What causes the picket fence appearance in the small bowel on imaging?
Let me know in the comments.
Click to reveal the answer
Answer: The picket fence appearance in the small bowel results from smooth, uniform thickening of the mucosal folds, typically caused by intramural hemorrhage, edema, or chronic inflammation. This pattern is often associated with conditions leading to bowel wall edema or bleeding, such as anticoagulant therapy, coagulopathies, or chronic inflammatory bowel disease. Clinically, patients may present with abdominal pain, bleeding, or bowel obstruction symptoms.
Why is it called so?
The sign is named “picket fence appearance” due to the visual resemblance of the regularly spaced, parallel, thickened bowel folds on imaging to the vertical slats of a traditional picket fence.
Pathophysiology
The thickening of valvulae conniventes (small bowel mucosal folds) occurs due to submucosal edema, hemorrhage, or inflammation causing expansion and prominence of the folds. The even spacing and parallel alignment produce the characteristic repetitive linear pattern seen on barium studies, CT, or other contrast-enhanced imaging modalities.
Alternative names: Often used interchangeably with “stack of coins sign,” though the picket fence appearance emphasizes the regular, linear fold pattern more typical of chronic inflammation rather than acute or irregular fold thickening.
Other associated named signs: None specific to this sign, but related bowel wall thickening signs include the coiled spring sign (intussusception) and thumbprinting (submucosal edema from ischemia or infection).
Improve Content And Help Your Colleagues!
Found an error in the post? Please let us know using our contact page and we will update it with due credits!
If you wish to contribute radiological images for this case (or any other article on the website), you can submit them here and you will be duly credited: Submit radiology case