Anatomic and Normal Radiologic Features

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The Duodenocolic Relationships:

Normal and

Pathologic Anatomy

10

The precise anatomic relationships between the duodenal loop and the transverse colon are often of critical importance in the radiologic interpretation of upper abdominal pathology. Their points of most intimate relationship represent anatomic crossroads between intraperitoneal and extraperitoneal structures and thus permit specific localization and diagnosis of a disease process.¹ Because of this relationship, a lesion originat- ing in one may exert its major effects on the other. Par- ticularly if radiologic investigation is initiated by a study that manifests the striking secondary effects, the presentation of findings may then be very misleading until the nature of the relationship and the primary site are ap- preciated.

Detailed knowledge of the intimate anatomic relationships is essential in the radiologic interpretation of a variety of diseases. These include defects of the mesocolon with internal herniation into the lesser sac, masses developing within the mesocolic leaves, extension of neoplasms, duodenocolic fistulas, gallbladder disease, renal masses, pancreatitis, and abdominal aneurysm.

Anatomic and Normal Radiologic Features

The key to understanding the significance of the duodenocolic relationships is the insertion of the root of the transverse mesocolon and its planes of reflection (Fig.

10–1).

The hepatic flexure of the colon is characteristically composed of two curvatures.² The proximal, more posterior one continues from the fixed extraperitoneal ascending colon and is related to the inferior and lateral edge of the right kidney and the posterolateral tip of the liver. The colon then passes immediately anteromedially over the descending duodenum to the second curve of the hepatic flexure, which is more anterior and is related above to the gallbladder.

At a point between the two curvatures of the hepatic flexure, as the colon is in intimate relationship to the descending duodenum (Fig. 10–2), it begins to pick up the peritoneal sling of the transverse mesocolon. The colon in this area is then in virtual contiguity with the second portion of the duodenum, with the very short edge of the beginning reflection of the transverse mesocolon providing a mesenteric plane (Figs. 10–3 and 10–4).

The root of the transverse mesocolon broadly inter- sects the infraampullary portion of the descending duodenum and then continues along the anterior surface of the pancreas. Here it is attached to the midportion of the head and the inferior surface of the body and tail.

The nonperitonealized bare area, wide on the right and progressively thinner toward the left, thus provides a shared anatomic plane, between the pancreas and descending duodenum behind and the transverse colon in front, along the leaves of the transverse mesocolon.

The transverse mesocolon itself is a fan-shaped structure in the horizontal plane of the body. Short at its beginning, it is longest in the midsagittal plane, becom-

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10. The Duodenocolic Relationships: Normal and Pathologic Anatomy

Fig. 10–1. The root of the transverse mesocolon.

It extends across the infraampullary portion of the duodenum and lower border of the pancreas. Note the relationships of the anterior hepatic flexure of the colon (AF) and of the duodenojejunal junction. PF = posterior hepatic flexure. MP marks the location of Morison’s pouch, the intraperitoneal posterior extension of the right subhepatic space anterior to the right kidney.

(Reproduced from Meyers and Whalen.¹)

Fig. 10–2. A normal upper GI series frequently shows lateral pressure on the descending duodenum from a feces- distended anterior hepatic flexure of the colon. This reflects their contiguous anatomic relationship.

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Anatomic and Normal Radiologic Features

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Fig. 10–3. Transverse section through the right abdomen at the level of the duodenal bulb (DB) and the proximal descending duodenum (DD).

Note the intimate relationship of the hepatic flexure of the colon (C) at the beginning reflection of the transverse mesocolon. S = stomach; Gb = gallbladder; L = liver;

K = kidney.

Fig. 10–4. Right parasagittal section at the level of the duodenal bulb (DB) and the decending duodenum (DD), showing their relationship to the anterior hepatic flexure (AF) of the colon before it continues ventrally as the transverse colon (TC). The dashed line indicates the transverse mesocolon.

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10. The Duodenocolic Relationships: Normal and Pathologic Anatomy

ing abbreviated laterally once again as the colon comes into relationship to the left kidney and the spleen. The length of the transverse mesocolon varies. It tends to be short in stocky individuals and long in tall, thin individuals.

The retroperitoneal duodenum bends forward after its ascending portion at the level of the ligament of Treitz to penetrate the posterior parietal peritoneum and con- tinue as the intraperitoneal jejunum.

Although usage of the term ligament of Treitz for the duodenojejunal function is widely employed, it is not only inaccurate but may be misleading.³ The duodenojejunal flexure is generally about 2.5 cm left of the midline at the level of the inferior border of the first lumbar vertebra.⁴ In 1853, Treitz⁵ (Fig. 10–5) described the suspensory muscle of the duodenum as a thin tri- angular band ascending behind the pancreas to blend with the dense connective tissue around the stems of the superior mesenteric artery and celiac axis.⁶ It is a curious fact that anatomists refer to the structure as the suspensory muscle of the duodenum, whereas clinicians refer to it as the ligament of Treitz. It is generally conceived of and illustrated in anatomic atlases as a thin fibromuscular band limited to the duodenojejunal junction. Yet, exclusive attachment to the flexure is rare. Rather, the muscle is usually attached to the third and fourth portions of the duodenum and frequently to the duode-

nojejunal flexure as well (Fig. 10–6). At its base, the smooth muscle fibers of the suspensory muscle are con- tinuous with the longitudinal and circular muscle fibers of the duodenum. Superiorly, the muscle is gradually replaced by collagenous and elastic fibers. Its overall length varies from 1.25–6.4 cm. The fibromuscular structure plays an important role in the embryologic ro- tation of the bowel and in facilitating normal progression of contents from the extraperitoneal duodenum to the mesenteric small bowel and contributes to the effects of the superior mesenteric artery syndrome.^3,8

The duodenojejunal junction is in intimate relationship to the inferior reflection of the transverse mesocolon (Figs. 10–1 and 10–7). It also serves as a useful landmark for dividing the body and tail of the pancreas.

The duodenojejunal junction, fixed by the ligament of Treitz, generally maintains its position throughout life. The duodenal bulb and proximal portion of the second duodenum, however, tend to descend with age, with progressive laxity of support, a change most marked in the fifth and sixth decades.⁹ Nevertheless, the position of the root of the transverse mesocolon, which separates the peritoneal cavity from the lesser sac, can be con- stantly indicated on an upper GI series by a line drawn from the infraampullary segment of the descending duodenum to a point immediately above the duodenojejunal junction. This delimits the most superior ascent of

Fig. 10–5. Václav (Wenzel) Treitz (1819–1872), age 41.

Treitz was a Bohemian-born pathoanatoinist who held faculty positions in Vienna, Kraków, and Prague. In 1853, he described “A new muscle in the human duodenum, over elastic sinews and some other anatomical relations,” now generally referred to as the ligament of Treitz. In 1857 in an article entitled “Hernia Retroperitonealis: A Contribution to the History of the Internal Hernias,” he discussed the anatomic relationships at the site of the passage of the duodenum into the jejunum bordered by the inferior mesenteric vein and left colic artery, also called the vascular arch of Treitz.

(Courtesy of the Institut für Geschichte der Medizin der Universitãt Wien, Museum Josephinum, Vienna.)

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Anatomic and Normal Radiologic Features

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Fig. 10–6. Variations of the attachment of the suspensory muscle of the duodenum (ligament of Treitz).

(a) Attachment to the third and fourth portions of the duodenum and the duodenojejunal flexure.

This occurs in 40–61% of cases.

(b) Multiple, separate divisions are not unusual.

(c) Attachment to the third and fourth positions of the duodenum only. This occurs in 31–53%

of cases.

(d) Attachment to the duodenojejunal flexure only. This occurs in 0–8% of cases.

(Reproduced from Akin et al.⁷)

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10. The Duodenocolic Relationships: Normal and Pathologic Anatomy

Fig. 10–7. Left parasagittal section at a level lateral to the duodenojejunal junction.

Shown are the relationships of the proximal jejunal loops (JL) to the transverse colon (TC) and its mesocolon (arrowheads), coursing along the inferior aspect of the tail of the pancreas (P). The section is also through the spleen (Sp) and the left kidney (LK).

small bowel loops posterior to the transverse colon normally possible (Fig. 10–8).

