DAVID SUTTON PICTURES THE LARGE BOWEL ONLY FOR STUDY PURPOSE

1. 21
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. Fig. 21.1 Barium enema reveals two patches of
filiform polyposis at the hepatic flexure in a
patient with known Crohn's disease.

4. • Fig. 21.2 Transverse colon lipoma. Note its
exquisitely well-defined margins and
compressibility under the compression
paddle.

5. • Fig. 21.3 A sigmoid villous adenoma,
evidenced by a fine carpeting of frond-like
projections.

6. • Fig. 21.4 Familial adenomatous polyposis (FAP). There
are innumerable colonic adenomas. This adult woman
refused colectomy, with the inevitable consequence of
a cancer (arrow).

7. • Fig. 21.5 Axial T 2 -weighted MR image
reveals a large central mesenteric desmoid
tumour (arrows), with mixed signal.

8. • Fig. 21.6 A rectal adenoma visualised as a
luminal nodule (arrow). This lesion was
missed at sigmoidoscopy, presumably because
of inadequate inspection during instrument
insertion.

9. • Fig. 21.7 A small polyp where the meniscal rim of barium between
the polyp base and adjacent mucosa causes the 'bowler-hat' sign.

10. • Fig. 21.8 A large, pedunculated sigmoid
polyp.

11. • Fig. 21.9 When seen en face, stalked polyps
produce a 'target' sign.

12. • Fig. 21.10 Typical 'apple-core' sigmoid
carcinoma.

13. • Fig. 21.11 Double-contrast barium enema
reveals a diffuse, plaque-like sigmoid cancer
(arrows).

14. • Fig. 21.12 Multiple bizarre strictures and
mucosal pleating in a woman with extensive
peritoneal carcinomatosis from an ovarian
primary.

15. • Fig. 21.13 CT reveals a strongly enhancing
caecal carcinoma (arrow) in this elderly
patient. Note associated small-bowel
obstruction.

16. • Fig. 21.14 Self-expanding metal stent crossing a
low rectal tumour in a frail patient with extensive
metastatic disease.

17. • Fig. 21.15 (A) Transrectal ultrasound reveals a
right posterior quadrant tumour that has
penetrated the muscularis propria to reach
surrounding tissue (arrows); stage uT3. (B) Axial
T2 -weighted MR scan at the same level confirms
the ultrasound finding of rectal wall penetration
(arrows).

18. • Fig. 21.16 Splenic flexure polyp revealed by
virtual colonoscopy in a patient whose
endoscopic colonoscopy had been normal.

19. • Fig. 21.17 Primary
colonic non-Hodgkin's
lymphoma. Note the
irregular but intact
mucosal line, suggesting
the tumour has a
submucosal origin.

20. • Fig. 21.18 Barium enema reveals severe
sigmoid diverticular disease with a
complicating fistula to the vagina (arrow).

21. • Fig. 21.19 CT was used to place a
percutaneous drain into this large paracolic
collection secondary to diverticular disease.

22. • Fig. 21.20 CT reveals intravesical gas and the
site of sigmoid fistulation on delayed scans.

23. • Fig. 21.21 Toxic megacolon. Luminal
dilatation, abnormal haustration, mural
thickening and mucosal islands.

24. • Fig. 21.22 Instant
enema in a patient
with ulcerative colitis
reveals fine,
continuous,
symmetrical, left-sided
ulceration.

25. • Fig. 21.23 Patulous, rigid ileocaecal valve with
associated terminal ileal granularity ('back-
wash ileitis') in a patient with total ulcerative
colitis.

26. • Fig. 21.24 Innumerable aphthoid ulcers in
Crohn's disease.

27. • Fig. 21.25 Instant enema in Crohn's disease
demonstrates extensive 'cobblestoning' due to linear
ulceration and mucosal oedema. Note the rectum is
relatively spared but contains aphthoid ulcers.

28. • Fig. 21.26 Barium enema showing the typical
pseudodiverticula found in Crohn's disease.

29. • Fig. 21.27 T2- weighted, fat-suppressed, axial
MR scan demonstrates a right-sided psoas
abscess (compare to the contralateral side).

30. • Fig. 21.28 Water-soluble pouchography
reveals a presacral collection (arrow)
originating from the posterior aspect of the
pouch-anal anastomosis.

