Bowel Wall Thickening Research Articles

Clinical characteristics of pneumoperitoneum with pneumatosis intestinalis detected using computed tomography: A descriptive study.

Pneumoperitoneum has always been considered a surgical emergency as it represents a perforation of the gastrointestinal tract. Although several cases of pneumoperitoneum with pneumatosis intestinalis (PI) have been reported, the characteristics of such cases remain unclear. The current study aimed to clarify the clinical characteristics of pneumoperitoneum cases with PI detected using computed tomography (CT).This descriptive study was conducted at a single center. In a total of 18,513 abdominal CT scans obtained between January 2010 and February 2017, extraluminal free air was detected in 254 examinations of 182 cases. The medical records and CT images of these 182 patients were retrospectively analyzed.Pneumoperitoneum with PI was detected through 23 examinations in 21 cases, and the average age of the patients was 80.1 years. The frequency was 0.12% in all abdominal CT examinations, but 24.7% in the 85 cases with extraluminal free air, excluding iatrogenic air. PI was classified as benign in 20 cases and as life-threatening in 1 case. The majority of cases with benign PI showed good general and local findings and little leukocytosis, while the case with life-threatening PI showed severe conditions. No evidence of bowel wall discontinuity, segmental bowel-wall thickening, perivisceral fat stranding, and abscesses were observed. Ascites were detected less frequently in the cases with PI than in the other pneumoperitoneum cases (P < .01). Pneumoperitoneum and PI occasionally recurred, and PI and/or extraluminal free air generally disappeared quickly.Pneumoperitoneum with PI is a relatively common condition in older patients, and the majority of cases are caused by benign PI. The characteristics of pneumoperitoneum cases with benign PI include well-maintained physical conditions, normal laboratory data, absence of CT findings indicative of peritonitis, and infrequent ascites. In pneumoperitoneum cases with PI, predicting whether the PI is benign or life-threatening is clinically very important, whereas the presence of extraluminal free air is considered to be insignificant.

Utility of bowel ultrasound in assessing disease activity in Crohn's disease.

Gastrointestinal ultrasound (GIUS) has been used increasingly for monitoring inflammatory bowel disease (IBD) patients. The aim of this study was to assess the utility of GIUS in assessing disease activity in Crohn's disease (CD). Consecutive patients with CD (diagnosis establishedfor at least 6months) between July 2017 and July 2018 requiring assessment of disease activity were prospectively assessed by magnetic resonance enterography, colonoscopy (CS), and GIUS within a 2-week period and without any change in ongoing treatment. Features on GIUS which correlated with disease activity were assessed. Sensitivity and specificity of the GIUS in assessing disease activity and localization were calculated. Thirty-five patients were enrolled in the study. Bowel wall thickness (BWT) ≥ 3mm and Doppler activity ≥ 2 had the highest sensitivity (100% and 95.6%, respectively) for detecting active disease on CS. BWT ≥ 3mm had sensitivity, specificity,positive predictive value, and negative predictive value of 100%, 83.3%, 92%, and 100%, respectively for assessing active disease. Combination of median BWT, Doppler activity, and loss of bowel wall stratification correlated with simplified endoscopic score (SES) for CD (r= 0.8, p 0.009) and Harvey-Bradshaw index (HBI, r= 0.76, p 0.04). For localizing active disease in the ileum, GIUS had a sensitivity of 93.7%, 80% for lesions in the right colon, 100% for transverse colon, and 89% for the left colon. Specificity was 100% for ileal and colonic lesions. Loss of stratification, BWT,and Doppler activity in the bowel wall correlate with endoscopic and clinical disease activityin CD. GIUS is a sensitive modality in assessing disease activity in CD.

S2657 A Common Hepatitis C Treatment With an Uncommon Finding: Abdominal Perforation After Initiation of Mavyret

INTRODUCTION: Mavyret (glecaprevir/pibrentasvir) is a prescription medicine used to treat adults with chronic Hepatitis C Virus (HCV) typically over a course of 8–16 weeks. The mechanism of action involves inhibiting HCV NS3/4A and HCV NS5A proteases, both of which are essential for viral RNA replication. The most common severe gastrointestinal (GI) adverse effects reported include reactivation of Hepatitis B infection and in rare cases hepatic failure. We present a case of an adult female found to have an atypical GI adverse effect: a contained abdominal perforation seven days after the initiation of Mavyret. CASE DESCRIPTION/METHODS: A 60-year-old Caucasian female with past medical history of hypothyroidism and cholecystectomy was referred for Hepatitis C treatment in August 2018. She denied jaundice, edema, confusion or ascites. Labs revealed elevated AST/ALT to 118/106 IU/L, normal bilirubin, alkaline phosphatase and total protein. A hepatitis panel was positive for hepatitis C antibody and negative for hepatitis A and B. Additional labs revealed a positive RNA viral load, genotype 1b with FibroSURE fibrosis score of 0.84. An abdominal US showed no cirrhosis. A FibroScan showed cirrhosis with F4 disease. In April 2019, the patient began HCV treatment with Mavyret. One week later she developed severe, sharp abdominal pain localized to the lower abdomen. She presented to an outside emergency department and was admitted after an abdominal CT scan showed severe bowel wall thickening of a loop of the distal jejunum with associated pneumatosis and potential focal perforation. The Surgery team was consulted and recommended conservative management. Mavyret was discontinued and IV antibiotics were started. Within a few days she had marked improvement in abdominal pain and was discharged home to complete a seven day course of Ciprofloxacin/Flagyl. A repeat abdominal CT scan three weeks later showed a normal liver and no abnormal bowel wall thickening, obstruction or evidence of pneumatosis. DISCUSSION: This case identifies a female found to have abdominal pain early in the onset of taking Mavyret with an abdominal CT scan concerning for a contained perforation. No other cases of perforation have been reported with Mavyret use. Whether this was an actual adverse effect of Mavyret is remains uncertain; however this case documents a potentially new and life threatening side effect of Mavyret about which patients and providers should be aware.

S3388 Tormenting Typhlon: A Rare Case

INTRODUCTION: Neutropenic enterocolitis is acute inflammation of cecum, ascending colon, terminal ileum and appendix, seen in immunocompromised patients with leukemia. Incidence in healthy adults unknown, few cases due to clostridium perfringens type A. More seen in neutropenic children/adults who had undergone induction chemotherapy for acute leukemia, lymphoma, multiple myeloma, myelodysplastic syndromes, aplastic anemia, acquired immunodeficiency syndrome, cyclic or drug induced neutropenia or immunosuppressive therapy. Frequency is increasing with use of cytotoxic agents. CASE DESCRIPTION/METHODS: 48 year old male with no history presented with 8 days of worsening abdominal pain, few days of watery brown diarrhea, no neutropenia. CT showed acute appendicitis, perforation, periappendiceal collection and marked inflammatory reaction. Patient was taken for laparoscopic appendectomy. There was generalized peritonitis, pus with feculent odor. Appendix was inflamed, not perforated. Cecum had areas with false membrane consistent with cecal gangrene. Abscess posterior to cecum was fusing medially towards mesentery of small bowel and ascending colon. Right hemicolectomy with ileal transverse anastomosis was done. Pathology consistent with gangrenous typhlitis with retroperitoneal abscess. Intraop cultures were positive for ecoli. Patient was treated with IV antibiotics and then oral. DISCUSSION: Typhlitis, is neutropenic enterocolitis of ileocecal region. Cecum is affected due to diminished vascularization. Signs & symptoms: right lower quadrant pain, fever, abdominal distention, cramping, tenderness, nausea, vomiting, diarrhea, and hematochezia. Histology: bowel wall thickening, ulcers, mucosal loss, intramural edema, hemorrhage and necrosis. Patients suspected of typhlitis should have oral & IV contrast for CT. Blood & stool cultures, and C dificile toxin testing. CT can show bowel wall thickening, bowel dilation, mesenteric stranding, mucosal enhancement and pneumatosis. Cultures positive for polymicrobial infection. Treatment in patients without complications: bowel rest, NG suction, IV fluids, nutritional support & broad spectrum antibiotics covering pseudomonas, e coli, gram-negative bacilli & anaerobes. Surgical intervention if signs of perforation, bleeding despite correction of coagulopathy and cytopenias. It mimics appendicitis like in our patient leading to immediate surgery. It is important to consider neutropenic enterocolitis in the differential diagnosis of patients that are not immunocompromised.Figure 1Figure 2

S2833 A Midlife Crisis - A Rare Case of Late Onset Eosinophilic Gastroenteritis in a Middle-Aged Male, Caused by a New Onset Dairy Allergy

INTRODUCTION: Eosinophilic gastroenteritis (EG) is a rare disease of the digestive tract characterized by gastrointestinal tract (GIT) eosinophilia, abnormal function of the GIT and exclusion of other causes of eosinophilia (Eos). It is seen in 28/100,000 persons with equal male to female distribution with the majority of cases seen in children. Majority of occurrences can be linked to a food hypersensitivity especially if atopy (asthma, eczema, hay fever) is co-expressed. CASE DESCRIPTION/METHODS: 54-year-old male with dyspepsia and atopy presented with abdominal pain, vomiting, diarrhea and weight loss. He was discharged with diagnosis of gastroenteritis and dyspepsia. On last admission CBC showed Eos 39% and CT scan with gastric, small bowel and colonic thickening. Stool enteric pathogens, C. diff, ova and parasites, ESR/CRP, autoimmune panel, IGE levels, EGD and colonoscopy with biopsies were obtained. Autoimmune serologies were negative, ESR and CRP were elevated. Duodenal biopsy was negative for celiac disease but gastric and colonic biopsies revealed 34 Eos per Hpf. Patient worked on a dairy farm and consumed 4 servings of dairy per day his entire life. During the hospitalization he was placed on a dairy-free diet and was started on oral steroids. His symptoms improved in 48 hours. As an outpatient he underwent allergen testing, revealing grass allergies as well as a severe dairy allergy. He was tapered off steroids, placed on a PPI and with diet modification has been asymptomatic for over a year. DISCUSSION: EG in adults is likely missed as it can be self limited in up to 50% of cases. Careful history, high level of suspicion and a meticulous diagnostic approach is imperative to decrease the need for hospitalizations, and improve quality of life in patients with EG. Overall, there is conflicting data in regards to long term management. Studies of antihistamines, mast-cell stabilizers, leukotriene receptor antagonists, even biologic monoclonal antibodies as an adjunct to dietary modification all have yielded equivocal results. Corticosteroids are considered as the gold standard of therapy, but their unfavorable long term effects limit their use. Over the last 16 years there has been an increase in prevalence of EG, and there is growing evidence linking functional dyspepsia (FD) with an increase in GIT Eos. Prevalence of food sensitivities in FD has not been adequately studied, however it can possibly identify a largely underdiagnosed population with EG.Figure 1.: CT with IV Contrast showing small bowel and gastric wall thickening, with mesenteric edema and small volume ascites.Figure 2.: Endoscopic view of the Gastric Body and Antrum (Upper Panels), and small bowel with mild erythema (Lower Panels).Figure 3.: Hematoxylin and Eosin stain of representative gastric mucosa with noted eosinophilic infiltrate (white arrow).

S2797 First Case of Isolated Angioedema of the Bowel Caused by Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

INTRODUCTION: Visceral angioedema (VA) has been widely reported as a side-effect of angiotensin-converting enzyme inhibitors (ACEI). We report the first case of VA from NSAIDs. CASE DESCRIPTION/METHODS: An 80 y/o F with history of multiple abdominal surgeries, hypertension on lisinopril, and lumbago on aspirin 325 mg twice daily presented with acute epigastric pain, nausea, and vomiting. A CT scan showed moderate thickening and dilation of the distal small bowel (SB), without transition point. Symptoms resolved within days with supportive measures. One month later, while asymptomatic, a non-contrast MRI for pancreatic cyst surveillance showed normal SB. Two weeks after the MRI, her abdominal symptoms recurred. CT scan revealed multiple dilated, edematous fluid-filled stretches of SB, without transition point. Symptoms resolved spontaneously within days. Two months later, symptoms returned, with CT showing similar edema in the colon wall (Figure 1). Due to sharp angulations from edematous bowel, only a gastroscope could traverse the colon, with normal appearance of mucosa from the anus to the hepatic flexure. No SB evaluation was attempted due to SB edema. She improved after conservative management. She discontinued her lisinopril. One month later, symptoms recurred, with CT scan showing worsened bowel wall edema from prior CT (Figure 2). Labs were unremarkable for serum complement C4, C1 esterase inhibitor functional assay, extended stool pathogen panel, complete blood count, monoclonal gammopathy screen, and serum cytomegalovirus DNA. Aspirin was stopped. Symptoms abated within 24 hours. Five weeks later, while asymptomatic, her CT showed normalization of bowel wall (Figure 3). In no episode did the patient experience constitutional symptoms, dermatologic changes, dyspnea/wheezing, diarrhea, melena, or hematochezia. She had no new exposure to medications, travel, or dietary changes. In all cases where intravenous contrast was used, splanchnic vessels were patent. DISCUSSION: Episodic bowel obstructive symptoms associated with bowel thickening—and interval clinical improvement paralleling radiologic improvement of bowel thickening—illustrate the cadence of VA. As the VA occurred one month after stopping her ACEI, and symptoms resolved after stopping NSAIDs, it was likely triggered by her NSAID use. The shared pathogenesis and presentation of angioedema and enteropathy caused by NSAIDs provide a rationale for NSAID-induced VA. In patients without resolution of VA after stopping ACEI, NSAID cessation is the next step.Figure 1.: Computed tomography scan of the abdomen with intravenous contrast showed diffuse wall thickening of the descending and rectosigmoid colon. No transition point observed. Wall thickening, edema, and increased mucosal enhancement of multiple loops of the ileum and distal jejunum were observed, as well.Figure 2.: Computed tomography scan of the abdomen with intravenous contrast showed worsened evaluation compared to the previous scan. Diffuse wall thickening of the descending and rectosigmoid colon can be seen. No transition point can be seen. Wall thickening, edema, and increased mucosal enhancement of multiple loops of the ileum and distal jejunum were observed as well.Figure 3.: Five weeks after discontinuing her twice-daily aspirin, the patient underwent computed tomography scan with oral contrast (no intravenous contrast used), which showed interval resolution of the small bowel and colon wall thickening.

S2312 Management Dilemmas of an Intra-Abdominal Abscess in Crohn’s Disease

INTRODUCTION: Intra-abdominal abscess is a common complication affecting 10-28% of patients with Crohn’s disease. Abscesses often affect the peritoneum and the retroperitoneum. These abscesses are often formed spontaneously by fistula, hematologic seeding, or with surgical intervention. CASE DESCRIPTION/METHODS: An 18-year-old male with Crohn’s disease presents with fever, right hip pain, and increasing loose stools. CT abdomen showed active colitis involving the cecum, ascending colon and distal ileum. There was also fistulization from the ascending colon or terminal ileum to an irregular right-sided iliopsoas abscess which measured approximately 6.6 × 4.9 × 4.3 cm. A percutaneous drainage (PD) catheter was placed into the abscess and he was managed with antibiotics and steroids. He was discharged with the drain in place due to high volume output. About three weeks later, patient was found to be septic with increasing purulent drainage and pain in the drain site. Repeat CT abdomen showed almost complete resolution of abscess but minimally improved mural thickening of the terminal ileum, cecum and proximal ascending colon as well as extensive phlegmonous changes in the iliopsoas muscle. He was again treated and discharged on antibiotics and steroids. In the outpatient IBD clinic, steroids were tapered and he was started on infliximab 5 mg/kg monotherapy with proactive therapeutic drug monitoring. His drain was removed after he had minimal output and a fistulogram without persistent abscess or fistula. His infliximab was increased to 10 mg/kg every 6 weeks after being sub-therapeutic week 10. DISCUSSION: Crohn’s disease complicated by intra-abdominal abscess presents two management dilemmas. First, is the method for drainage of the abscess. Traditionally, abscesses were treated with early surgical intervention. Currently, initial PD is favored as it allows for either avoidance of surgery and it decreases the likelihood of a multi-stage surgery. PD is successful in 74-100% of cases, although 8-20% will need more than one drainage. The second dilemma is the use of immunosuppression to treat active Crohn’s disease which could theoretically worsen the abscess. This has not been well studied but in a case series, 55% of patients had abscess resolution and were able to avoid surgery when treated with both high-dose steroids and antibiotics. Some experts favor initiation of anti-TNF therapy immediately after PD placement, while others wait for complete drainage of the abscess.Figure 1.: Original irregular right-sided iliopsoas abscess measuring 6.6 × 4.9 × 4.3 cm.Figure 2.: Resolution of iliopsoas abscess with drainage catheter in place. Continued mural thickening of bowel wall.

S1834 A Case of Neutropenic Enterocolitis With a Hyperinflammatory Twist

INTRODUCTION: Neutropenic enterocolitis is a life-threatening diagnosis of exclusion commonly presenting with fever, abdominal pain, and radiographic evidence a thickened bowel wall (1). Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immune-mediated disorder characterized by systemic inflammation, severe cytokine storms, and organ damage (2). HLH is commonly triggered by viral infection or malignancy and is associated with significant in-hospital mortality (3). It is not commonly triggered by bacterial infection and does not typically present as neutropenic enterocolitis. We present a case of a patient who presented with neutropenic enterocolitis, which may have been a cause or consequence of HLH. CASE DESCRIPTION/METHODS: A 56-year old African American male with hypertension, type 2 diabetes mellitus, end-stage renal disease on hemodialysis, cardiomyopathy, and recurrent left-sided pleural effusions, presented with sudden-onset diffuse abdominal pain associated with nausea, vomiting, and non-bloody diarrhea. On admission, he was febrile and tachypneic. On exam, he appeared to be in pain. His abdomen was nondistended with hypoactive bowel sounds. He exhibited guarding, and there was tenderness to palpation, however there was no rebound tenderness. His labs were significant for bicytopenia (leukopenia and anemia), and a lactate of 9.42 mmol/L. CT scan of the abdomen and pelvis was consistent with enterocolitis (Figure 1). Despite supportive measures with broad spectrum antibiotics and fluids, his mental status and respiratory status declined, eventually requiring an ICU level of care. Although no specific pathogen was identified, workup revealed a likely diagnosis of HLH. Patient was treated with intravenous steroids, followed by a steroid taper. Treatment with etoposide was postponed due to the patient’s renal dysfunction, rapid deterioration and death. DISCUSSION: Neutropenic enterocolitis has yet to be documented as the initial presentation of HLH. We present a case of a patient who presented with severe neutropenic enterocolitis, who met diagnostic criteria for HLH. The overlap between diagnostic features of severe sepsis and HLH made the diagnosis of HLH challenging. Continued rapid decline and persistent leukocyte dysfunction prompted further investigation, which led to his diagnosis. Early identification of HLH in the setting of neutropenic enterocolitis may expand therapeutic possibilities and help improve outcomes for patients with this life-threatening condition.Figure 1.: Radiographic image revealing diffuse large bowel wall thickening.

S3542 Ulcerative Roux Limb Jejunitis: Unusual Finding on Endoscopy

INTRODUCTION: Obesity is a common health issue in the United States. Roux-en-Y Gastric Bypass (RYGB) is most frequently performed in the US. Although, it has promising effects on weight loss but overall complication rate is 21% (1). We present a unique case of ulcerative roux limb jejunitis. CASE DESCRIPTION/METHODS: 38 y/o female with a history of RYGB 13 yrs ago presented with LUQ abdominal pain and dark stools of one day's duration. She took Motrin and drank a large quantity of alcohol 4 days prior to presentation. Subsequently, she began been having intermittent LUQ abdominal discomfort with loss of appetite and nausea. She had no history of GI bleed. Her last endoscopy and colonoscopy in 2015 were normal. She smokes cigarettes 1 PPD, is a social drinker, and has no history of IVDA. Abd exam was positive for LUQ tenderness but no rebound tenderness. DRE was negative for melena. Labs showed Hb 14.8, BUN/Cr 5/0.5, AST/ALT 153/121, lipase 1053, lactic acid 2.3, vit B12 169, ANA/ASMA/ESR/viral hepatitis panel/EtOH/fibrin split products/UDS normal. CT abdomen pelvis with IV contrast showed bowel wall thickening and inflammatory change surrounding the loop of bowel emanating from the bypass. Esophagogastroduodenoscopy (EGD) showed inflammation involving the gastric pouch and extending from the gastrojejunal anastomosis (at 45 cm) to involve almost the entire roux limb (about 35 – 40 cm in length). It was characterized by marked edema, erythema, friable mucosa with erosion and ulceration. There was a short afferent limb with inflammation. The jejunojejunal anastomosis was normal at about 90cm. Biopsies were taken and histopathology showed acute inflammation. Based on the EGD findings, ischemia was a concern but CTA abdomen and pelvis were unremarkable. Her Hb remained stable during the hospital course and she was discharged with outpatient follow up with GI and surgery. DISCUSSION: RYGB is associated with early and late postoperative complications which include anastomotic leak, ileus, GI tract hemorrhage, anastomotic stricture, bowel obstruction, intussusception, and marginal ulceration. However, extensive jejunitis both involving the entire roux limb and confined to the roux limb has rarely been reported. NSAID and heavy alcohol consumption were thought to be the culprit in light of negative CTA abdomen.Figure 1.: GastroJejunal Anastomosis showing friable mucosa, ulceration, erosions, and extensive inflammation.Figure 2.: Roux limb showing extensive inflammation and hemorrhagic appearance.Figure 3.: Roux limb showing extensive inflammation.

S2854 Peripheral T-Cell Lymphoma, Not Otherwise Specified (PTCL, NOS) Presenting With Gastrointestinal Bleeding in an HIV Patient

INTRODUCTION: Peripheral T-Cell lymphomas (PTCL) are a rare type of Non-Hodgkin’s Lymphoma (NHL) with an incidence of < 1 case per 100,000 people in the USA. PTCL, not otherwise specified (NOS) is an EBV-associated malignancy, encompassing a spectrum of disorders that do not fulfill the criteria of other PTCL subtypes. Presentation of PTCL, NOS with gastrointestinal bleeding has only been described in rare case reports. CASE DESCRIPTION/METHODS: A 32-year-old female with congenital HIV, on highly active anti-retroviral therapy (HAART), presented with multiple episodes of hematochezia, diffuse abdominal pain and hypotension. After hemodynamic stabilization with multiple units of packed red blood cells and intravenous fluids, esophagogastroduodenoscopy and colonoscopy were performed revealing no obvious source of bleeding. Subsequently, CT scan and MRI of the abdomen delineated two segments of small bowel wall thickening, luminal narrowing and mesenteric lymphadenopathy. Capsule endoscopy showed scattered patches of erythematous mucosa in the small bowel without active bleeding or stigmata of bleeding. Afterwards, she underwent a small bowel push enteroscopy revealing a large, non-obstructing, infiltrative mass in the mid-jejunum which was successfully biopsied (Figure 1). Biopsy was consistent with PTCL, NOS with a high Ki-67 proliferation index (80-90%) and positive Epstein-Barr encoding regions-in situ hybridization (EBER-ISH) (Figure 2, 3). Further staging workup showed a normal bone marrow biopsy. PET-CT scan demonstrated intense FDG uptake in jejunum and small bowel segments in the left and right lower quadrants but no distant metastases. During the preparation for chemotherapy, she developed acute small bowel perforation. Given the rapid deterioration, definitive treatment was not feasible. After family discussions, she was transferred to inpatient hospice where she passed away. DISCUSSION: Push enteroscopy is an effective tool for the diagnosis of small bowel malignancies like PTCL. The presence of HIV increases the risk of PTCL by 15 times and adversely impacts the prognosis, with a median survival of around 1 year. Around 30% cases of PTCL, NOS are EBV positive and the presence of EBER-ISH portends worse outcomes. Induction with anthracycline-based chemotherapy regimens along with brentuximab vedotin (an antibody-drug conjugate against CD30) for CD30 + PTCL, and early consolidation with autologous stem cell transplant (ASCT) are the cornerstones of PTCL, NOS treatment.Figure 1.: Small bowel push enteroscopy: Panel (A) and (B) show a prominent mass lesion in the mid-jejunum. Panel (C) and (D) show the same area after biopsy and tattooing.Figure 2.: Small bowel mucosa with large pleomorphic cells infiltrating the lamina propria. Surface ulceration and extensive areas of punctate necrosis are also present. Figure (A) is X10 and Figure (B) is X25 magnification.Figure 3.: The large pleomorphic cells are positive for (A) CD3 (B) CD7 and (C) CD8 immunostains as well as (D) EBER-ISH (X25).

Features of Intestinal Disease Associated With COVID-Related Multisystem Inflammatory Syndrome in Children.

