Abdominal Radiology

, Volume 42, Issue 5, pp 1319–1341 | Cite as

Multidetector CT enterography of focal small bowel lesions: a radiological–pathological correlation

  • Farnoosh Sokhandon
  • Sayf Al-katibEmail author
  • Lawrence Bahoura
  • Alexander Copelan
  • Daniel George
  • Dominic Scola
Pictorial Essay


Focal small bowel lesions present a diagnostic challenge for both the radiologist and gastroenterologist. Both the detection and characterization of small bowel masses have greatly improved with the advent of multidetector CT enterography (MD-CTE). As such, MD-CTE is increasingly utilized in the workup of occult gastrointestinal bleeding. In this article, we review the spectrum of focal small bowel masses with pathologic correlation. Adenocarcinoma, the most common primary small bowel malignancy, presents as a focal irregular mass occasionally with circumferential extension leading to obstruction. Small bowel carcinoid tumors most commonly arise in the ileum and are characterized by avid enhancement and marked desmoplastic response of metastatic lesions. Aneurysmal dilatation of small bowel is pathognomonic for lymphoma and secondary findings of lymphadenopathy and splenomegaly should be sought. Benign small bowel masses such as leiomyoma and adenoma may be responsible for occult gastrointestinal bleeding. However, primary vascular lesions of the small bowel remain the most common cause for occult small bowel gastrointestinal bleeding. The arterial phase of contrast obtained with CTE aids in recognition of the vascular nature of these lesions. Systemic conditions such as Peutz–Jeghers syndrome and Crohn’s disease may be suggested by the presence of multiple small bowel lesions. Lastly, potential pitfalls such as ingested material should be considered when faced with focal small bowel masses.


CT enterography Focal small bowel 


Compliance with ethical standards


No funding was received for this study.

Conflicts of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Statement of informed consent was not applicable since the manuscript does not contain any patient data.


