What causes the picket fence appearance in the small bowel on imaging?
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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: Stack of coins sign (widely used interchangeably, both describing the same parallel, symmetric fold thickening)
Other associated named signs: Thumbprinting (submucosal edema from ischemia or infection), coiled spring sign (intussusception), hidebound bowel sign (systemic sclerosis)
References
Access all radiology signs posted so far: https://radiogyan.com/radiology-signs/
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