The Mucosal Pattern of the Terminal Ileum in Children

Abstract

The mucosal pattern of the barium-filled normal terminal ileum under pressure in the adult appears as slender regular lines (Fig. 1) produced by the mucosal folds (Golden, 1). These folds may run either longitudinally or transversely. Referring to adults, Golden commented on the fact that the lymphoid cell collections in the mucous membrane do not produce a recognizable effect on the barium shadow. The mucosal pattern of the terminal ileum in children has been found to differ from that of adults. The purpose of this paper is to present evidence showing that this difference is produced by the relatively larger and more prominent normal lymphoid cell collections in children and that it is not abnormal. Anatomy The wall of the normal small intestine is composed of four coats, the serosa, tunica muscularis, submucosa, and mucosa (Fig. 2). The tunica muscularis consists of an outer longitudinal and inner circular layer. The submucosa consists of connective tissue, blood vessels, and lymph vessels. The mucosa is composed of the muscularis mucosa, the tunica propria, and the epithelium. The mucosal folds (valvulae con-niventes) are much higher and more numerous in the jejunum than in the ileum. These produce the mucosal pattern seen in barium studies. Small lymph nodes are present in the mucosa and submucosa; the apex of these solitary lymphatic nodes forms a domelike elevation of the surface of the mucous membrane. They are more numerous and higher in the ileum and may coalesce to form conglomerate groups of 20 to 30 nodules, commonly called Peyer's patches; these may be as much as 10 cm. in length (2). With increasing age, after puberty, the lymphoid tissue in the intestine, as well as that elsewhere in the body, is reduced in quantity (3). Roentgen Observations In routine gastro-intestinal studies on children under thirteen years of age, in the Babies Hospital (New York), it was noted that the terminal ileal pattern was different from that seen in adults. Small, rounded filling defects rather than slender, regular lines were found when pressure films were made. Since the patients in which these observations were made were examined because of abdominal complaints, it was decided to examine asymptomatic children as a further check on the roentgenographic appearance of the ileum. Studies were accordingly made on 14 hospitalized children, none of whom had abdominal complaints or was seriously ill. These patients were given barium sulfate in the morning on a fasting stomach. In 9 cases the barium was suspended in tap water; in the remaining 5 the suspension was made with normal saline, with distilled water, to rule out a possible response to an allergen. The patients were examined by fluoroscopy about two hours and a half later, and at intervals thereafter until the terminal ileum was filled. If the terminal ileum was not filled with barium after four hours, the patient was allowed to have food.