ABSTRACTMultisystem inflammatory syndrome in children (MIS-C) is a recently identified syndrome that appears to be temporally associated with novel coronavirus 2019 infection. MIS-C presents with fever and evidence of systemic inflammation, which can manifest as cardiovascular, pulmonary, neurologic, and gastrointestinal (GI) system dysfunction. Presenting GI symptoms are seen in the majority, including abdominal pain, diarrhea, and vomiting. Any segment of the GI tract may be affected; however, inflammation in the ileum and colon predominates. Progressive bowel wall thickening can lead to luminal narrowing and obstruction. Most will have resolution of intestinal inflammation with medical therapies; however, in rare instances, surgical resection may be required.

Abdominal imaging findings in patients with SARS-CoV-2 infection: a scoping review.

PurposeThis scoping review evaluated the currently available data related to abdominal imaging in the SARS-CoV-2 infection.MethodA systematic review of MEDLINE, EMBASE, SCOPUS, and Web of Science was performed from inception to July 15, 2020 using PRISMA-ScR guidelines. The review included case reports and series discussing radiologic manifestations of SARS-CoV-2 infection in abdominal imaging studies. Studies published from inception to March 31, 2020, were independently screened and reviewed by one author, and another author reviewed studies published after March 31 to July 15, 2020. Study screening and full-text review for publications before March 31, 2020, was performed by one author, and another author for publications after March 31 to July 15, 2020.ResultsThirty-six studies were included in qualitative synthesis. The prevalence of gastrointestinal symptoms is roughly 18% and includes loss of appetite, nausea, vomiting, diarrhea, and abdominal pain. Sixteen percent of COVID-19 cases may only present with gastrointestinal symptoms. Many patients presenting this way demonstrate evidence of COVID-19 incidentally through abdominal CT imaging at the lung bases. Studies published to date have also reported abdominal imaging findings including small and large bowel wall thickening, fluid-filled colon, pneumatosis intestinalis, pneumoperitoneum, intussusception, and ascites.ConclusionGastrointestinal manifestations and imaging manifestations of SARS-CoV-2 infection are increasingly reported and warrant specific attention during abdominal imaging.Electronic supplementary materialThe online version of this article (10.1007/s00261-020-02739-5) contains supplementary material, which is available to authorized users.

The association between mesenteric fat hypertrophy and behavior and activity of Crohn's disease

Objective: Mesenteric fat hypertrophy is present in about a quarter of Crohn's disease (CD) patients and it can be easily detected by bowel ultrasound (US). The purpose of this research was to assess the correlation between mesenteric fat hypertrophy and behavior and activity of CD. Methods: A total of 89 CD patients who admitted to the First Affiliated Hospital of Nanjing Medical University from August 2018 to November 2019 were recruited in this study. The total CD patients were divided into two groups depending on with or without mesenteric fat hypertrophy by US tests. Crohn's disease activity index (CDAI), simplified endoscopic score for Crohn's disease (SES-CD), serum inflammatory indicators and fecal calprotectin were assessed. Results: Mesenteric fat hypertrophy was significantly associated with stricturing behavior (B2, P<0.01). CDAI (P=0.002) , blood platelet (P=0.001) , C-reactive protein (P=0.024) , fecal calprotectin (P=0.004) and bowel wall thickness (P<0.01) in patients with mesenteric fat hypertrophy were significantly higher than those without, but not the erythrocyte sedimentation rate (P=0.110) and SES-CD (P=0.115) . Serum albumin (P=0.001) in patients with mesenteric fat hypertrophy was lower than that in patients without mesenteric fat hypertrophy. Conclusion: Mesenteric fat hypertrophy is correlated with intestinal stenosis and disease activity in patients with Crohn's disease.

Doppler Activity and Ultrasonographic Detection of Intra-Abdominal Fistulas Are Predictors of Surgery in Crohn’s Disease

Bakground and Aim: Predictors of the need for surgery in sticturing Crohn’s disease (SCD) are lacking. Bowel ultrasound (US) is a harmless, noninvasive, and inexpensive diagnostic procedure that has proven to be a valuable tool in the management of Crohn’s disease (CD). Our aim was to identify ultrasonographic findings in SCD that may associate with a higher risk of surgery, allowing us to make early choices regarding treatment election in this specific group of patients. Materials and Methods: This was a retrospective, case-control study. Twenty-four patients diagnosed with SCD between 2013 and 2017 with a past history of stricture-related surgery were included and then matched with 46 non-operated controls. Prior US from patients in both groups were analyzed. US features considered for analysis were as follows: bowel wall thickness, degree of parietal vascularization (measured by Doppler activity), prestenotic dilation, involvement of mesenteric fat, and newly detected concomitant fistulas or abscess. Results: Doppler activity (p < 0.001), enteroenteric fistulas (p = 0.04), enteromesenteric fistulas (p = 0.003), and associated abscess (p = 0.004) were significantly associated with the need for surgery in the short-term period. Multivariate analysis showed strong association of these features with the risk of surgery but failed to reach statistical significance. Conclusion: US features may potentially be used as point-of-care tools to aid clinicians in the assessment of the surgical risk in patients with SCD.

Imaging Findings in Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With Coronavirus Disease (COVID-19).