31. • Fig. 21.29 Classical
splenic flexure 'thumb-
printing' diagnosing
ischaemic colitis.

32. • Fig. 21.30 Splenic
flexure sacculation
and stricturing as
sequelae to
ischaemic colitis.

33. • Fig. 21.31 Generally narrowed sigmoid and
proximal rectum following radiotherapy.

34. • Fig. 21.32 Evacuation
proctography
demonstrates a
moderate Rectocoele.

35. • Fig. 21.33 Sagittal T 1 -weighted MR during
straining reveals a cystocoele (arrow),
diagnosed by bladder descent below the
symphysis pubis.

36. Fig. 21.34 Anal endosonography reveals an
anterior external and internal sphincter tear
due to obstetric injury (between the arrows).

37. • Fig. 21.35 Coronal MR STIR image reveals a right-
sided extrasphincteric fistula (straight arrows)
with its enteric communication in the rectum
(curved arrow).

38. • Fig. 21.36 Small-bowel bleeding. 99 mTc-colloid study
showing extravasated blood (arrows) moving along
jejunal loops on consecutive images. Note normal
uptake in bone marrow and in liver and spleen (partly
excluded by lead screening placed on the patient).

39. • Fig. 21.37 Large-bowel bleeding. 99 mTc-colloid
study showing extravasation in caecum which
remains static up to 10 min, but moves to the
transverse colon at 15 min (arrows).

40. • Fig. 21.38 Small-bowel bleeding. 99 'Tc-RBC
study showing extravasation into small bowel
loops at 20, 40 and 60 min (arrows), with the
extravasation reaching the colon by 4 h.

41. • Fig. 21.39 Colonic bleeding. 99 rtTc-RBC study
showing no bleeding up to 10 min, but a clear
bleeding site at 20, 30 and 40 min following
the line of the sigmoid colon.

42. • Fig. 21.40 Meckel's study. Normal appearance
after injection of 99 "'Tc-pertechnetate showing
concentration in the normal gastric mucosa, and
also renal excretion outlining the bladder.

43. • Fig. 21.41 Meckel's study. The patient did not
take H 2 blockade as requested, and the later
images show pertechnetate in the lumen of the
small bowel, resulting from gastric secretion of
the tracer.

44. • Fig. 21.42 Meckel's study. Typical appearance
of Meckel's diverticulum in the right side of
the pelvis (surgically confirmed).

45. • Fig. 21.43 Crohn's disease. Labelled white cell
study shows a single long loop of abnormal
small bowel (A). Barium study (B) shows
diffuse narrowing and mucosal irregularity
affecting the same segment.

46. • Fig. 21.44 Early Crohn's disease. Labelled WBC
study shows low-grade disease localised to distal
ileum 1 h after injection of 99 "Tc-HMPAO-WBC.
Note normal uptake in bone marrow. Concurrent
barium examination was negative, but the patient
later developed overt signs of disease.

47. • Fig. 21.45 Extensive small-bowel Crohn's
disease. 99‘ Tc-HMPAO-WBC study at 1 h after
injection showing multiple loops of abnormal
small bowel.

48. • Fig. 21.46 Ulcerative colitis. 99 "Tc-HMPAO-
WBC study (left, anterior view; right, left
lateral view) showing extensive involvement
of transverse and descending colon, but no
small-bowel disease.

49. • Fig. 21.47 Crohn's disease. 99 "Tc-HMPAO-
WBC study (left, 1 h; right 4 h) showing patchy
abnormality in both large and small bowel.

50. • Fig. 21.48 Carcinoid. Somatostatin receptor
scintigraphy (SRS) shows functioning tumour
in the right iliac fossa (arrow).

51. • Fig. 21.49 Primary and metastatic carcinoid.
SRS (left, anterior view; right, posterior view)
shows a small active lesion in the right iliac
fossa and an adjacent lymph node deposit
(arrows) together with multiple liver

52. • Fig. 21.50 Primary and metastatic carcinoid.
SRS (left, 4 h; right, 24 h) shows multiple
functioning liver tumours, but also shows
nodal disease in mid abdomen and primary
focus in the right iliac fossa, best seen on
delayed images at 24 h.