On the right, the colon inferiorly and the descending duodenum medially provide two of the boundaries of the posterior extension of the subhepatic space (Mori- son’s pouch) anterior to the kidney (Fig. 10-1).

Abnormal Radiologic Features

Defect of Mesocolon with Internal Herniation into Lesser Sac

Occasionally, jejunal loops may normally present within the upper abdomen anterior to the transverse colon and, perhaps, the stomach. Cephalad extension of small

bowel loops posterior to the transverse colon above the line of the root of the transverse mesocolon in relationship to the descending duodenum and duodenojejunal junction indicates a defect of that mesentery with internal herniation into the lesser sac¹ (Fig. 10–9).

Masses Within the Mesocolic Leaves

Pathologic alteration in the contour of the duodenum by a localized abnormality arising in the origin of the reflections of the transverse mesocolon is shown in Fig- ure 10–10. The bare area is widest at this site so that symmetric growths developing within the leaves may impress upon the duodenum over a considerable length.

The typical points of pressure then are at the immediate infraampullary and the genu locations.

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Abnormal Radiologic Features

545

Fig. 10–8. The transverse mesocolon (arrows) is outlined by the limitation of cephalad extension of jejunal loops posterior to the transverse colon, resulting in flattening of their superior contour. It corresponds to a line drawn from the mid-descending duodenum to the duodenojejunal junction.

(a) Normal gastrointestinal series.

(b) Post-Billroth II antecolic gastrojejunostomy.

(c) Postduodenojejunostomy.

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10. The Duodenocolic Relationships: Normal and Pathologic Anatomy

Fig. 10–9. Internal hernia into the lesser sac through a large defect in the transverse mesocolon.

This is indicated by the high position of the loops of small bowel above the normal insertion of the transverse mesocolon, which no longer determines their contour.

(a) Frontal.

(b) Prone oblique. Note that the herniated loops present posterior to the transverse colon and stomach.

Effect upon the Descending Duodenum by Carcinoma of the Hepatic Flexure

The virtual contiguity of the hepatic flexure to the descending duodenum allows ready spread of a neoplasm.^1,10 Figures 10–11 and 10–12 illustrate early stages of this process. The occult nature of carcinoma of the right colon is well known, and the presence of fever, abdominal distress, and a palpable epigastric mass may lead to radiologic investigation being initiated with an upper gastrointestinal series. In such cases, striking changes involving the descending duodenum may include extrinsic pressure defects and, occasionally, gas- containing cavities (Fig. 10–13a). These may be very misleading unless a barium enema study is done and the primary site in the hepatic flexure of the colon is revealed (Fig. 10–13b).

Duodenocolic Fistulas

Although most duodenocolic fistulas result from an infiltrating adenocarcinoma of the hepatic flexure,¹¹ the communication may be established by ulcerative or inflammatory disease.^12–14 Granulomatous colitis is being increasingly recognized as an underlying cause.^13,14 With the right-sided colonic involvement of this transmural inflammatory and ulcerating condition, fistulization may develop between the hepatic flexure particularly or the transverse colon and the duodenum (Figs. 10–14 through 10–16). Malabsorption may result if the small bowel is bypassed significantly, but the fistula need not be a serious complication of Crohn’s disease and should not serve as an indication for surgical correction for its own sake.^13–15 Intestinal tuberculosis is another chronic granulomatous disease that may result in fistulization^16,17

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Abnormal Radiologic Features

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Fig. 10–10. Lymphangitic cysts within the leaves of the transverse mesocolon produc- ing extrinsic nodular indentations on the descending duodenum.

(a) Prone. Three discrete mass impressions are shown (arrows).

(b) Right lateral projection. The larger, more proximal indentation presents on the anterior aspect of the descending duodenum (arrow- heads). Note its relationship to the hepatic flex- ure of the colon (C).

(c) Cysts within the mesocolon leaves bridging the bare area of the descending duodenum.

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10. The Duodenocolic Relationships: Normal and Pathologic Anatomy

Fig. 10–11. Carcinoma of the hepatic flexure adherent to the descending duodenum.

Upper GI series shows pressure effects on the duodenum by a nodular malignancy within the hepatic flexure outlined by gas. At surgery, this required careful dissection.

