Intramural and Mesenteric Bleeding

Bleeding into the wall of the small intestine and into the mesentery may be a consequence of many different disorders. It is seen in mesenteric thromboses and emboli, segmental ischemic disease, abdominal trauma, anticoagulation medication, underlying diseases associated with

Distal Ileum Mural Thickening

Fig. 14—36. CT comb sign of Crohn's disease in two cases.

(a) Spiral CT demonstrates a distal ileal loop with mural thickening, including a curvilinear zone of fluid. Increased mesenteric fat is present in the right lower quadrant, within which enhanced vessels show dilatation and tortuosity. The vasa recta approaching the mesenteric side of the diseased loop are pushed apart by the fatty proliferation, resulting in the comb sign.

(b) In another patient, an enlarged view demonstrates the conspicuous features of the comb sign.

Fig. 14—36. CT comb sign of Crohn's disease in two cases.

(a) Spiral CT demonstrates a distal ileal loop with mural thickening, including a curvilinear zone of fluid. Increased mesenteric fat is present in the right lower quadrant, within which enhanced vessels show dilatation and tortuosity. The vasa recta approaching the mesenteric side of the diseased loop are pushed apart by the fatty proliferation, resulting in the comb sign.

(b) In another patient, an enlarged view demonstrates the conspicuous features of the comb sign.

Mesorectal Fat And Muscularis Propria

Fig. 14-37. Crohn's disease with fibrofatty proliferation and hypervascularity of the mesentery.

(a) Low magnification of cross-sectioned ileum with transmural Crohn's disease and mesenteric border ulceration (thick arrow). The serosa (small arrows) is displaced from the muscularis propria by an increased accumulation of fat. Transmural fibroinflammatory changes involve vessels and extend into the fat (medium arrows).

(b) Chronic inflammation with subsequent fibrosis extends in a fanlike perivascular pattern (arrows) into the mesenteric fat from the edge of the muscularis propria (arrowheads). (Trichrome stain, x 12.) (Reproduced from Herlinger et al.31)

Fig. 14-37. Crohn's disease with fibrofatty proliferation and hypervascularity of the mesentery.

(a) Low magnification of cross-sectioned ileum with transmural Crohn's disease and mesenteric border ulceration (thick arrow). The serosa (small arrows) is displaced from the muscularis propria by an increased accumulation of fat. Transmural fibroinflammatory changes involve vessels and extend into the fat (medium arrows).

(b) Chronic inflammation with subsequent fibrosis extends in a fanlike perivascular pattern (arrows) into the mesenteric fat from the edge of the muscularis propria (arrowheads). (Trichrome stain, x 12.) (Reproduced from Herlinger et al.31)

CT demonstrates mural thickening of an opacified ileal loop in the left lower quadrant strikingly limited to its mesenteric border (arrow). This is accompanied by retroperitoneal adenopathy and stellate infiltration of the mesentery.

CT demonstrates mural thickening of an opacified ileal loop in the left lower quadrant strikingly limited to its mesenteric border (arrow). This is accompanied by retroperitoneal adenopathy and stellate infiltration of the mesentery.

Mesenteric Bleeding

Fig. 14-39. Lymphosarcoma.

The process is revealed as masses discretely separating and pressing on the concave mesenteric borders of distal ileal loops in the right lower quadrant. (Reproduced from Meyers.2)

Intestinal Hemorrhage

coagulation defects (hemophilia, leukemia, multiple myeloma, lymphoma, and metastatic carcinoma), and the vasculitis of collagen diseases (polyarteritis nodosa, systemic lupus erythematosus), thromboangiitis obliterans (Buerger's disease), and the Henoch-Schönlein syndrome.

While diffuse intramural fluid results in a compact appearance of prominent mucosal folds, sometimes described as the "stacked-coin" or "picket-fence" arrange ment, coalescence of the submucosal edema and hemorrhage produces the characteristic scalloped or nodular filling defects along the contours of the bowel referred to as "thumbprinting."

These distinctive thumbprint defects in intramural intestinal bleeding are by far most consistently localized to the mesenteric borders of the loops (Figs. 14-40 through 14-42). In advanced cases, the defects may

Borders For Intramurals

Fig. 14—40. Intramural bleeding, secondary to overanticoagulation.

Rectal bleeding in a 56-year-old male on anticoagulants while recovering from a myocardial infarction prompted this small intestinal series. Note that the thumbprint defects (arrows) of coalescent intramural blood are localized specifically to the concave, mesenteric borders. (The dashed line indicates the mesenteric root.) Diffuse submucosal fluid is also present. (Reproduced from Meyers.2)

Fig. 14—41. Intramural bleeding in a heroin addict.

The thumbprint filling defects (arrows) of intramural bleeding are confined to the concave mes-enteric borders. The dashed line indicates the axis of the root of the mesentery. Intramural fluid is also evident.

(Reproduced from Meyers.2)

Fig. 14—41. Intramural bleeding in a heroin addict.

The thumbprint filling defects (arrows) of intramural bleeding are confined to the concave mes-enteric borders. The dashed line indicates the axis of the root of the mesentery. Intramural fluid is also evident.

(Reproduced from Meyers.2)

Female Loop ContraceptionMesenteric Bleeding

Fig. 14-42. Ischemic enteritis.

(a and b) Small bowel series (45 min and 2 hr, respectively) in a female taking oral contraceptive pills show the features of ischemic enteritis involving several ileal loops, with the changes most prominent on their mesenteric borders.

Fig. 14-42. Ischemic enteritis.

(a and b) Small bowel series (45 min and 2 hr, respectively) in a female taking oral contraceptive pills show the features of ischemic enteritis involving several ileal loops, with the changes most prominent on their mesenteric borders.

randomly involve both margins of the involved loops, but in early or limited stages, the nodular masses are clearly localized to the concave borders in 75% of pa-tients.2 These defects are typically superimposed on a pattern indicating diffuse intramural fluid. Iffibrosis progresses, the antimesenteric border then forms multiple sacculations or pseudodiverticula. Severe involvement may result in a concentric stricture.

Mesenteric bleeding exaggerates and tends to fix the coiled nature of the small intestine. It is further revealed by mass separation and extrinsic compression on the mesenteric borders of the loops (Fig. 14-43).

Bleeding Mesenteric

Fig. 14-43. (a and b) Two different cases of mesenteric bleeding secondary to Henoch-Schonlein purpura.

Bleeding into the mesentery has resulted in mass separation and displacement upon the concave, mesenteric borders of small bowel loops.

Accompanying intramural fluid is also evident.

(Reproduced from Meyers.2)

Fig. 14-43. (a and b) Two different cases of mesenteric bleeding secondary to Henoch-Schonlein purpura.

Bleeding into the mesentery has resulted in mass separation and displacement upon the concave, mesenteric borders of small bowel loops.

Accompanying intramural fluid is also evident.

(Reproduced from Meyers.2)

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