The small bowel remains the most challenging segment of the alimentary canal to examine, due to its length, caliber, and overlap of loops1. Number of imaging modalities for evaluating patients with small bowel disease have changed dramatically in the past few decades. Several years ago, the only methods to assess the small bowel were conventional enteroclysis or small- bowel follow-through but it has many limitations like, unsatisfactory bowel distention, no differentiation between bowel wall and high attenuating content, visualisation of only intraluminal lesions, patient compliance & so on. Further more invent of computed tomography gained popularity for evaluating small bowel lesions, but this examinitation also showed some limitations like inadequate distension of bowel, non visualization of mucosal pathology & improper delination of ileo-caecal junction. However, with the advent of the third generation detectors, increased speed and resolution of multi– detector computed tomography have made CT first-line modality for the examination of small bowel disease.3 However, CT Enterography in specific differs from routine abdomino-pelvic CT which makes use of thin sections and large volumes of enteric contrast material to better display the small bowel lumen and wall. The use of neutral enteric contrast agents combined with the use of intravenously administered contrast material, permits excellent assessment of hypervascular lesions and hyperenhancing segments.[1,2] Previously luminal distension of small bowel was achieved by fluoroscopic placement of a nasojejunal feeding tube to infuse oral contrast agent. Although this technique provides excellent image quality, most patients find placement of this nasojejunal feeding tube uncomfortable and many patients perceive duodenal intubation as traumatizing. Therefore, for small-bowel imaging to gain wider clinical acceptance, the features of noninvasiveness has to be retained. Thus, contrast agents that provide distention need to be administered orally without duodenal intubation. Although, numerous contrast agents are used for luminal opacification and optimal visualization of the small bowel, we propose mannitol as a oral contrast agent in our study because it is good in taste, provides optimal luminal distension, contrast homogeneity, satisfactory visualization of ileocaecal junction, various patterns of mural enhancements.[3,4] The purpose of this study is to evaluate effectiveness of mannitol as a orally administered neutral contrast agent for small bowel distension & to study the various features of the small bowel diseases. As many patients of small bowel disease, comes to our hospital, we proposed to study 40 patients with small bowel disease and 30 control patients to assess distension of small bowel.

The study of 70 patients referred to the radiology department for evaluation of small bowel, most of them had clinical presentation suggestive of some small bowel disease process, out of these 70 cases we have observed radiological findings suggestive of small bowel pathology in 40 patients. Out of the remaining 30 cases which did not reveal any radiological findings suggestive of any disease process, and also after reviewing these cases by two faculty members, we then considered these cases for assessing the distension ability of small bowel by mannitol and this group was further referred to as control group. Exclusion criteria included mannitol intolerance or mannitol contraindication e.g. diabetes, acute renal failure etc. and inability to hold the breath for 20-30 sec during CT examination. Patient Preparation The cleansing Preparation of patient followed: (a) Low residue diet for two days before examination. (b) Laxatives for one - two days. (Tab. Dulcolax: 0.25mg/kg) (c) Water enema to be given previous night and morning on the day of examination. (d) Ample fluid intake: double the normal intake. (e) Abstain from oral intake at least for 4 hours prior to scanning. Oral Contrast The imaging protocol began with the administration of a large volume of oral contrast material. In our study mannitol was proposed as an oral contrast agent. About 200 ml of 10% mannitol is mixed with 1200 ml of water and patient was asked to drink continuously for 30-40 minutes. (Its underlying chemical structure prevents intestinal absorption, and its inherent osmotic property leads to increased bowel