Fig. 10–12. Adherence of colonic carcinoma to duodenum.

Computed tomography shows early adhesive contiguity (arrow) to the inferior genu of the duodenum (D) of a carcinoma that thickens the wall of the hepatic flexure of the colon (C). Thickening of the anterior renal fascia and increased reticulation through the perirenal fat are noted.

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Abnormal Radiologic Features

549

Fig. 10–13. Extension of colonic carcinoma across the mesocolon to the paraduodenal area.

(a) Upper gastrointestinal series reveals numerous gas-containing abscess cavities (arrows) within a mass in the area of the head of the pancreas. There are edema and distortion of the mucosal folds of the descending duodenum.

(b) A subsequent barium enema shows a primary infiltrating carcinoma of the anterior hepatic flexure with a pericolonic–paraduodenal abscess.

(Fig. 10–17). A similar duodenocolic fistula may be seen as a postoperative complication (Fig. 10–18).

Examples have been described of fistulous communication between the third part of the duodenum and the transverse colon, which contained a well-marked muscular layer and an intact epithelium. This rare variety is presumably on an embryologic basis.¹⁸

Effect of Gallbladder Disease on the Duodenocolic Relationships

The nonspecificity of signs and symptoms of diseases of the gallbladder often makes a clinical diagnosis difficult.

At times, it is the striking manifestation of the secondary effects on the neighboring bowel that first brings the patient to medical attention.

Inflammatory adhesions may develop between the gallbladder and the postapical duodenum, permitting the development of fistulous communication (Fig. 10–

19).

The gallbladder is closely applied to the superior aspect of the anterior hepatic flexure in most individuals¹⁹ (Fig. 10–20). The distance between the inner walls of the gallbladder and the adjacent colon is normally less than 1.5 cm.

When the gallbladder enlarges, as in acute cholecystitis, hydrops, empyema, or Courvoisier’s sign of pan- creaticoduodenal malignancy, plain films or barium enema study may reveal smooth extrinsic compression of the hepatic flexure (Figs. 10–21 and 10–22). Accom- panying pericholecystitis or marked fibrous adhesions may result in mucosal edema or fixation (Fig. 10–23).

The postapical duodenum is characteristically displaced text continues on page 556

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10. The Duodenocolic Relationships: Normal and Pathologic Anatomy

Fig. 10–14. Duodenocolic fistula secondary to granulomatous colitis.

Upper GI series demonstrates fistulous communication (arrow) from the infraampullary portion of the descending duodenum to the hepatic flexure, with premature opacification of the transverse colon. Crohn’s disease of the large intestine is apparent.

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Abnormal Radiologic Features

551

(a and b) Upper GI series demonstrates wide communication (arrows) between the third portion of the duodenum and the transverse colon, which is involved by Crohn’s disease. The partially bypassed small intestinal loops show changes of malabsorption.

Barium enema (a) and upper GI series (b) demonstrate fistulas between the hepatic flexure of the colon and the duodenum and between the transverse colon and the greater curvature of the stomach (arrows). Extensive Crohn’s disease of the large intestine is evident.

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10. The Duodenocolic Relationships: Normal and Pathologic Anatomy

Fig. 10–17. Duodenocolic fistula secondary to intestinal tuberculosis.

(a) Barium enema demonstrates fistulization to the duodenum (D) from the colon, which has multiple areas of stricture with severe adhesions. The colonic wall is fibrotic and thin.

(b) CT clearly documents the duodenocolic fistula (arrow).

(Reproduced from Ha et al.¹⁷)

Fig. 10–18. Duodenocolic fis- tula from chronic “blow- out” of duodenal bulb.

Following a Billroth II gastrojejunostomy, a fistulous communi-

cation (arrow) has developed be- tween the sewn-over duodenal bulb and the hepatic flexure of the colon.

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Abnormal Radiologic Features

553

Fig. 10–19. Cholecystoduodenal fistula with gallstone ileus.

(a) Upper GI series demonstrates tract (curved ar- row) between the duodenum and gallbladder. A large gallstone is impacted in a proximal jejunal loop (arrows).

