CASE 8940 Published on 04.12.2010

The accordion sign in chronic alcoholic liver disease

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Arora A, Puri SK, Kapoor A, Upreti L.

Department of Radiodiagnosis, G.B. Pant Hospital and associated Maulana Azad Medical College, New Delhi, India.

Patient

36 years, male

Categories
Area of Interest Abdomen, Colon ; Imaging Technique CT
Clinical History
A 36 year old chronic alcoholic male presented with worsening diarrhoea of 15 days duration. He also complained of loss of appetite, and one episode of haematemesis. There was no history of fever, melaena or vomiting. Clinical examination revealed icterus, mild pedal oedema and an enlarged spleen. Grade-1 oesophageal varices were detected at endoscopy.
Imaging Findings
CT examination of the abdomen revealed gross fatty infiltration of the liver, mild splenomegaly and free intraperitoneal fluid. The spleno-portal venous axis was patent. There was a generalized oedematous thickening of the small and large bowel loops. The hyperaemic enhancing mucosa of the colon, stretched over the markedly thickened submucosal folds simulated the appearance of an accordion (Fig. 1-5).
Discussion
The "accordion sign" was first described in 1991 by Fishman et al in a series of 5 of the 26 patients of pseudomembranous colitis (PMC) evaluated with CT [5]. The accordion sign is seen on abdominal CT examinations and refers to the similarity between the thickened oedematous colonic walls to that of an accordion (Fig. 6). The appearance arises as a result of positive oral contrast being trapped between oedematous haustral folds. Occasionally, even in the absence of oral contrast material, the hyperaemic enhancing mucosa stretched over the markedly thickened submucosal folds, can simulate the accordion sign.

Although initially it was described as a sign specific of PMC, it has been reported to represent diffuse colonic oedema of several other aetiologies. Accordion sign can be seen in diverse conditions such as: ischemic colitis, infectious colitis (Campylobacter, Salmonella, Shigella and Cytomegalovirus), Crohn disease, ulcerative colitis, granulomatous colitis, cirrhosis and lupus vasculitis. Amongst these, PMC produces one of the most severe degrees of wall thickening amongst all types of colitis.

Because of significant overlap of imaging findings and non-specificity of the accordion sign, the clinical details and laboratory results play a vital role in reaching a definitive diagnosis. We report a case of a patient with alcoholic liver disease, whose abdominal CT scan presented the typical accordion sign throughout the entire large bowel together with signs of liver disease. The generalized thickening of the small and large bowel loops in a chronic alcoholic patient with deranged liver function suggested hypoproteinemia as the causative factor. Laboratory results confirmed markedly decreased serum albumin.
Differential Diagnosis List
Accordion sign in chronic alcoholic liver disease
Pseudomembranous colitis
Ischemic colitis
Final Diagnosis
Accordion sign in chronic alcoholic liver disease
Case information
URL: https://eurorad.org/case/8940
DOI: 10.1594/EURORAD/CASE.8940
ISSN: 1563-4086