distension). Intravenous contrast and technique After the consumption of the oral contrast within 30 to 40 minutes, the patient was given right lateral position for 10 minutes and Inj. buscopan 0.2mg/kg (hyoscine- N butyl bromide) was injected intravenously to the patients just before scanning to supress intestinal motility. Following which CT scanning was done in prone position on a 16 slice MDCT scanner with 120 KVP & 250 mAs. Plain scan were taken from lower part of xiphisternum to pubis symphysis followed by 100ml of iohexol (inj. Omnipaque) administered intravenously at a rate of 4 ml/sec. and CT scan was obtained in venous phase 40-45 seconds. All the Images were acquired with a section thickness of 3.0mm and reconstruction of 1 mm in coronal and saggital section was done. All images of duodenum, jejunum, ileum, and ileocecal regions were assessed, and interpretations were done segment-by-segment basis. Analysis was done both quantitatively & qualitatively. Qualiitative Analysis: It consisted of luminal distension, evaluated as described by Minowa et al.28 Small-bowel loops were evaluated using a 3-point scale (0, poor; 1, good; 2, optimal). A distension score on the basis of an estimate of the percentage of small bowel with adequate distension was done. If greater than 70% of the small bowel demonstrated distension, then the score was optimal; if 40–70% of the small bowel was distended, the examination received a distension score of good; if less than 40% of small bowel was distended, the examination received a score of poor distension. The first two levels of distension (i.e., > 70% and 40–70%) were considered as a positive result, which was adequate luminal distension and separation of the lumen by enteric contrast material without collapse. Quantitative Analysis: Included an evaluation of bowel caliber and bowel wall thickness. Bowel luminal caliber not exceeding 3 cm and wall thickness less than 3 mm was considered suggesting of normal bowel distension and wall thickness. OTHER RADIOLOGICAL FEATURES CONSIDERED FOR EVALUATION 1) Homogeneity of contrast opacification along with satisfactory visualization of ileocaecal junction was noted. 2) The demonstration of the mesenteric vasculature with superior mesenteric artery & superior mesenteric vein relationship was evaluated. 3) Incidental findings were tabulated. ADVERSE EFFECTS OF ORAL CONTRAST (MANITOL) All the patients were interviewed about their tolerance of the procedure 1 hr after the examination. Patients were asked about the taste of the mannitol solution which was graded as good or acceptable or not acceptable. Their experience about any side effects such as nausea, vomiting, abdominal discomfort, or diarrhoea was noted. All these parameters were classified on a standardized questionnaire with a 2-point scale (i.e., score of 0 for no side effects; 1 for side effects (nausea, vomiting, abdominal discomfort, diarrhea or other). B] IMAGE EVALUATION IN SMALL BOWEL DISEASED PATIENTS CT Enterography features and characteristics of the various small bowel diseases were observed and analyzed in a specific format. A small bowel loop was considered abnormal when the wall thickness was > 3 mm despite adequate luminal distension & bowel caliber more than 3cm.65 Six criteria 9 were applied in the evaluation of the abnormal small bowel, including 1. Bowel loop involved. 2. Changes in bowel wall. a) Degree of thickening: mild [3-4 mm] / moderate [5-9mm] /marked [ >10mm]. b) Predominantly: intramural / intraluminal / extraluminal. c) Length of involvement:focal [< 5cm] / segmental [6 – 40 cm] / diffuse [>40 cm] d) Thickening: asymmetrical / symmetrical. e) Enhancement; i. Venous: ii. Mural enhancement patterns : target / homogenous / heterogenous / diminished 3. Changes in bowel caliber ( involved segment ,proximal and distal segments). 4. Surrounding mesentry & vessels. a) Fat : b) Vessels : c) Lymphnodes : 5. Other specific features of mass lesion (calcification / necrosis etc.) 6. Other associated findings (ascites / peritoneal involvement / other organ metastasis/ any other)

