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Everything you need to know about Computed Tomography (CT) & CT Scanning

Small Bowel: Benign Tumors Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Small Bowel ❯ Benign Tumors

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  • “Small bowel lipomas commonly occur in the ileum, especially in the terminal ileum. They usually appear as well-defined, intraluminal masses with lipid attenuation (− 100 to − 50 HU) without apparent enhancement. While most small lipomas (less than 1 cm) are asymptomatic, patients with larger tumors may present with various degrees of abdominal pain, gastrointestinal bleeding, or palpable abdominal masses. Some of the patients have abdominal pain resulting from small bowel or ileocolic intussusception due to lipoma as a leading cause.”
    Tumors of the jejunum and ileum: a pattern‐based imaging approach on CT
    Kim SW et al.
    Abdominal Radiology (2019) 44:2337–2345

  • Tumors of the jejunum and ileum: a pattern‐based imaging approach on CT
    Kim SW et al.
    Abdominal Radiology (2019) 44:2337–2345 
  • “Small bowel lipomas commonly occur in the ileum, especially in the terminal ileum. They usually appear as well-defined, intraluminal masses with lipid attenuation (− 100 to − 50 HU) without apparent enhancement. While most small lipomas (less than 1 cm) are asymptomatic, patients with larger tumors may present with various degrees of abdominal pain, gastrointestinal bleeding, or palpable abdominal masses. Some of the patients have abdominal pain resulting from small bowel or ileocolic intussusception due to lipoma as a leading cause.”
    Tumors of the jejunum and ileum: a pattern‐based imaging approach on CT
    Kim SW et al.
    Abdominal Radiology (2019) 44:2337–2345
  • “Small bowel lipomas commonly occur in the ileum, especially in the terminal ileum [10]. They usually appear as well-defined, intraluminal masses with lipid attenuation (− 100 to − 50 HU) without apparent enhancement. While most small lipomas (less than 1 cm) are asymptomatic, patients with larger tumors may present with various degrees of abdominal pain, gastrointestinal bleeding, or palpable abdominal masses. Some of the patients have abdominal pain resulting from small bowel or ileocolic intussusception due to lipoma as a leading cause.”
    Tumors of the jejunum and ileum: a pattern‐based imaging approach on CT
    Kim SW et al.
    Abdominal Radiology (2019) 44:2337–2345
  • “A lymphangioma is a benign proliferation of lymph vessels, producing fluid filled cysts that result from a blockage of the lymphatic system. ae incidence of abdominal lymphangiomas is unknown; however they account for from 3% to 9.2% of all pediatric lymphangiomas, with retroperitoneal lymphangioma representing less than 1% of abdominal lymphangiomas.”

    
Retroperitoneal Cystic Lymphangioma: A Diagnostic and Surgical Challenge 
Oguzhan Güven Gümüştaş et al.
Case Reports in Pediatrics
Volume 2013 (2013), Article ID 292053 

  • “The incidence of abdominal lymphangiomas is unknown: however they account for from 3% to 9.2% of all pediatric lymphangiomas, with retroperitoneal lymphangioma representing less than 1% of abdominal lymphangiomas. Although retroperitoneal lymphangiomas may sometimes be asymptomatic, they usually present as a palpable abdominal mass and are easily confused with other retroperitoneal cystic tumors including those arising from the liver, kidney and pancreas.”


    Retroperitoneal Cystic Lymphangioma: A Diagnostic and Surgical Challenge 
Oguzhan Güven Gümüştaş et al.
Case Reports in Pediatrics
Volume 2013 (2013), Article ID 292053 

  • “Retroperitoneal lymphangiomas manifest with clinical symptoms of abdominal pain, fever, fatigue, weight loss, and hematuria, due to their size and occasionally might be complicated by intracystic hemorrhage, cyst rupture, volvulus or infection. Differentiating cystic lymphangiomas from other cystic growths by imaging studies alone is often inconclusive and surgery is most frequently required for definitive diagnosis and to ameliorate the symptoms.”

    
Retroperitoneal Cystic Lymphangioma: A Diagnostic and Surgical Challenge 
Oguzhan Güven Gümüştaş et al.
Case Reports in Pediatrics
Volume 2013 (2013), Article ID 292053 

  • “The lymphatic system is derived during the third or fourth fetal month from 2 paired and unpaired endothelial channels proliferate centrifugally from these sacs, which are located in the neck, mesenteric root, and bifurcation of the femoral and sciatic veins . A lymphangioma is a benign proliferation of lymphatic tissue believed to originate from the early sequestration of lymphatic vessels that fail to establish connections with normal draining lymphatics. Lymphangiomas are therefore considered a congenital rather than an acquired tumor.”


    Retroperitoneal Cystic Lymphangioma: A Diagnostic and Surgical Challenge 
Oguzhan Güven Gümüştaş et al.
Case Reports in Pediatrics
Volume 2013 (2013), Article ID 292053 

  • “Intravenous contrast-enhanced CT may show enhancement of the cyst wall and septa. The fluid component is typically homogeneous with low attenuation values. Occasionally, negative attenuation values occur in the presence of chyle. Calcification may occur but is uncommon .If hemorrhage occurs, the intracystic attenuation values may simulate a solid tumor mass or abscess. ae mass may traverse adjacent retroperitoneal anatomical compartments, displacing organs and vessels . They can compress and infiltrate vital structures or present with complications like intracystic hemorrhage, cyst 
rupture, volvulus, or infection.”


    Retroperitoneal Cystic Lymphangioma: A Diagnostic and Surgical Challenge 
Oguzhan Güven Gümüştaş et al.
Case Reports in Pediatrics
Volume 2013 (2013), Article ID 292053 

  • “Diagnostic important point for cystic lymphangioma: an elongated shape and a crossing from one retroperitoneal compartment to an adjacent one. Also at CT, cystic lymphangioma typically appears as a large, thin-walled, multiseptate cystic mass. A teratoma with a large cystic component can resemble a lymphangioma.”


    Retroperitoneal Cystic Lymphangioma: A Diagnostic and Surgical Challenge 
Oguzhan Güven Gümüştaş et al.
Case Reports in Pediatrics
Volume 2013 (2013), Article ID 292053
  • “Ectopic pancreas, also known as heterotopic pancreatic tissue, is defined as aberrant pancreatic tissue with no ductal or vascular continuity to the main pancreatic gland. Most patients are asymptomatic and this disorder is typically found incidentally. Ectopic pancreas is normally located in the submucosal layer of the stomach, duodenum, and/or jejunum and may easily be misconstrued as a submucosal tumor, such as a gastrointestinal stromal tumor (GIST).” 


    Imaging Spectrum of Non-neoplastic Duodenal Diseases
Sitthipong S et al.
Clinical Imaging (in press)
  • “Ganglioneuroma is a rare tumor which should nevertheless be included in differential diagnosis of retroperitoneal masses when presenting as a well-delimited tumor with possible tendency to surround or displace major blood vessels, low density on non-enhanced CT, and delayed progressive enhancement on CT and MRI.”


    Imaging of retroperitoneal ganglioneuroma
 Otal P et al.
May 2001, Volume 11, Issue 6, pp 940-945
  • “Various types of neurogenic tumors can affect the abdomen. These tumors can be classified as being of ganglion cell origin (ganglioneuromas, ganglioneuroblastomas, neuroblastomas), paraganglionic system origin (pheochromocytomas, paragangliomas), or nerve sheath origin (neurilemmomas, neurofibromas, neurofibromatosis, malignant nerve sheath tumors).”

    Neurogenic Tumors in the Abdomen: Tumor Types and Imaging Characteristics 
Sung Eun Rha et al. 
RadioGraphics2003;23:29–43
  • “Ganglioneuromas are rare, benign neurogenic tumors that arise from sympathetic ganglia. The tumors are composed of mature Schwann cells, ganglion cells, and nerve fibers. Ganglioneuromas may arise anywhere along the paravertebral sympathetic plexus and occasionally from the adrenal medulla. The retroperitoneum (32%–52% of cases) and posterior mediastinum (39%– 43%) are the two most common locations for a ganglioneuroma, followed by the cervical region (8%– 9%).”

