Signs Stack of Coin Sign

Stack of Coins Sign

Etymology: The term “stack of coins sign” originates from the appearance resembling a stack of coins in radiologic imaging, particularly in the gastrointestinal tract.

AKA:

  • Stack of Coins Appearance
  • Stack Sign
  • Picket Fence Sign (often used interchangeably)

What is it? The stack of coins sign is a radiologic pattern seen on imaging of the gastrointestinal tract, where the bowel folds appear thickened and closely apposed, resembling stacked coins. It indicates submucosal edema or hemorrhage, leading to thickened and prominent valvulae conniventes.

Caused by:

  • Mucosal or submucosal edema
  • Intramural hemorrhage
  • Ischemia
  • Infectious enteritis
  • Inflammatory bowel disease
  • Hematologic malignancies (e.g., lymphoma)

Resulting in:

  • Thickened and closely apposed small bowel folds
  • Luminal narrowing

Structural Changes:

  • Thickened valvulae conniventes (mucosal folds)
  • Submucosal edema or hemorrhage causing luminal narrowing
    • Features
      • Folds > 3 mm thick
      • Perpendicular to lumen
      • Parallel to each other
      • “Stack of coins”, “picket fence”
    • Cause: Fluid infiltration of submucosa
      • Blood
      • Edema
    • Types of Regular, Smooth Thickened Folds
      • Diffuse
      • Long segment
      • Focal

Pathophysiology: The stack of coins sign results from mucosal or submucosal pathology causing thickening and edema of the bowel wall, particularly the valvulae conniventes. This leads to a classic appearance on contrast studies due to prominent, closely spaced folds.

Pathology:

  • Thickening of the mucosal folds due to edema, inflammation, or hemorrhage

Diagnosis:

  • Radiologic Criteria: Characteristic appearance of stacked mucosal folds on contrast-enhanced imaging.
  • Clinical Correlation: Often diagnosed alongside clinical features of abdominal pain, bleeding, or obstruction.

Clinical:

  • Abdominal pain
  • GI bleeding
  • Bowel obstruction symptoms

Radiology:

  • KUB (Abdominal X-Ray): Limited utility but may demonstrate thickened bowel loops.
  • CT:
    • Thickened valvulae conniventes.
    • Bowel wall thickening with luminal narrowing.
  • Barium Studies:
    • Best modality for visualizing the stack of coins appearance.
    • Characteristic closely spaced folds resembling stacked coins.
  • Other Imaging:
    • MRI can show bowel wall edema with thickened folds.

Differentiation from Coiled Spring Sign, Thumbprinting, Pinky Printing, and Picket Fence Sign:

  • Stack of Coins Sign: Thicker, closely spaced folds due to edema or hemorrhage.
  • Coiled Spring Sign: Thinner curving layers due to telescoping bowel loops and contrast in intussusception.
  • Thumbprinting: Caused by submucosal edema, creating broad-based, finger-like projections into the bowel lumen.
  • Pinky Printing: Less severe form of thumbprinting with smaller, rounded projections due to less pronounced edema.
  • Picket Fence Sign: Often used interchangeably with the stack of coins sign, but can describe more regular, linear folds, typically seen in chronic inflammatory bowel disease.

Labs:

  • Not directly diagnostic but may show signs of inflammation or coagulopathy in some cases.

Management:

  • Address underlying cause (e.g., treat infection, manage ischemia)
  • Supportive care with fluids and bowel rest

Radiology Detail:

  • KUB (Abdominal X-Ray): Thickened bowel loops may be noted but limited sensitivity.
  • CT:
    • KUB (Abdominal X-Ray): Limited utility but may demonstrate thickened bowel loops.
    • CT:
      • Parts: Involves the small bowel, particularly the jejunum.
      • Size: Thickened mucosal folds with luminal narrowing.
      • Shape: Fold thickening presenting as closely apposed parallel lines.
      • Position: Typically seen in the small intestine.
      • Character: Edematous, with uniform fold thickening due to submucosal pathology.
      • Time: Often acute in hemorrhage or ischemia but can be chronic in inflammatory conditions.
  • Barium Studies: Classic appearance of stacked mucosal folds.

Pulmonary Function Tests (PFTs):

  • Not applicable.

Recommendations:

  • Appropriate follow-up imaging for suspected bowel ischemia or obstruction.
  • Multidisciplinary approach for underlying conditions.

Key Points and Pearls:

  • The stack of coins sign reflects submucosal edema or hemorrhage.
  • Differentiation from the coiled spring sign, thumbprinting, pinky printing, and picket fence sign is based on fold thickness and the nature of the underlying pathology.
  • Best visualized on contrast studies.
  • The Picket Fence Sign is often used interchangeably with the stack of coins sign but can refer to more linear and regular fold thickening patterns in chronic conditions.

References:

  1. Radiopaedia – Stack of Coins Sign:
  2. Radiology Key – Gastrointestinal Radiology:
  3. Radiographics – Intestinal Ischemia: 
  4. American Journal of Roentgenology – Thickening of Small Bowel Folds: