ABDOMINAL KOCH'S

neerajlalwani's picture
Author(s)
Dr.Neeraj Lalwani MBBS,DMRD,MD
N.Delhi,India
Images

Figure Legends : 

 Fig-1: Axial scan showing dilated bowel loops and generalized bowel wall thickening. 

Fig-2: Coronal reconstruction created with volume rendering technique shows level & extent of dilated bowel loops.

Fig-3: Axial scan showing caecal wall thickening and associated peri-caecal stranding. 

Fig-4 & 5:Coronal reconstructions, showing exact extent of the thickening in caecum as well as involvement of terminal ileum.

Fig-6:Barium enema study shows ileum emptying into a deformed cone-shaped cecum at right angle.The cecal position in turn is hiked up.The colon distal to lesion is dilated significantly. 

Fig-7: Axial scan showing ascitic fluid filling the abdomen along with the thickened wall of caecum. 

Fig-8: 3D reconstruction in coronal plane not only delineates the extent of lesion in caecum but also the status of peritoneal cavity. Diffrential diagnosis of Tuberculosis and malignancy was suggested on CT.However, histology confirmed malignancy. 

Fig-9 & 10: Axial scans showing generalized bowel wall thickening and dilated fluid filled loops. Diffrential diagnosis of both Tuberculosis & Malabsorption was given on CT basis. Finally it was proven as malabsorption. 

Case Description

Clinical History: 

 Tuberculosis peritonitis presents with high density ascites and mesenteric involvement, consisting of thickening and adenopathy, as possible criteria for the diagnosis by CT. 

Diagnosis: 

 Diffrential Diagnosis:Malignancy Ilieocecal region

Discussion: 

 Abdominal tuberculosis shows mild circumferential wall thickening of the terminal ileum and cecum, thickening of the ileocecal valve, and a few regional nodes. adenopathy, splenomegaly, hepatomegaly, ascites, bowel involvement, pleural effusion, intrasplenic masses, and intrahepatic masses. Characteristic features were a tendency for adenopathy to prominently involve peripancreatic and mesenteric compartments, low-density centers within enlarged nodes and adenopathy adjacent to sites of gastrointestinal tract involvement. Recognition of these manifestations and maintenance of an index of suspicion, especially in patients at risk, should help optimize the correct diagnosis. 

To differentiate the wall thickening from CD,the associated fibrofatty change may provide us a clue.

Tuberculosis v/s Malabsorption

Malabsorption,usually presents as dilated bowel loops on CT.However,with the findings of dilated bolwel loops alone diagnosis of malabsorption becomes difficult.On barium study,associated mucosal thickening and flocculation & segmentation of barium column provides additional clue to diagnose mlabsorption. CT has capability to provide 3D reconstruction of contrast filled small bowel compareable to barium studies by ‘Volume Rendering technique’ but demonstration of ‘ Flocculation & segmentation’ is inferior to conventional Barium.On the other hand CT also provides the status of neighbouring organs,lymphadenopath and ascitis which is not possible on Barium.

References / Suggested Reading: 

 

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Citation:

ABDOMINAL KOCH'S, Dr.Neeraj Lalwani MBBS,DMRD,MD, Imaging Science Today, 2009, 52.