  1. 1.
    Maglinte DD, O’Connor K, Bessette J, Chernish SM, Kelvin FM (1991) The role of the physician in the late diagnosis of primary malignant tumors of the small intestine. Am J Gastroenterol 86:304–308PubMedGoogle Scholar
  2. 2.
    Ciresi DL, Scholten DJ (1995) The continuing clinical dilemma of primary tumors of the small intestine. Am Surg 61:698–703PubMedGoogle Scholar
  3. 3.
    Paulsen RS, Huprich J, Fletcher J, et al. (2006) Diagnostic tool in evaluating small bowel disorders: review of clinical experiences with over 700 cases. RadioGraphics 26:641–662CrossRefGoogle Scholar
  4. 4.
    Deepak G, Sharma V, Rana S, Bhasin D (2014) Small bowel bleeding: a comprehensive review. Gastroenterol Rep 2:262–275CrossRefGoogle Scholar
  5. 5.
    Huprich J, Fletcher J, Fidler J (2011) Obscure GI bleeding: the role of multiphase CT enterography. Appl Radiol. Accessed at 4 Feb 2015 from
  6. 6.
    Dabaja BS, Suki D, Pro B, Bonnen M, Ajani J (2004) Adenocarcinoma of the small bowel: presentation, prognostic factors, and outcome of 217 patients. Cancer 101(3):518–526 (PubMed PMID: 15274064)CrossRefGoogle Scholar
  7. 7.
    Weber NK, Fletcher JG, Fidler JL, et al. (2014) Clinical characteristics and imaging features of small bowel adenocarcinomas in Crohn’s disease. Abdom Imaging 40(5):1060–1067 ([Epub ahead of print])CrossRefGoogle Scholar
  8. 8.
    Buckley JA, Fishman EK (1998) CT evaluation of small bowel neoplasms: spectrum of disease. Radiographics 18(2):379–392CrossRefGoogle Scholar
  9. 9.
    Soyer P, Boudiaf M, Fishman EK, et al. (2011) Imaging of malignant neoplasms of the mesenteric small bowel: new trends and perspectives. Crit Rev Oncol Hematol 80(1):10–30. doi: 10.1016/j.critrevonc.2010.09.010 CrossRefPubMedGoogle Scholar
  10. 10.
    Loke TK, Lo SS, Chan CS (1997) Case report: Krukenberg tumors arising from a primary duodenojejunal adenocarcinoma. Clin Radiol 52(2):154–155CrossRefGoogle Scholar
  11. 11.
    Cronin CG, Scott J, Kambadakone A, et al. (2012) Utility of positron emission tomography/CT in the evaluation of small bowel pathology. Br J Radiol 85(1017):1211–1221. doi: 10.1259/bjr/64534573 CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Iacobuzio-Donahue, CA. II, Montgomery, E. Gastrointestinal and liver pathology. Copyright © 2012, 2005 by Saunders, an imprint of Elsevier Inc.Google Scholar
  13. 13.
    Pelage JP, Soyer P, Boudiaf M, et al. (1999) Carcinoid tumors of the abdomen: CT features. Abdom Imaging 24(3):240–245CrossRefGoogle Scholar
  14. 14.
    Horton KM, Kamel I, Hofmann L, Fishman EK (2004) Carcinoid tumors of the small bowel: a multitechnique imaging approach. AJR Am J Roentgenol 182(3):559–567CrossRefGoogle Scholar
  15. 15.
    Soyer P, Dohan A, Eveno C, et al. (2013) Carcinoid tumors of the small-bowel: evaluation with 64-section CT-enteroclysis. Eur J Radiol 82(6):943–950. doi: 10.1016/j.ejrad.2013.02.013 CrossRefPubMedGoogle Scholar
  16. 16.
    Horton KM, Fishman EK (2004) Multidetector-row computed tomography and 3-dimensional computed tomography imaging of small bowel neoplasms: current concept in diagnosis. J Comput Assist Tomogr 28(1):106–116CrossRefGoogle Scholar
  17. 17.
    Fernandes DD, Galwa RP, Fasih N, Fraser-Hill M (2012) Cross-sectional imaging of small bowel malignancies. Can Assoc Radiol J 63(3):215–221. doi: 10.1016/j.carj.2010.10.001 CrossRefPubMedGoogle Scholar
  18. 18.
    Mendelson RM, Fermoyle S (2006) Primary gastrointestinal lymphomas: a radiological-pathological review. Part 2: Small intestine. Australas Radiol 50(2):102–113CrossRefGoogle Scholar
  19. 19.
    Ghai S, Pattison J, Ghai S, et al. (2007) Primary gastrointestinal lymphoma: spectrum of imaging findings with pathologic correlation. Radiographics 27(5):1371–1388CrossRefGoogle Scholar
  20. 20.
    Morgan PB, Kessel IL, Xiao SY, Colman M (2004) Uncommon presentations of Hodgkin’s disease. Case 1. Hodgkin’s disease of the jejunum. J Clin Oncol 22(1):193–195CrossRefGoogle Scholar
  21. 21.
    Pisters PWT, Blanke CD, von Mehren M, et al. (2011) A USA registry of gastrointestinal stromal tumor patients: changes in practice over time and differences between community and academic practices. Ann Oncol 22(11):2523–2529CrossRefGoogle Scholar
  22. 22.
    Ma GL, Murphy JD, Martinez ME, Sicklick JK (2015) Epidemiology of gastrointestinal stromal tumors in the era of histology codes: results of a population-based study. Cancer Epidemiol Biomarkers Prev 24:298CrossRefGoogle Scholar
  23. 23.
    Zhao X, Yue C (2012) Gastrointestinal stromal tumor. J Gastrointest Oncol 3(3):189–208PubMedPubMedCentralGoogle Scholar