Table-1: Distension grading for duodenum in control group Duodenum Number of Patients Percentage Optimal 15 50% Good 10 33% Poor 5 17% Total 30 100 Jejunum Optimal 10 33% Good 20 77% Poor 0 0% Total 30 100% Ileum optimal 10 33.3% good 10 33.3% poor 10 33.3% total 30 100% (Table 1) Out of 30 patients in the control group, luminal distension of the duodenum was optimal in 15 patients (50%), good in 10 (33%), and poor in 5 (17%). The jejunum showed optimal distension in 10 patients (33%) and good distension in 20 (67%), with none demonstrating poor distension. The ileum demonstrated equal distribution with 10 patients (33.3%) each in optimal, good, and poor categories. Table-2: Distension score for individual bowel segments in control group Distension score score Duodenum 1.2 Jejunum 1.1 Ileum 1.4 Mean bowel caliber (cms) Duodenum 2.4 Jejunum 2.6 Ileum 2.8 Mean bowel wall thickness Duodenum 1.68 Jejunum 1.1 Ileum 0.9 Distension Score and Morphometry (Table 2) The calculated mean distension scores for duodenum, jejunum, and ileum were 1.22, 1.10, and 1.48 respectively. The mean bowel caliber was 2.4 cm in the duodenum, 2.6 cm in the jejunum, and 2.8 cm in the ileum. Mean bowel wall thickness was 1.68 mm for the duodenum, 1.1 mm for the jejunum, and 0.9 mm for the ileum. In all cases, the bowel wall thickness remained <3 mm. A distension score of ≥1, caliber ≤3 cm, and wall thickness <3 mm was considered a positive result, reflecting normal findings. Table-3: Side effects of mannitol as oral contrast agent in control group Side Effects Number Of Patients Percentage Nausea 5 16.6% Vomiting 5 16.6% Diarrhoea 5 16.6% No Side Effects 15 50% Total 30 100% Incidental Findings Liver Hemangioma 5 16.6% Cholelithiasis 4 13.3% Mid Gut Malrotation 1 3.3% Hiatus Hernia 1 3.3% Diverticulae 1 3.3% No Findings 18 60% Table 3) Side effects were observed in 15 patients (50%), most commonly nausea (16.6%), vomiting (16.6%), and diarrhea (16.6%). Fifteen patients (50%) had no side effects. Incidental findings included liver hemangiomas (16.6%), cholelithiasis (13.3%), midgut malrotation (3.3%), hiatus hernia (3.3%), and diverticulae (3.3%). No abnormalities were seen in 60% of patients. Table-4: Additional evaluated features in the control group Evaluated features Number of patients with satisfactory results Number of patients with non satisfactory results Percentage Contrast homogenicity 30 0 100% Depiction of sma – smv relationship 30 0 100% Depiction of ic junction 30 0 100% Total 30 0 100% (Table 4) Contrast homogeneity, depiction of SMA–SMV relationship, and visualization of the ileo-caecal junction were satisfactory in all 30 patients (100%). Table-5: Agewise distribution for the pathology group patients. Age group in years Number of patients percentage 0-10 1 2.5% 11-20 7 17.5% 21-30 11 27.5% 31-40 4 10% 41-50 10 25% 51-60 5 12.5% 62-70 1 2.5% 72-80 1 2.5% total 40 100% Gender Male 30 75% Female 10 25% Table 5) The age of patients in the pathology group (n=40) ranged from 0 to 80 years, with the majority between 21–30 years (27.5%) and 41–50 years (25%). The male-to-female ratio was 3:1 (75% males, 25% females). Table-6: Various small bowel diseases evaluated by ct enterography Smal bowel pathologies Number of cases Percentage small bowel tumors 10 25% tuberculosis 5 12.5% inflammatory bowel disease 14 35% post op adhesions 2 5% mesenteric ischemia 1 2.5% annular pancreas 1 2.5% mid gut volvulus 2 5% intussuception 2 5% malrotation 2 5% adenomatous polyp 1 2.5% total 40 100% small bowel tumors adeno carcinoma 4 40% peri ampullary carcinoma 1 10% gist 0 0% lymphoma 2 20% carcinoid 1 10% metastases/infiltration 2 20% total 10 100% various inflammatory bowel pathologies crohns disease 5 33% ulcerative colitis 1 7% non specific ibd 9 60% total 14 100% The distribution of small bowel pathologies included inflammatory bowel disease (35%), tumors (25%), tuberculosis (12.5%), post-operative adhesions (5%), intussusception (5%), malrotation (5%), and rarer conditions such as mesenteric ischemia, annular pancreas, volvulus, and adenomatous polyp (each 2.5%). Among tumors (n=10), adenocarcinoma was most common (40%), followed by lymphoma (20%), metastasis/infiltration (20%), peri-ampullary carcinoma (10%), and carcinoid (10%). No cases of GIST were identified. In patients with IBD (n=14), nonspecific IBD accounted for 64.2%, Crohn’s disease for 35.7%, and ulcerative colitis for 7.1%. Table-7: Distribution of bowel segments in various small bowel diseases small bowel pathologies and segments duod jejun ileum ileo cecal involvement of 2 or more segments total Tumors 3 1 2 1 3 10 Tuberculosis 0 0 0 3 2 5 IBD 0 2 5 4 3 14 Post Op Adhesions 0 0 2 0 0 2 Mesenteric Ischemia 0 0 