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Am Fam Physician. 2000;62(7):1660

Patients with cirrhosis frequently undergo computed tomographic (CT) scans for preoperative evaluation for transplantation and to exclude hepatocellular carcinoma. Gastrointestinal wall thickening has been noted in patients with cirrhosis and can be severe enough to lead to a misdiagnosis of ischemia, inflammation, hemorrhage or even carcinoma of the involved segments of bowel. In patients with cirrhosis, gastrointestinal wall thickening generally is caused by edema. Karahan and associates characterized the association of gastrointestinal wall thickening in patients with cirrhosis and control subjects.

Seventy-seven patients with cirrhosis and 100 without cirrhosis were examined with contrast-enhanced CT imaging of the abdomen. The scans were retrospectively assessed by three radiologists. The presence of gastrointestinal wall thickness from the stomach through the descending colonic wall was determined. Malignancy was ruled out with preliminary review of the CT images and with subsequent laparotomy in some patients. The gastric and intestinal wall thickening were determined according to published criteria.

Gastrointestinal wall thickening was seen in 49 (64 percent) of the patients in the cirrhosis group and in seven (7 percent) of the patients in the control group, a significant difference. In the various sections of the small intestine, the jejunum was the most common area of wall thickening. In the various sections of the colon, the ascending colon was the most common area of thickening. The lowest frequency of gastrointestinal wall thickening occurred in the stomach.

Multisegmental anatomic distribution of gastrointestinal wall thickening was seen in 30 of the 49 patients with cirrhosis and gastrointestinal wall thickening. Among these patients, the small intestine and the colon were involved in 14 (47 percent) of the patients. Single-segmental distribution was seen in 19 (39 percent) of the 49 patients with wall thickening.

Results of this study have clinical importance. When the jejunum was normal, no wall thickening was seen in the duodenum or the ileum. If the ascending colon was normal, no wall thickening was seen in the transverse or descending colon. The clinical implication of this finding is that gastrointestinal wall thickening should not be ascribed to cirrhosis alone if it involves the duodenum or the ileum without involvement of the jejunum or involves the transverse or descending colon without involvement of the ascending colon. Such findings on the CT scan of a patient with cirrhosis should prompt a search for coexistent, noncirrhotic causes of gastrointestinal wall thickening.

The authors conclude that it is important to recognize conditions other than cirrhosis when interpreting abdominal CT images. When gastrointestinal wall thickening patterns atypical for cirrhosis are encountered on contrast-enhanced CT scans, alternative diagnoses to cirrhosis should be considered.

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