BACKGROUND. A multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease (COVID-19) has recently been described. OBJECTIVE. The purpose of our study was to evaluate the imaging findings of MIS-C associated with COVID-19. METHODS. Imaging studies and medical records of patients (age range, 0-20 years) admitted with MIS-C between April 22 and May 21, 2020, were retrospectively reviewed. Thoracic imaging studies were evaluated for parenchymal, mediastinal and hilar, and cardiovascular abnormalities. Abdominal imaging studies were evaluated for abnormalities of solid viscera, hollow viscera, and the peritoneum as well as the mesentery and retroperitoneum. Studies were reviewed independently by two radiologists, and disagreements were resolved by a third senior radiologist. RESULTS. Sixteen patients (10 male and six female patients; age range, 20 months-20 years) were included in this study. All 16 patients presented with fever. Other presenting signs and symptoms included the following: vomiting (12/16, 75%), abdominal pain (11/16, 69%), rash (10/16, 63%), conjunctivitis (8/16, 50%), diarrhea (7/16, 44%), headache (6/16, 38%), and sore throat (5/16, 31%). Shortness of breath and cough were each present in one patient. Chest radiography showed cardiomegaly (10/16, 63%), congestive heart failure or cardiogenic pulmonary edema (9/16, 56%), atelectasis (9/16, 56%), pleural effusions (7/16, 44%), acute respiratory distress syndrome (2/16, 13%), and pneumonia (1/16, 6%). Eight patients (50%) were evaluated for pulmonary embolism (PE) (six [75%] by CT angiography [CTA] and two [25%] by ventilation-perfusion scintigraphy). In two of the eight patients (25%), CTA showed a segmental PE. Abdominal imaging findings (ultrasound, CT, and radiography) included small-volume ascites (6/16, 38%), hepatomegaly (6/16, 38%), echogenic kidneys (5/16, 31%), bowel wall thickening (3/16, 19%), gallbladder wall thickening (3/16, 19%), mesenteric lymphadenopathy (2/16, 13%), splenomegaly (1/16, 6%), and bladder wall thickening (1/16, 6%). The frequencies of findings based on all the reviewed modalities were as follows: cardiomegaly (12/16, 75%), pleural effusion (10/16, 63%), and atelectasis (10/16, 63%). Absolute interobserver agreement was 0.69-1 for thoracic findings and 0.17-1 for abdominal findings. Fifteen patients (94%) were discharged from the hospital (length of hospital stay: range, 3-20 days), and one patient remained in the hospital at the end of the study period. There were no mortalities. CONCLUSION. MIS-C associated with COVID-19 is characterized predominantly by cardiovascular abnormalities, although solid visceral organ, gallbladder, and bowel abnormalities as well as ascites are also seen, reflecting a multisystemic inflammatory process. CLINICAL IMPACT. The constellation of imaging findings in the setting of COVID-19 may alert radiologists to the diagnosis of MIS-C before rapid deterioration of patients.

“Meckel’s Diverticulum” – A diagnostic bizarre of abdominal pain in adults

A 30-year-old male presented to the emergency room with complaints of periumbilical abdominal pain and vomiting. A contrast-enhanced computed tomography scan of the abdomen revealed subacute intestinal obstruction with dilated small bowel loops and associated bowel wall thickening of mid and distal ileal bowel loops. There was a fairly large small bowel diverticulum arising from the antimesenteric border of distal ileum. Findings were suggestive of small bowel diverticulitis or possibly focal enteritis. The patient was then immediately taken to the operating room for emergency laparotomy and was intra-operatively found to have a thickened Meckel’s diverticulitis with adjacent small bowel obstruction. Meckel’s diverticulectomy was performed in continuity with the adjacent inflamed small bowel. The patient had a stable post-operative course without any complications and was discharged within a week.

A Prospective Evaluation of Point-of-Care Ultrasonographic Diagnosis of Diverticulitis in the Emergency Department

We evaluate the sensitivity and specificity of point-of-care ultrasonography, performed by ultrasonographic fellowship-trained emergency physicians and physician assistants, compared with computed tomography (CT) scan in diagnosing acute diverticulitis in the emergency department (ED). This was a prospective observational study of a convenience sample of patients with suspected diverticulitis who were treated at an academic ED between 2017 and 2020. Sonographers were blinded to clinical data, laboratory results, and CT scan findings. A total of 19 ultrasonographic fellowship-trained emergency physicians and physician assistants performed the ultrasonographic examinations. Point-of-care ultrasonographic diagnosis of acute diverticulitis was defined as the presence of bowel wall thickening, greater than 5 mm, surrounding a diverticulum, enhancement of the surrounding pericolonic fat, and sonographic tenderness to palpation. The primary outcome measures were sensitivity, specificity, positive predictive value, and negative predictive value of point-of-care ultrasonography in the diagnosis of diverticulitis compared with CT, which was considered the criterion standard. Data from 452 patients were analyzed. Median age was 60 years, 54% were women, and 36% had a diagnosis of diverticulitis based on CT scan. Of the 452 patients, there were 13 false-positive (3%) and 10 false-negative (2%) point-of-care ultrasonographic examinations. Overall, compared with CT, point-of-care ultrasonography had a sensitivity of 92% (95% confidence interval 88% to 96%), specificity of 97% (95% confidence interval 94% to 99%), positive predictive value of 94% (95% confidence interval 90% to 97%), and negative predictive value of 96% (93% to 98%) in the diagnosis of diverticulitis. In a convenience sample of ED patients with suspected diverticulitis, point-of-care ultrasonography performed by ultrasonographic fellowship-trained emergency physicians and physician assistants could be used as an imaging modality for diagnosing acute diverticulitis, with high sensitivity and specificity compared with CT scan.