(b) CT shows inflammatory changes (arrow) be- tween the duodenum (D) and the shrunken gall- bladder (GB), which contains air. A dilated loop of jejunum (J) is evident. P = pancreas.

(c) At a lower level, the partially calcified cho- lesterol gallstone within the obstructed loop is documented (arrow).

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10. The Duodenocolic Relationships: Normal and Pathologic Anatomy

Fig. 10–20. Right parasagittal section, showing the close relationship of the gallbladder (GB) to the anterior hepatic flexure of the colon (C). L = liver; RK = right kidney.

Fig. 10–21. Impression of adherent “porcelain” gallbladder.

(a) Plain film shows large calcified gallbladder with impacted stone in its neck (arrow).

(b) Barium enema study demonstrates displacement of gallbladder (black arrows) and impression upon anterior hepatic flexure to which it is adherent. White arrow shows impacted stone.

(Reproduced from Ghahremani and Meyers.¹⁹)

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Abnormal Radiologic Features

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Fig. 10–22. Acute cholecystitis.

(a) Mass impression on superior aspect of anterior hepatic flexure, with mucosal irregularities.

(b) Medial displacement and spasm of proximal descending duodenum.

Fig. 10–23. Acute acalculous cholecystitis.

The inflammatory process of the gallbladder (GB) produces intramural edema within the superior aspect of the anterior hepatic flexure of the colon (arrow).

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10. The Duodenocolic Relationships: Normal and Pathologic Anatomy

medially and may show features of spasm, luminal narrowing, and mucosal irregularities. Carcinoma of the gallbladder commonly infiltrates all layers of its wall and rapidly extends into the surrounding structures. As many as 15% show evidence of colonic invasion on barium

enema studies (Fig. 10–24). CT readily illustrates invasion of the colon (Fig. 10–25a) or duodenum (Fig. 10–

25b). Fistulous communication between the duodenum and colon may occur from acute cholecystitis or carcinoma of the gallbladder^22,23 (Figs. 10–26 through 10–32).

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Fig. 10–24. Carcinoma of the gallbladder.

(a) Fixation of mucosal folds of anterior hepatic flexure.

(b) Marked compression, narrowing, and medial displacement of the proximal descending duodenum.

Fig. 10–25. Gallbladder carcinoma invading the colon (a) and duodenum (b) in two different cases.

(a) CT demonstrates irregular thickening of the gallbladder wall (black arrow) and direct extension to the hepatic flexure of the colon (white arrows). (Reproduced from Ohtani et al.²⁰)

(b) CT shows an intraluminal mass of the gallbladder extending into the hepatic parenchyma (arrows). Contrast enhancement of the lateral wall of the descending duodenum (arrowheads) indicates direct invasion.

(Reproduced from Ohtani et al.²¹)

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Abnormal Radiologic Features

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Fig. 10–26. Cholecystoduodenal fistula secondary to chronic cholecystitis.

Enhanced CT demonstrates a narrow fistula (small arrow) between the contracted gallbladder (black arrow) and the duodenum (white arrow).

(Reproduced from Shimono et al.²³)

Fig. 10–27. Cholecystoduodenal fistula.

Enhanced CT shows air–fluid levels in the contracted gallbladder (black arrow), the result of a fistula from the duodenum (white arrow).

(Reproduced from Shomono et al.²³)

Fig. 10–28. Cholecystocolic fistula secondary to chronic cholecystitis.

(a) Frontal and (b) oblique views during a barium enema study demonstrate communication between the anterior hepatic flexure and a small deformed gallbladder.

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10. The Duodenocolic Relationships: Normal and Pathologic Anatomy

Fig. 10–29. Cholecystocolic fistula.

Enhanced CT demonstrates a narrow fistula (small arrow) between the gallbladder (black arrow) and the colon (white arrow).

(Reproduced from Shimono et al.²³)

Fig. 10–30. Cholecystocolic fistula complicating chronic cholecystitis in two patients.

(a) Barium enema study demonstrates a wide communication between the fundus of the gallbladder containing stones and the adherent hepatic flexure.