  24. 24.
    Hong X, Choi H, Loyer EM, et al. (2006) Gastrointestinal stromal tumor: role of CT in diagnosis and in response evaluation and surveillance after treatment with imatinib. Radiographics 26(2):481–495CrossRefGoogle Scholar
  25. 25.
    Tateishi U, Hasegawa T, Satake M, et al. (2003) Gastrointestinal stromal tumor. Correlation of computed tomography findings with tumor grade and mortality. J Comput Assist Tomogr 27:792–798CrossRefGoogle Scholar
  26. 26.
    Lens M, Bataille V, Krivokapic Z (2009) Melanoma of the small intestine. Lancet Oncol 10(5):516–521CrossRefGoogle Scholar
  27. 27.
    Kouladouros K, Gartner D, Munch S, et al. (2015) Recurrent intussusception as initial manifestation of primary intestinal melanoma: case report and literature review. World J Gastroenterol 21(10):3114–3120CrossRefGoogle Scholar
  28. 28.
    Sachs DL, Lowe L, Chang AE, et al. (1999) Do primary small intestinal melanomas exist? Report of a case. J Am Acad Dermatol 41(6):1042–1044CrossRefGoogle Scholar
  29. 29.
    Elsayes KM, Al-Hawary MM, Jagdish J, et al. (2010) CT enterography: principles, trends, and interpretation of findings. Radiographics 30(7):1955–1970CrossRefGoogle Scholar
  30. 30.
    Gong F, Swain P, Mills TN (2000) Wireless endoscopy. Gastrointest Endosc 51:725–729CrossRefGoogle Scholar
  31. 31.
    Xynopoulos D, Mihas A, Paraskevas E, Dimitroulopoulos D, et al. (2002) Small bowel tumors. Ann Gastroenterol 15:18–35Google Scholar
  32. 32.
    Gourtsoyiannis N, Mako E (1997) Imaging of primary small intestinal tumors by enteroclysis and CT with pathological correlation. Eur Radiol 7:625–642CrossRefGoogle Scholar
  33. 33.
    Thompson W (2005) Imaging and findings of lipomas of the gastrointestinal tract. Am J Roentgenol 184(4):1163–1171CrossRefGoogle Scholar
  34. 34.
    Heiken JP, Forde KA, Gold RP (1982) Computed tomography as a definitive method for diagnosing gastrointestinal lipomas. Radiology 142:409–414CrossRefGoogle Scholar
  35. 35.
    Savides TJ, Jensen DM (2010) Gastrointestinal bleeding. In: Feldman M, Frience S, Brandt LJ (eds) Sleisenger and Fordtran’s gastrointestinal and liver disease, 9th edn. Philadelphia: Elsevier MedicineGoogle Scholar
  36. 36.
    Raju GS, Gerson L, Das A, Lewis B, American Gastroenterological A (2007) American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology 133:1697–1717CrossRefGoogle Scholar
  37. 37.
    Huprich JE, Barlow JM, Hansel SL, Alexander JA, Fidler JL (2013) Multiphase CT enterography evaluation of small-bowel vascular lesions. AJR Am J Roentgenol. 201(1):65–72CrossRefGoogle Scholar
  38. 38.
    Imdahl A (2001) Genesis and pathophysiology of lower gastrointestinal bleeding. Langenbecks Arch Surg 386:1CrossRefGoogle Scholar
  39. 39.
    Singh AK, Federman DD (2015) Scientific American medicine. Ontario/Philadelphia: Decker Electronic Publishing, Inc.Google Scholar
  40. 40.
    Hara AK, Walker FB, Silva AC, Leighton JA (2009) Preliminary estimate of triphasic CT enterography performance in hemodynamically stable patients with suspected gastrointestinal bleeding. AJR Am J Roentgenol 193(5):1252–1260CrossRefGoogle Scholar
  41. 41.
    Soyer P (2012) Obscure gastrointestinal bleeding: difficulties in comparing CT enterography and video capsule endoscopy. Eur Radiol 22:1167–1171CrossRefGoogle Scholar
  42. 42.
    Huprich JE, Fletcher JG, Fidler JL, et al. (2011) Prospective blinded comparison of wireless capsule endoscopy and multiphase CT enterography in obscure gastrointestinal bleeding. Radiology 260:744–751CrossRefGoogle Scholar
  43. 43.
    Liao Z, Gao R, Xu C, Li ZS (2010) Indications and detection, completion and retention rates of small bowel capsule endoscopy: a systemic review. Gastrointest Endosc 71:280–286CrossRefGoogle Scholar
  44. 44.
    Boley SJ, Sammartano R, Adams A, et al. (1977) On the nature and etiology of vascular ectasias of the colon: degenerative lesions of aging. Gastroenterology 72:650–660PubMedGoogle Scholar
  45. 45.
    Poralla T (1998) Angiodysplasia in the renal patient: how to diagnose and how to treat? Nephrol Dial Transplant 13:2188–2191CrossRefGoogle Scholar
  46. 46.
    Regula J, Wronska E, Pachlewski J (2008) Vascular lesions of the gastrointestinal tract. Best Pract Res Clin Gastroenterol 22:313–328CrossRefGoogle Scholar
  47. 47.
    Huprich JE (2009) Multi-phase CT enterography in obscure GI bleeding. Abdom Imaging 34(3):303–309CrossRefGoogle Scholar
  48. 48.
    Boley SJ, Sprayregen S, Sammartano RJ, Adams A, Kleinhaus S (1977) The pathophysiologic basis for the angiographic signs of vascular ectasias of the colon. Radiology 125:615–621CrossRefGoogle Scholar
