Research Article - Journal of Gastroenterology and Digestive Diseases (2016) Volume 1, Issue 2
The Significance of Bowel Wall Thickening On Abdominal Computed Tomography at Australian Hospital
- *Corresponding Author:
- Saad Khan
Psychiatry Department at Yale Schol of Medicine Yale University, New Haven, CT 06519, USA
E-mail: [email protected]
Received date: September 01, 2016; Accepted date: October 26, 2016; Published date: October 28, 2016
The aim of this retrospective study was to determine the causes and significance of bowel wall thickening on abdominal computed tomography. Of 175 consecutive CT abdomens identified, diverticulitis (28%) and infection (24.6%) were the most common causes. Flare of known inflammatory bowel disease (7.4%) and new cancer (5.7%) were relatively uncommon causes. Overall, 50/175 (28.6%) patients underwent subsequent colonoscopy, and of these, 41/50 (82%) were either normal or showed uncomplicated diverticular disease only.
Bowel wall thickening; Abdominal computed tomography; Radiology practice; Abdominal CTs; Colonic diseases; Diverticular disease
Computed tomography (CT) is a widely used and important imaging modality for investigating the cause of abdominal symptoms. In particular, abdominal CT is highly sensitive for detecting both intramural and extramural extension of colonic diseases (Horton, 2000., Thoeni, 2006). While indications for ordering abdominal CTs are broad, radiological practice parameters for its use have been developed to assist clinicians in providing appropriate care. Bowel wall thickening (BWT) is a common, non-specific finding on abdominal CT and is caused by a variety of underlying aetiologies including inflammatory, infective, ischaemic and neoplastic (Fernandes, 2014., Macari, 2001). It frequently leads to further invasive investigations including colonoscopy; however, the relevance of BWT to the clinical presentation is often unclear. There have been only a few studies regarding the final causes of incidental BWT and its correlation with subsequent endoscopic findings. Recommendations from these studies are conflicting, with many authors suggesting high rates of underlying pathology requiring colonoscopy (A-Khowaiter, 2014., Ayala, 2006., Eskaros, 2009., Troppmann, 2012., Uzzaman, 2012), while others found benign or no pathology in the majority of patients and only recommended colonoscopy in high-risk patients (Stermer, 2008). Our group aimed to assess the causes and significance of BWT on abdominal CTs at an Australian metropolitan hospital and to review its significance when the CT ordered was appropriate or inappropriate for the clinical indication.
We retrospectively reviewed all consecutive abdominal CTs between February and May 2015 with findings of colonic ‘bowel wall thickening’ on the formal report (Modi, 2012). These were identified from our hospital’s radiology department reporting database. The CT request details, formal report and medical records were reviewed for each patient. The indication for ordering the CT and the appropriateness of this indication was assessed. Patients’ past medical history, associated symptoms, faecal cultures, inflammatory markers, inpatient course and subsequent colonoscopy findings were also reviewed. The American College of Radiology practice parameter for the performance of CT of the abdomen and pelvis 2014 was used to determine the appropriateness of CT ordering. The Peninsula health human research ethics and governance committee approved the study.
Of the 175 abdominal CTs identified, the final causes of bowel wall thickening were diverticulitis (28%), infection (24.6%), reactive to extra-colonic inflammation (10.9%), flare of known inflammatory bowel disease (7.4%), bowel obstruction (5.7%), new cancer (5.7%) and ischaemic colitis (0.6%). Surprisingly, none of the patients had a new diagnosis of inflammatory bowel disease. Table 1 outlines the patient characteristics and the complete list of final causes. 10/175 (5.7%) CTs ordered were deemed inappropriate for the indication given. Of these, 3/10 (30%) underwent subsequent colonoscopy as a result, and none of these patients had any significant pathology identified. Overall, 50/175 (28.6%) patients underwent subsequent colonoscopy and of these, 41/50 (82%) were either normal (17/50) or showed uncomplicated diverticular disease only (24/50). Table 2 outlines the findings on colonoscopy. Mean age for patients with new cancer diagnosed was 73 years (standard deviation 10.7; range 56-86). The distribution of BWT in all of these patients was focal. 5/10 of the new cancer diagnoses were confirmed with endoscopic correlation. Of the remaining 5 cases, 3 cases progressed directly to surgery, and 2 were palliated without endoscopy.
|Number(n = 175)||Percentage(%)|
|Mean age, years (range)||61.3 (20-96)|
|Final cause of BWT|
|Flare of known CD||9||5.1|
|Flare of known UC||4||2.3|
|Known GI malignancy||2||1.1|
†Reactive to extra-colonic inflammation (cholecystitis, pancreatitis or appendicitis).
