ... ... . . 70 Radiological findings .. .... ... .. . .. .. .. ... ... ... . .. . .. . . . . ... .. . .. . . .. .. . .. .. ..... 70 Analysis of the lesions according to histological type ........... 70

Leomyomas .. . ... ... ... ... ... ... .... .. . .. . .. . ... ... ... .. . ... ... ... ... . . . .. . .. . .. . 70 Neurogenie tumors ........................................................... 70 Fibromas . .. .. . .... ... .. .. .. ... .. ... . ... . .. . . . .. .. .. . .. ... .. .. . .. .. . .. .. . .. .. . .. .. .. 72 Lipomas ............................................................................ 72 Epithelial tumors ... ... . .. . .. . .. ..... .. .. . ... . .. . .. . . . . ... .. . .. ..... .. . .. .. .. .. 72 Vascular tu mors . .. .. . ... . .. . . . .. .. ... .. ... ..... .. . . . .. . . ... .. .. . .. .. ... .. . ... . . 72 Inflammatory tumors and pseudotumors .......................... 74 The polyposis syndromes ................................................. 76

Malignant tumors ......................................................................... 76 Carcinoid tumors .................................................................... 76 Lymphomas and immunoproliferative syndromes (Hematosarcoma) ................................................................... 86

Malignant non-Hodgkin's Iymphoma ............................... 86 Hodgkin's disease ............................................................. 93 Alpha-chain disease and mediterranean Iymphoma ...... 99 Leukemia, Waldenström's disease, plasmocytoma .......... 107 Sarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1

Adenocarcinoma .................................................................... 118 Metastases . .. ... .. . .. .. .. ... ... . .. . .. . .. ....... .. . .. . . .. . .. .. . ....... .. . .. . . .. ... .. . .. .. 121

References .................................................................................... 128

Inflammatory diseases. .. . . . .. . .. . . .. .. . .. . .... .. . .. .. .. .. . .. . .. . ... . . . .. . .. .. .. .. . ... .. .. 130 Crohn's disease ............................................................................ 130 Tuberculosis ................................................................................. 152 Yersiniosis ................................................................................... 165 Intestinal infections ...................................................................... 167 Backwash ileitis . .. . .. .. .. ... .. ... . . .. .. . .. . .... .. . . . .. .. ... .. ... ..... .. .. . .. . . .. .. . .. ..... 169 Whipple's disease ........................................................................ 169 Non-specific ulcers .. . .. ... ... ... . .. . .. ... .... ... .. . ... ... ... ... ... . .. . .. .. .. .. . .. . .. .... 172 The Zollinger-Ellison syndrome .................................................. 174 Chronic ulcerative jejunoileitis .................................................... 175

Contents XV

Beh9et's disease ........................................................................... 177 Eosinophilic gastroenteritis ......................................................... 178 References .................................................................................... 181

Celiac disease and malabsorption . ................................................. 187 Celiac disease ............................................................................... 187 Disorders causing villous atrophy other than celiac disease ....... 193

Duhring's disease ................................................................... 193 Collagenous sprue ..... ........ ...... .. .. .. . . ........ .. ... . .. ... . . . .. ... .. . .. ... ... . 193 Tropical sprue ........................................................................ 193 Lymphoma and alpha-chain disease ...................................... 193 Immunodeficient states . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 194

Functional small intestine ............................................................ 194 References .................................................................................... 195

Parasitic infections . ......................................................................... 199 Giardia lamblia ............................................................................ 199 Isospora belli ................................................................................ 199 Cryptosporidium .......................................................................... 199 Ascaris 1umbricoides ................................................................... 200 Strongy1oides stercoralis (eelworm) ............................................ 201 Ankylostoma duodenale .............................................................. 201 Anisakis ....................................................................................... 20 I Trenia saginata ............................................................................. 201 Candida albicans .......................................................................... 201 Histoplasma capsulatum .............................................................. 201 Paracoccidioides brasiliensis ....................................................... 201 Mucoracere ................................................................................... 203 References .................................................................................... 203

Vascular diseases . ............................................................................ 205 Nongangrenous intestinal ischemia ............................................. 205 Venous thrombosis ...................................................................... 212 Intramural hematomas of the small intestine ............................... 212 References .................................................................................... 212

Iatrogenic conditions . ...................................................................... 215 Drug-induced lesions ................................................................... 215

Hematomas caused by anticoagulant therapy ........................ 215 Ulcer induced by potassium chloride tablets ......................... 218 Other drug induced lesions .................................................... 218

Radiation-induced lesions ............................................................ 220 Graft-versus-host disease ............................................................. 225 References .................................................................................... 226

Immune-mediated disorders . ......................................................... 229 References .................................................................................... 232

Connective tissue diseases . .............................................................. 235 Scleroderma ................................................................................. 235 Other connective tissue diseases .................................................. 238 References .................................................................................... 238

XVI Radiology of the small intestine

Miscellaneous diseases . ................................................................... 241 Lymphangiectasia ........................................................................ 2~1 Intestinal edema caused by hypoproteinemia .............................. 243 Amy1oidosis ................................................................................. 244 Pneumatosis cystoides intestinalis ............................................... 245 Food allergies ............................................................................... 247 Henoch-Schönlein purpura .......................................................... 248 Sarcoidosis ................................................................................... 248 Intraluminal foreign bodies .......................................................... 250 Acquired diverticula .................................................................... 251 Pseudo obstruction ....................................................................... 252 Isolated transittime acceleration ................................................. 252 Fabry's disease ............................................................................. 253 Xanthomatosis ............................................................................. 254 Mastocytosis ................................................................................ 254 Abetalipoproteinemia .................................................................. 254 Hereditary angioneurotic edema .................................................. 254 Paroxysmal noctumal hemoglobinuria ........................................ 254 Degos' disease .............................................................................. 255 Wegener's syndrome ................................................................... 255 References .................................................................................... 255

Extrinsic pathology . ......................................................................... 263 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269

The post operative patient. ............................................................. 279 Post surgical small intestine ......................................................... 279

Normalimages ....................................................................... 279 Complications ........................................................................ 282

The small intestine following gastric surgery .............................. 284 Normal images ....................................................................... 284 Pathological images ............................................................... 284

References .................................................................................... 291

Acute conditions . ............................................................................. 295 Plain abdominal radiography ....................................................... 295

Air fluid Ievels ....................................................................... 295 Abnormallucencies ................................................................ 298 Abnormal opacities ................................................................ 299

Abdominal ultrasonography ........................................................ 299 Computed tomography ................................................................ 299 Iodinated enema ........................................................................... 299 Celiomesenteric arteriography ..................................................... 299 Barium studies ............................................................................. 299 References .................................................................................... 300

Practical conclusions . ...................................................................... 301