The Comb Sign

A 20-year-old woman with no significant past medical history presented with a 3-year history of intermittent cramping lower abdominal pain, worse post-prandial, with no change in bowel habit, nausea, or vomiting. Physical examination revealed a soft abdomen with tenderness to deep palpation across the periumbilical area. C-reactive-protein was mildly elevated at 31 mg/L and normal erythrocyte sedimentation rate of 5 mm/h. Gastroscopy and colonoscopy were normal. Computed tomography scan of the abdomen revealed a long segment of abnormality, approximately 60 cm, involving the mid small bowel and Comb sign was present (Figures A and B, arrows). A further magnetic resonance enterography revealed circumferential bowel wall thickening (Figure C, arrow). Subsequent deep intubation retrograde endoscopy revealed several scattered ulcers. Small bowel and colon biopsies revealed noncaseating granulomas (Figure D, arrow) consistent with Crohn’s disease. Comb sign is the engorgement of the mesenteric vessels with vascular dilatation, tortuosity with spacing of the vasa recta, and prominence of surrounding mesenteric fat resembling a comb and is associated with Crohn’s disease. However, it is not pathognomonic of Crohn’s disease and can also be associated with other inflammatory diseases of the bowel or vasculitis. Comb sign can be used to differentiate active inflammatory bowel disease from lymphoma, which is more likely to be hypovascular.

Systematic Review: Gastrointestinal Ultrasound Scoring Indices for Inflammatory Bowel Disease.

Serial measurements of luminal disease activity may facilitate inflammatory bowel disease management. Gastrointestinal ultrasound is an easily performed, non-invasive alternative to other assessment modes. However, its widespread use is limited by concerns regarding validity, reliability, and responsiveness. We systematically identified ultrasound scoring indices used to evaluate inflammatory bowel disease activity and examine their operating characteristics. Electronic databases were searched from inception to June 14, 2019 using pre-defined terms. Studies that reported on gastrointestinal ultrasound index operating properties in an inflammatory bowel disease population were eligible for inclusion. Study characteristics, index components, and operating property data [ie, validity, reliability, responsiveness, sensitivity, specificity, accuracy, positive predictive value, and negative predictive value] were extracted. The QUADAS-2 tool was used to examine study-level risk of bias. Of the 2610 studies identified, 26 studies reporting on 21 ultrasound indices were included. The most common index components included bowel wall thickness, colour Doppler imaging, and bowel wall stratification. The correlation between ultrasound indices and references standards ranged r = 0.62-0.95 and k = 0.40-0.96. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive values ranged 39-100%, 63-100%, 73-100%, 57-100%, and 40-100%, respectively. Reliability and responsiveness data were limited. Most [92%, 24/26] studies received at least one unclear or high risk of bias rating. Several gastrointestinal ultrasound indices for use in inflammatory bowel disease have been developed. Future research should focus on fully validating existing or novel gastrointestinal ultrasound scoring instruments for assessment of Crohn's disease and ulcerative colitis.

Chronic Active Epstein-Barr Virus-Associated Enteritis: CT Findings and Clinical Manifestation.

Aim To improve the identification and computed tomography (CT) diagnostic accuracy of chronic active Epstein-Barr virus (EBV)-associated enteritis (CAEAE) by evaluating its CT findings and clinical manifestation. Methods The data of three patients with pathologically and clinically confirmed CAEAE who underwent CT enterography (CTE) were retrospectively reviewed from January 2018 to October 2019. The following data were evaluated: imaging characteristics (length of involvement, pattern of mural thickening, pattern of attenuation, perienteric abnormalities), clinical symptoms, endoscopic records, laboratory examinations, and pathologic findings. Results Based on CT findings, two patients demonstrated segmental bowel wall thickening (involvement length >6 cm), asymmetric thickening, layered attenuation, fat stranding, and adenopathy, whereas the remaining one had no positive finding. The endoscopic results of all patients showed numerous irregular ulcers in the colon, and one patient had a focal esophageal ulcer. The major clinical symptoms were abdominal pain (n = 3), retrosternal pain (n = 1), fever (n = 3), diarrhea (n = 2), hematochezia (n = 1), and adenopathy (n = 3). The main laboratory examination indicators were increased serum EBV DNA load (n = 1) and increased inflammatory markers (n = 3). With regard to the main pathologic findings, all patients showed positive EBV-encoded RNA (EBER) situ hybridization in the colonic biopsy specimen, with one patient being positive in the esophagus. Conclusion CAEAE is rare and is usually misdiagnosed as inflammatory bowel disease (IBD). The imaging features of CAEAE overlap with those of Crohn's disease and ulcerative colitis. The presence of segmental and asymmetric bowel wall thickening, layered attenuation, and fat stranding in the CTE image may be helpful in differentiating CAEAE from IBD.