(b) Gallstone ileus due to impaction of large nonopaque gallstones (large arrows) in the sigmoid colon with distended intestinal loops proximally. The Cholecystocolic fistula and the shrunken gallbladder (small arrow) are partially opacified with barium.

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Abnormal Radiologic Features

559

Fig. 10–31. Cholecystocolic fistula secondary to carcinoma of the gallbladder.

Barium enema study demonstrates the malignancy infiltrating the anterior hepatic flexure and projecting within the partially opacified gallbladder lumen (arrows).

Fig. 10–32. Carcinoma of the gallbladder with duodenocolic fistula.

Upper GI series demonstrates the communication to the hepatic flexure of the colon across the malignant bed of the gallbladder (arrows).

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Duodenocolic Displacements from Right Renal Masses

The right kidney bears intimate relationships to both the descending duodenum and the region of the hepatic flexures of the colon. Renal masses may thus be revealed by their characteristic effects on the bowel. This is discussed in Chapter 9.

Effect on Colon of Mass Arising in Descending Duodenum

It has been shown that the distal hepatic flexure is in intimate relationship posteriorly to the descending duodenum. Localized anterior displacement of this portion of the colon then indicates a mass arising not in the

nearby right kidney or gallbladder but specifically in the second portion of the duodenum.¹⁹ Following identification of the displacement on an initial barium enema study, radiologic investigation can then be immediately directed to the primary site.

Inframesocolic Extension of Neoplasm of Third Duodenum

The third portion of the duodenum lies retroperito- neally below the root of the transverse mesocolon. Ex- tension of a mass arising in this structure is then revealed on barium enema examination by a characteristic elevation of the proximal transverse colon (Fig. 10–33a).

While this type of displacement may occur secondary to such conditions as mesenteric cysts or primary ret-

Fig. 10–33. Leiomyosarcoma of third portion of the duodenum with large extramural component.

(a) There is gross elevation and displacement of the proximal transverse colon by a huge mass.

(b) Upper GI series documents the changes of leiomyosarcoma arising in the transverse duodenum, characterized by irregular ulcerations and sinus tracts within a lobulated and serpiginous submucosal tumor.

(Reproduced from Meyers.²⁴)

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Abnormal Radiologic Features

561

roperitoneal tumors, initial identification of this inframesocolic component should lead to careful investigation of the transverse duodenum (Fig. 10–33b).

Acute Pancreatitis

Several of the plain film changes associated with acute pancreatitis, while strongly suggestive of the diagnosis, are by no means pathognomonic. Ileus of the transverse colon in a pattern approaching the “colon cut-off” sign may be seen in a variety of conditions.¹ “Sentinel-loop”

dilatation of the descending duodenum may occur secondary to acute cholecystitis or acute right perinephri- tis. However, simultaneous paralytic dilatation of both, secondary to the effects of the extravasated enzymes along the shared anatomic planes, is diagnostic of acute pancreatitis (Fig. 10–34).

Duodenojejunal Junction:

Relation to Colon

The intimate relationship of the duodenojejunal junction superiorly to the root of the transverse mesocolon as it extends across the pancreas is of importance in the identification of both locally arising processes and re- mote colonic pathology.

At this level, the mesocolon is generally long enough so that the transverse colon is considerably anterior. It is then apparent that minor effects on the distal transverse colon on an initial barium enema study may be shown to reflect a process that predominantly involves the ascending duodenum or duodenojejunal junction (Figs. 10–35 and 10–36).

Fig. 10–34. Acute pancreatitis.

The radiologic finding of associated ileus of the transverse colon and of the descending duodenum (shown by stasis of barium within the dilated loop, here superimposed upon the gas-distended transverse colon) is diagnostic of this condition.

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Fig. 10–35. Cyst of the posterior parietal peritoneum below the root of the mesocolon.

(a) Mild extrinsic pressure effect on the superior contour of the transverse colon (arrows).

(b) Gross medial displacement of the fourth portion of the duodenum and duodenojejunal junction, with pressure on the greater curvature of the gastric antrum.

Fig. 10–36. Large calcified aneurysm of the abdominal aorta (arrows).

(a) There is mild pressure on the transverse colon, but (b) marked medial displacement of the ascending duodenum and superior displacement of the duodenojejunal junction.

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