  49. 49.
    Baxter M, Aly EH (2010) Dieulafoy’s lesion: current trends in diagnosis and management. Ann R Coll Surg Engl 92:548–554CrossRefGoogle Scholar
  50. 50.
    Dulic-Lakovic E, Dulic M, Hubner D, et al. (2011) Bleeding Dieulafoy lesions of the small bowel: a systematic study on the epidemiology and efficacy of enteroscopic treatment. Gastrointest Endosc 74:573–580CrossRefGoogle Scholar
  51. 51.
    Norton ID, Petersen BT, Sorbi D, et al. (1999) Management and long-term prognosis of Dieulafoy lesion. Gastrointest Endosc 50:762–767CrossRefGoogle Scholar
  52. 52.
    Boyle L, Lack EE (1993) Solitary cavernous hemangioma of the small intestine: case report and literature review. Arch Pathol Lab Med 117:939–941PubMedGoogle Scholar
  53. 53.
    Tang SJ, Jutabha R, Jensen DM (2002) Push enteroscopy for recurrent gastrointestinal hemorrhage due to jejunal anastomotic varices: a case report and review of the literature. Endoscopy 34:735–737CrossRefGoogle Scholar
  54. 54.
    Norton ID, Andrews JC, Kamath PS (1998) Management of ectopic varices. Hepatology 28:1154–1158CrossRefGoogle Scholar
  55. 55.
    Watanabe N, Toyonaga A, Kojima S, et al. (2010) Current status of ectopic varices in Japan: results of a survey by the Japan Society for Portal Hypertension. Hepatol Res 40:763–776CrossRefGoogle Scholar
  56. 56.
    De Palma GD, Rega M, Masone S, et al. (2005) Mucosal abnormalities of the small bowel in patients with cirrhosis and portal hypertension: a capsule endoscopy study. Gastrointest Endosc 62:529–534CrossRefGoogle Scholar
  57. 57.
    Rana SS, Bhasin DK, Jahagirdar S, et al. (2006) Is there ileopathy in portal hypertension? J Gastroenterol Hepatol 21:392–397CrossRefGoogle Scholar
  58. 58.
    Giardiello FM, Trimbath JD (2006) Peutz–Jeghers syndrome and management recommendations. Clin Gastroenterol Hepatol 4:408–415CrossRefGoogle Scholar
  59. 59.
    Utsunomiya J, Gocho H, Miyanaga T, et al. (1975) Peutz–Jeghers syndrome: its natural course and management. Johns Hopkins Med J 136:71–82PubMedGoogle Scholar
  60. 60.
    Vogel T, Schumacher V, Saleh A, et al. (2000) Extraintestinal polyps in Peutz–Jeghers syndrome: presentation of four cases and review of the literature. Deutsche Peutz–Jeghers–Studiengruppe. Int J Colorectal Dis 15:118–123CrossRefGoogle Scholar
  61. 61.
    Betts AD, Latchford AR, Vasen AR, et al. (2010) Peutz–Jeghers syndrome: a systematic review and recommendations for management. Gut 59(7):975–986CrossRefGoogle Scholar
  62. 62.
    Buck JL, Hamed RK, Lichenstein JE, Sobin LH (1992) Peutz–Jeghers syndrome. RadioGraphics 12:365–378CrossRefGoogle Scholar
  63. 63.
    Jass JR, Williams CB, Bussey HJ, et al. (1988) Juvenile polyposis—a precancerous condition. Histopathology 13:619–630CrossRefGoogle Scholar
  64. 64.
    Buck J, Dachman A, Sobin L (1991) Polypoid and pseudopolypoid manifestations of inflammatory bowel disease. RadioGraphics 11:293–304CrossRefGoogle Scholar
  65. 65.
    Sinha R, Rajiah P, Murphy P, Hawker P, Sanders S (2009) Utility of high-resolution mr imaging in demonstrating transmural pathologic changes in Crohn disease. RadioGraphics 29(6):1847–1867CrossRefGoogle Scholar
  66. 66.
    Elpek GO, Bozova S, Kupesiz GY, Ogus M (2007) An unusual cause of cholecystitis: heterotopic pancreatic tissue in the gallbladder. World J Gastroenterol 13(2):313–315CrossRefGoogle Scholar
  67. 67.
    Rooney DR (1959) Aberrant pancreatic tissue in the stomach. Radiology 73:241–244CrossRefGoogle Scholar
  68. 68.
    Thoeni RF, Gedgaudas RK (1980) Ectopic pancreas: usual and unusual features. Gastrointest Radiol 5:37–42CrossRefGoogle Scholar
  69. 69.
    Grendell JH, Ermak TH (1998) Anatomy, histology, embryology, and developmental anomalies of the pancreas. In: Felman M, Friedman L, Brandt L (eds) Sleisenger & Fordtran’s gastrointestinal and liver disease. Philadelphia, PA: Saunders, pp 761–771Google Scholar
  70. 70.
    Wei R, Wang WB, Chen QH, Liu JS, Zhang B (2011) Upper gastrointestinal tract heterotopic pancreas: findings from CT and endoscopic imaging with histopathologic correlation. Clin Imaging 35(5):353–359CrossRefGoogle Scholar
  71. 71.
    Kim JY, Lee JM, Kim KW, et al. (2009) Ectopic pancreas: CT findings with emphasis on differentiation from small gastrointestinal stromal tumor and leiomyoma. Radiology 252(1):92–100CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  1. 1.Department of Radiology, Beaumont HealthOakland University William Beaumont School of Medicine, Royal OakRoyal OakUSA

Personalised recommendations