Case nn -  Small bowel thickening secondary to graft versus host disease

There are multiple dilated loops of small bowel throughout the abdomen (1,2,3).  How do you know the loops are dilated?  Notice how thick the wall is adjacent to a bleb of air in this portion of the bowel.  By comparison, look how thin the wall is adjacent to this bubble of air in the adjacent, normal, colon.  Some of the loops almost have a "stack of coins" appearance (1,2).  There is no target sign because no IV contrast was administered.  The target sign is from hyper-ehancement of the mucosa and serosa around a hypodense, thickened bowel wall.  See the abnormal small bowel wall thickening schematic for a review.

The differential diagnosis for a long segment of bowel wall thickening is edema from shock, infection, or allergic drug reaction; hemorrhage from ischemia, vasculitis (including Lupus, HSP, prior external beam radiation), or coagulopathy; and infiltration from lymphoma, tumor, or inflammatory cells (infection, IBD).  Entities such as IBD usually present as multiple short segments of thickening.   Vasculitis, infection, and shock bowel usually result in some mesenteric stranding or ascites.  This helps to narrow the differential.  However, the history of prior bone marrow transplant suggests the diagnosis of graft versus host disease.  Post transplant lymphoproliferative disorder (lymphmoma) in a patient post solid organ transplant could have a similar appearance.

The small nodes in the mesentery (1,2) and vague mesenteric stranding are non specific findings.  These are consistent with the diagnosis of lymphoma and BMT but are usually not associated with a significant pathologic process.

I do not know what these dense things in the IVC are.