    Neurogenic Tumors in the Abdomen: Tumor Types and Imaging Characteristics 
Sung Eun Rha et al. 
RadioGraphics2003;23:29–43
  • “Ganglioneuromas are often asymptomatic even if they are large. Otherwise, abdominal pain or the palpation of an abdominal mass is the most common clinical feature. Hormonally active forms have been reported, and the secretion of catecholamines, vasoactive intestinal polypeptides, or androgenic hormones explains such symptoms as hypertension, diarrhea, and virilization.”


    Neurogenic Tumors in the Abdomen: Tumor Types and Imaging Characteristics 
Sung Eun Rha et al. 
RadioGraphics2003;23:29–43
  • “At unenhanced CT, the tumors appear homogeneous, with an attenuation less than that of muscle. At CT, they contain calcification in about 20% of cases. The calcifications are discrete and punctate rather than amorphous and coarse as in neuroblastomas . Varying degrees of contrast material enhancement in 
ganglioneuroma have been reported, from slight to moderate to marked.”


    Neurogenic Tumors in the Abdomen: Tumor Types and Imaging Characteristics 
Sung Eun Rha et al. 
RadioGraphics2003;23:29–43
  • “Ichikawa et al reported an interesting contrast enhancement pattern in ganglioneuroma that consisted of delayed heterogeneous uptake . These enhancement features are explained by the presence of an abundance of myxoid matrices in the tumors, resulting in delayed progressive accumulation of contrast material in the extracellular space.”

    Neurogenic Tumors in the Abdomen: Tumor Types and Imaging Characteristics 
Sung Eun Rha et al. 
RadioGraphics2003;23:29–43
  • “Tumors of small intestine account for only 1%-2% of all gastrointestinal tumors, and benign tumors account for approximately 30% of all small intestinal tumors. Gastrointestinal stromal tumors are the most common symptomatic benign tumors of the small bowel, while the lipomas are rare benign tumors, representing 2.6% of non-malignant tumors of the intestinal tract.”


    Small intestinal lipomas: Diagnostic value of multi-slice CT enterography
Song-Hua Fang et al.
World J Gastroenterol. 2010 Jun 7; 16(21): 2677–2681.
  • “Small bowel lipomas tend to occur in the elderly, and the sixth to seventh decades of life are considered to be the most risky period. Jejunum and ileum, especially the terminal ileum, are common locations. Eleven of the 15 lesions arose from jejunoileum and the mean age of the patients was 63.2 years in this study, which was consistent with those previously reported. Patients may be completely asymptomatic with small lipomas (< 1 cm), which are usually detected incidentally. Larger tumors may produce symptoms .”

    Small intestinal lipomas: Diagnostic value of multi-slice CT enterography
Song-Hua Fang et al.
World J Gastroenterol. 2010 Jun 7; 16(21): 2677–2681.
  • “Approximately 25% of patients with benign intestinal neoplasm have alimentary tract hemorrhage. Small bowel lipomas usually cause lower gastrointestinal hemorrhage, and lipomas arising from duodenum may cause upper gastrointestinal hemorrhage and symptoms like peptic ulcer. Some of the bleeding is intermittent, some is continuous in small amount or only presents as microscopically positive fecal occult blood.”


    Small intestinal lipomas: Diagnostic value of multi-slice CT enterography
Song-Hua Fang et al.
World J Gastroenterol. 2010 Jun 7; 16(21): 2677–2681.
  • “Abdominal CT scans are considered to be the most definitive diagnostic measure of recognizing small bowel lipomas. With the fast volume scan technique of multiple spiral CT, reformation in any dimensions is feasible, and the quality of the reformatted images is almost as same as the axial ones, which ensures a good overall observation. The finding of lipid attenuation (-100 to -50 HU) is vital to the diagnosis of a lipoma.”