1 0 0 1 Annular Pancreas 1 0 0 0 0 1 Mid Gut Volvulus 2 0 0 0 0 2 Intussuception 0 0 2 0 0 2 Malrotation 0 2 0 0 0 2 Adenomatous Polyp 0 0 1 0 0 1 Total 8 5 18 8 1 40 (Table 7) Tumors were most frequently located in the duodenum (3 cases) and ileum (2 cases), with 3 cases involving multiple segments. Tuberculosis predominantly affected the ileo-caecal region (3 cases). Crohn’s disease commonly involved the ileum (5 cases), while jejunal and ileo-caecal involvement was also noted. Other pathologies such as post-operative adhesions, intussusception, and adenomatous polyp showed a predilection for the ileum. Table-8: Degree of bowel wall thickening in various small bowel diseases Degree of thickening Mild ( 3-5 Mm) Moderate (5-10mm) Marked (>10mm) No Obvious Thickening Total Tumors 1 2 7 0 10 Tuberculosis 0 2 3 0 5 IBD 5 8 1 0 14 Post Op Adhesions 0 0 0 2 2 Mesenteric Ischemia 0 0 0 1 1 Annular Pancreas 0 0 0 1 1 Mid Gut Volvulus 0 0 0 2 2 Intussuception 0 1 0 2 2 Malrotation 0 0 0 2 2 Adenomatous Polyp 0 0 0 1 1 Total 6 12 11 11 40 (Table 8) Degree of wall thickening varied among pathologies: tumors predominantly showed marked thickening (>10 mm in 7/10 cases), tuberculosis showed moderate (2) to marked (3) thickening, and IBD cases mostly showed mild (5) to moderate (8) thickening. Table-9: Length of involvement of bowel in various small bowel diseases Length of involvment Focal (<3cms) Segmental (3-5 Cms) Diffuse (>5cms) Total Tumors 7 2 1 10 Tuberculosis 3 1 1 5 IBD 3 8 3 14 Post Op Adhesions 0 2 0 2 Mesenteric Ischemia 0 1 0 1 Annular Pancreas 1 0 0 1 Mid Gut Volvulus 2 0 0 2 Intussuception 2 0 0 2 Malrotation 0 2 0 2 Adenomatous Polyp 1 0 0 1 Total 19 16 5 40 Tumors and tuberculosis typically demonstrated focal (<3 cm) involvement (70% and 60% respectively). IBD more often showed segmental (57%) or diffuse (21%) disease. Table-10: Mural enhancement patterns in various small bowel diseases Mural enhancement pattern target homogenous hetrogenous diminished not applicable total Tumors 6 2 2 0 0 10 Tuberculosis 0 3 2 0 0 5 IBD 0 8 6 0 0 14 Post Op Adhesions 0 0 0 2 0 2 Mesenteric Ischemia 0 0 0 1 0 1 Annular Pancreas 0 0 0 0 1 1 Mid Gut Volvulus 0 0 0 2 0 2 Intussuception 0 0 0 2 0 2 Malrotation 0 0 0 0 2 2 Adenomatous Polyp 0 0 1 0 0 1 Total 6 13 11 7 3 40 Tumors frequently showed target-type enhancement (6/10), tuberculosis demonstrated predominantly homogenous enhancement (3/5), and IBD showed mixed homogenous (8/14) and heterogeneous (6/14) patterns. Table-11: Small bowel diseases causing small bowel obstruction Small Bowel Diseases number of cases present number of cases absent total Tumors 3 7 10 Tuberculosis 0 5 5 IBD 1 13 14 Post Op Adhesions 1 1 2 Mesenteric Ischemia 1 0 1 Annular Pancreas 0 1 1 Mid Gut Volvulus 2 0 2 Intussuception 2 0 2 Malrotation 0 2 2 Adenomatous Polyp 0 1 1 Total 10 30 40 Obstruction was most commonly caused by tumors (3 cases), intussusception (2), volvulus (2), and post-operative adhesions (1). Table-12: Small bowel diseases with mesentry involvement (fat, vessels, lymphnodes) Small Bowel Diseases fat involvement present fat involvement absent total Tumors 10 0 10 Tuberculosis 5 0 5 IBD 9 5 14 Post Op Adhesions 2 0 2 Mesenteric Ischemia 0 1 1 Annular Pancreas 0 1 1 Mid Gut Volvulus 0 2 2 Intussuception 2 0 2 Malrotation 0 2 2 Adenomatous Polyp 0 1 1 Total 28 12 40 Fat: Seen in tumors (10/10), tuberculosis (5/5), and IBD (9/14). Table-13: Small bowel diseases with mesentry involvement (fat, vessels, lymphnodes) Small Bowel Diseases vessel involvement present vessel involvement absent total Tumors 4 6 10 Tuberculosis 0 5 5 IBD 0 14 14 Post Op Adhesions 0 2 2 Mesenteric Ischemia 1 0 1 Annular Pancreas 0 1 1 Mid Gut Volvulus 2 0 2 Intussuception 2 0 2 Malrotation 2 0 2 Adenomatous Polyp 0 1 1 Total 11 29 40 Vessels: (Table 13) Present in 4/10 tumors, mesenteric ischemia (1/1), volvulus (2/2), intussusception (2/2), and malrotation (2/2). Table-14: Small bowel diseases with mesentry involvement (fat, vessels, lymphnodes) Small Bowel Diseases Lymphnodal involvement present Lymphnodal involvement absent Total Tumors 10 0 10 Tuberculosis 4 1 5 IBD 7 7 14 Post Op Adhesions 0 2 2 Mesenteric Ischemia 0 1 1 Annular Pancreas 0 1 1 Mid Gut Volvulus 0 2 2 Intussuception 0 2 2 Malrotation 0 2 2 Adenomatous Polyp 0 1 1 Total 21 19 40 Lymph nodes: (Table 14) Seen in all tumors (10/10), tuberculosis (4/5), and IBD (7/14).

