Picket-Fence and Stack of Coins Signs

The picket-fence sign, in radiologic terminology, is the spiked appearance of intestinal mucosal folds seen in some cases of intramural hemorrhage by barium examination. Jerome Wiot and colleagues’ (University of Cincinnati) described this sign in a 1961 report that described the roentgenologic picture of two patients who had duodenal hematomas induced by coumarin. They said, ‘The normal feathery appearance was lost and the duodenal margins showed ‘spikes’ of varying height. Longitudinal folds were not visible, so the mucosal pattern had a ‘picket-fence’ appearance’ (Figure 1). This pattern can be seen elsewhere in the small and large intestine as was reported in a 1964 review of intramural intestinal bleeding. In the jejunum and ileum, Khilnani and co-workers ² (Mount Sinai Hospital, New York) used the stack of coins imagery (Figure 2) to describe its appearance. ‘The small intestine fold pattern may have a highly characteristic appearance and varies slightly with the different entities producing intramural hemorrhage. There is uniform, regular thickening of the folds, sharp delineation of their margins, and a parallel arrangement producing a symmetric spike-like configuration simulating a stack of coins.’ ² Other processes, besides hemorrhage, may lead to thickening of the bowel wall with a similar appearance (e.g. edema, cellular infiltration) and they should be considered in the differential diagnosis. Figure 1 ‘There are marked mucosal changes of the duodenum, with rigid thickened folds and narrow troughs between them. The pattern simulates a ‘picketfence’.’ Reprinted from Wiot et <italic>at.’.</italic> Duodenal hematoma induced by coumarin. <italic>Am. J. Roentgenol.,</italic> 1961, 86, 70–5, with the permission of the ARRS https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9781003076568/34c29fd5-5662-4e8f-b58c-badd7fa5d724/content/fig62_1_B.jpg"/> Figure 2 ‘Idiopathic thrombocytopenic purpura with hemorrhage into the small intestinal wall. The folds in the distal ileum are thickened and have a stacked coin appearance.’ Reprinted from Khilnani <italic>et al.<xref ref-type="bibr" rid="ref62_2"> ² </xref>.</italic> Intramural intestinal haemorrhage. <italic>Am. J. Roentgenol.,</italic> 1964, 92, 1061–71, with the permission of the ARRS https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9781003076568/34c29fd5-5662-4e8f-b58c-badd7fa5d724/content/fig62_2_B.jpg"/>