‡Chemotherapy for extra-colonic malignancies.BWT, bowel wall thickening; UC, ulcerative colitis; CD, Crohn’s Disease; IBD, inflammatory bowel disease; GI, gastrointestinal.
Table 1: Patient characteristics and final causes of bowel wall thickening.
|Number of patients||Percentage(%)|
|Indication for CT|
|Colonoscopic findings (n=50)|
|Diverticular disease only||24||48|
|New GI malignancy †||5||10|
†Note that 5 other cases of new malignancy were diagnosed without endoscopic correlation.GI, gastrointestinal; IBD, inflammatory bowel disease.
Table 2: Appropriateness of indication for ordering CT and colonoscopic findings.
Our findings reveal that most causes of BWT could be attributed to either diverticulitis or infectious colitis and that a new diagnosis of malignancy as the underlying cause of BWT was a relatively uncommon occurrence. Modi et al. showed similar findings in their retrospective study, with low rates of underlying malignancy and new IBD as the cause for lower gastrointestinal tract wall thickening (5.1% and 3.8% respectively) and high rates of infection and diverticulitis (16.5% and 12.7% respectively). This represents a large number of patients with underlying benign aetiology as a cause of their BWT and suggests the need for guidelines and clear management parameters to determine the need for endoscopic correlation. Despite the lack of clear data regarding the significance of non-specific BWT, the majority of authors recommend subsequent endoscopic correlation.
We support the use of practice parameters for ordering CTs, because adherence to these practice parameters more frequently identified significant pathology when compared to non-adherence. Benefits of reducing inappropriate investigations include reductions in cost, unnecessary workload, ‘incidentalomas’, procedure related complications and radiation exposure.
A-Khowaiter, S.S., Brahmania, M., Kim, E., Madden, M., Harris, A. (2014). Clinical and endoscopic significance of bowel-wall thickening reported on abdominal computed tomographies in symptomatic patients with no history of gastrointestinal disease. Can AssocRadiol J, 65(1), 67-70.
Ayala, G.P., Huang, C., Jones, D.M., Richter, S. (2006). The significance of correlating incidental bowel wall thickening on CT with endoscopic evaluation. Am J Gastroenterol,101(9), s205-s205.
Eskaros, S., Ghevariya, V., Diamond, I., Anand, S., Eskaros, S. (2009). Correlation of incidental colorectal wall thickening at CT compared to colonoscopy. EmergRadiol,16(6), 473-476.
Fernandes, T., Oliveira, M.I., Castro, R., Araujo, B., Viamonte, B., Cunha, R. (2014). Bowel wall thickening at CT: simplifying the diagnosis. Insights Imaging,5(2), 195-208.
Horton, K.M., Corl, F.M., Fishman, E.K. (2000).CT evaluation of the colon: inflammatory disease 1. Radiographics, 20(2), 399-418.
Modi, R.S., Singh, H., Patel, N., Matin, A., Ringold, D.A. (2012). Bowel wall thickening on CT scan is a high yield colonoscopy indication. Clin Gastroenterol Hepatol,10(3), 330-331.
Stermer, E., Lavy, A., Rainis, T., Goldstein, O., Keren, D., Zeina, A.R. (2008). Incidental colorectal computed tomography abnormalities: would you send every patient for a colonoscopy? Can J Gastroenterol,22(9), 758.
Thoeni, R.F., Cello, J.P. (2006).CT Imaging of Colitis 1. Radiology,240(3), 623-638.
Macari, M., Balthazar, E.J. (2001).CT of bowel wall thickening: significance and pitfalls of interpretation. Am J Roentgenol,176(5), 1105-1116.
Troppmann, M., Lippert, E., Hamer, O.W., Kirchner, G., Endlicher, E. (2012). Colonic bowel wall thickening: Is there a need for endoscopic evaluation? Int J Colorectal Dis, 27(5), 601-604.
Uzzaman, M.M., Alam, A., Nair, M.S., Borgstein, R., Meleagros, L. (2012). Computed tomography findings of bowel wall thickening: its significance and relationship to endoscopic abnormalities. Ann R Coll Surg Engl,94(1), 23-27.