Our control cohort demonstrated consistently adequate small-bowel distension (duodenum: 83% optimal/good; jejunum: 100% optimal/good; ileum: 66.6% optimal/good) with mannitol. This mirrors prior work showing mannitol/neutral agents yield reliable luminal distension for enterography while being inexpensive and easy to administer. Multiple series—spanning MDCT/MR enterography—report comparable distension quality between mannitol and PEG solutions, with no clear benefit to volumes >1 L (and higher volumes increasing minor GI side effects), in line with our 50% minor adverse-event rate (nausea/vomiting/diarrhea) yet high overall acceptance (93.3%). [5] In our study, small bowel wall thickness in asymptomatic controls ranged from 1–2 mm, with jejunal loops slightly thicker than ileal loops. These findings are consistent with those of Cronin et al. (8), who established normal small bowel parameters on MR enterography and reported jejunal thickness up to 2 mm in the distended state. Similarly, Macari and Balthazar (9) emphasized that thickness greater than 3 mm in adequately distended loops should be regarded as abnormal. With respect to luminal diameter, our results (2.5–3 cm in jejunum and ileum) are in agreement with Raptopoulos et al. (5), who described a normal small bowel calibre of less than 3 cm on CT enterography. Kuehle et al. (10) also highlighted the importance of adequate luminal distension in avoiding false interpretation of wall thickening. Mannitol proved to be an effective neutral oral contrast agent in our study, providing adequate luminal distension and good image quality with minimal side effects. Li et al. (11) first introduced the use of iso-osmotic mannitol in multidetector CT enterography and demonstrated its feasibility and tolerability. Subsequent comparative studies by Choi et al. (12) confirmed that mannitol offers superior wall visibility compared to water and methylcellulose, with fewer adverse effects. Our findings further support mannitol’s role as a safe and effective agent for routine use in CT enterography. In evaluating disease spectrum, we observed bowel wall thickening and stratification in inflammatory bowel disease, while irregular asymmetrical thickening and enhancing masses were predominant in neoplastic conditions. These observations are concordant with Paulsen et al. (3) and Huprich & Fletcher (13), who described stratified mural enhancement as a hallmark of Crohn’s disease and irregular focal thickening as more suggestive of neoplasm. Furthermore, Kedia et al. (14) emphasized that differentiating Crohn’s disease from intestinal tuberculosis remains challenging, although certain imaging features such as longer segment involvement and skip lesions favour Crohn’s disease. Overall, our findings align closely with previously published literature, validating the utility of CT enterography in assessing both normal and pathological small bowel. Recent consensus guidelines by Bruining et al. (15) further reinforce the role of CT enterography as a first-line tool in the evaluation of small bowel disorders, particularly when endoscopic access is limited. CT Enterography with mannitol as oral contrast agent did not cause any major side effects and was acceptable to majority of the patients. Luminal distension was optimal to good in majority of the patients with adequate contrast homogeneity and satisfactory visualization of ileo-caecal junction. The study of the various features of the small bowel diseases in a systematic pattern helped to narrow the differential diagnosis. In Malignancy majority of the patients showed focal bowel segment involvement, with marked bowel wall thickening and heterogeneous mural enhancement pattern where as majority of benign inflammatory and infective conditions showed segmental or diffuse bowel segment involvement with moderate to mild bowel wall thickening and homogenous or target mural enhancement pattern along with changes in the surrounding mesentery. Limitations and future directions Our study’s single-center design and modest sample sizes within subgroups (e.g., ischemia, carcinoid) limit precision of subgroup estimates. Future work could (i) incorporate standardized activity indices and radiologic scoring (particularly for IBD), (ii) correlate with histopathology or endoscopic/biologic endpoints, and (iii) evaluate dose-optimization or photon-counting CT for reduced radiation without sacrificing mural detail, while continuing to compare CTE with MRE/US in longitudinal care.

This study showed that CT Enterography with mannitol as neutral contrast agent is a simple, noninvasive and effective method of distending and evaluating the small bowel. When the study is combined with a systematic pattern approach it can be used to narrow the differential diagnosis when an abnormal small-bowel loop is detected on MDCT. So, CT Enterography with mannitol as neutral contrast agent should be used when a clinical concern exists for small-bowel disease.

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