Case ll - Diffuse Small Bowel Wall Edema - Lupus

There is abdominal and pelvic ascites. There are long segments of diffuse small bowel wall thickening (1, 2) with normal decompressed bowel distally.  Additionally, there is a cystic mass in the left adnexa. 

This case is an excellent example of diffuse small bowel wall thickening.  The appearance is textbook "stack of coins," or submucosal edema (1, 2).  Notice how the submucosa is thickened and low attenuation (1, 2). This accentuates the mucosal folds (1, 2).  Notice how the mucosa and serosa enhance (1, 2).   In cross section, notice the "target sign" appearance.  Again, the mucosa and serosa are hyper-enhancing and the submusoca is thickened and hypodense.  This case is also provides a nice example of using air in the lumen to determine if the bowel is thickened.  In the areas of thickening intraluminal air is separated from the serosa..  In this loop of bowel slightly more distal, you can use the air to prove that the wall remains thin.  See the schematics for normal and abnormal small bowel.

The generic differential diagnosis for diffuse small bowel thickening is shock bowel (global hypo-perfusion); hemorrhage from trauma, vasculitis, or coagulopathy; and infiltration from tumor, graft versus host disease, or post XRT changes.  In this case, the edema is diffuse but limited to the jejunum.  The differential can thus be expanded to include infectious etiologies like Giardia and Cryptosporidium.  However, in a young otherwise healthy female, this degree of small bowel edema is typical for Lupus, which is a  form of vasculitis.  Lab tests confirmed this diagnosis.

This degree of ascites can be seen with Lupus and also shock bowel, and trauma.  It would be unusual to have this much ascites with infection or inflammatory bowel disease.

Ultrasound 6 weeks later confirmed resolution of the physiologic cysts in the left adnexa.