    Small intestinal lipomas: Diagnostic value of multi-slice CT enterography
Song-Hua Fang et al.
World J Gastroenterol. 2010 Jun 7; 16(21): 2677–2681.
  • “ Mesenteric fibromatosis, sclerosing mesenteritis, inflammatory pseudotumor, and extrapleural solitary fibrous tumor constitute a loosely associated group of benign fibrous tumors and tumorlike lesion of the mesentery.”
    Benign Fibrous Tumors and Tumorlike Lesions of the Mesentery: Radiologic-Pathologic Correlation
    Levy AF et al.
    RadioGraphics 2006; 26:245-264
  • Benign Fibrous Tumors and Tumorlike Lesions of the Mesentery: Facts
    - Mesenteritis fibromatosis
    - Sclerosing mesenteritis
    - Inflammatory pseudotumor
    - Extrapleural solitary fibrous tumor
  • Mesenteric Fibromatosis: Facts
    - AKA intraabdominal fibromatosis or abdominal desmoid
    - Tumors infiltrate but do not metastasize
    - Small bowel mesentery is most common location
    - Age range of 14-75 years (mean 41 years)
    - 13% of cases associated with Gardner’s syndrome
    - When associated with Gardners syndrome often after abdominal surgery
  • Mesenteric Fibromatosis: Presentation and Complications
    - Abdominal pain or palpable mass
    - GI bleeding
    - Small bowel obstruction
    - Fistula formation
    - Bowel perforation
  • Mesenteric Fibromatosis: CT Findings
    - Mesenteric mass which may be discrete or infiltrating
    - Displacement of bowel
    - Bowel obstruction may occur
    - Variable enhancement pattern
  • Mesenteric Fibromatosis: Differential Diagnosis
    - GIST tumor
    - Lymphoma
    - Metastatic disease
    - Soft tissue sarcoma
    - Duplication Cyst
  • Sclerosing Mesenteritis: Facts
    - Idiopathic disorder with chronic, nospecific inflammation, fat necrosis and fibrosis
    - Usually involves the small bowel mesentery but may involve the colonic mesocolon
    - Synonyms include;
    1. Mesenteric panniculitis
    2. Retractile mesenteritis
    3. Mesenteric lipodystrophy
    4. Lipogranuloma of the mesentery
  • Sclerosing Mesenteritis: Facts
    - Average age of presentation is 60 years
    - More common in men by 2-1
    - Abdominal pain is the most common presentation but weight loss, distension, and FUO are other presentations
  • Sclerosing Mesenteritis: CT Findings
    - Retraction and shortening of small bowel mesentery
    - Partial or complete SBO
    - Well defined or ill-defined mesenteric mass with soft tissue or mixed fat and soft tissue attenuation
    - May encase mesenteric vessels with preservation of fatty collar around the vessels (“fat ring sign”)
    - Punctate or coarse calcifications may be seen
  • Sclerosing Mesenteritis: Differebtial Diagnosis
    - Carcinoid tumor
    - Metastatic disease to mesentery
    - Lymphoma
    - Soft tissue sarcomas
    - Weber Christian disease
  • Inflammatory Pseudotumor: facts
    - Benign, chronic inflammtory lesion of unclear etiology
    - May be difficult to distinguish from a true neoplasm
    - May occur in mesentery but also lung and orbit
    - More common in the pediatric or young adult population
    - Presentation may include fever, malaise, weight loss or abdominal pain
  • Inflammatory Pseudotumor: CT Findings
    - Heterogeneous mass in mesentery
    - May or may not have well defined margins
    - Variable enhancement patterns with IV contrast
  • Lipoma of the Small Bowel
    - Benign submucosal tumor
    - Duodenum is most common small bowel location
    - Usually asymptomatic but can rarely present with hemorrhage or obstruction if large
    - Usually smooth in appearance on CT
    - No malignant potential
  • Lymphangioma
    - Multiloculated large thin walled cystic mass
    - Usually in mesentery when it involves the GI tract
    - Can simulate a mesenteric cyst, duplicated cyst, cystic pancreatic mass or in theory an abscess
© 1999-2019 Elliot K. Fishman, MD, FACR. All rights reserved.