Shofar sign
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CLASSICS IN ABDOMINAL RADIOLOGY
Shofar sign Liam du Preez1 · Naiim Ali1 · Dmitriy Akselrod1 · Robert D’Agostino1 Received: 8 May 2020 / Revised: 23 June 2020 / Accepted: 4 July 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
First reported by Farman in 1975, the shofar sign, or ram’s horn sign, refers to the appearance of tubular narrowing of the gastric antrum and duodenal bulb commonly seen on fluoroscopy in gastroduodenal Crohn disease [1]. Farman likened these deformities to a sacramental ram’s horn, specifically a shofar, which is used to signal the beginnings of Rosh Hashanah in traditional Judaic customs (Fig. 1). Crohn disease typically manifests in the distal ileum/ colon, with involvement of the upper gastrointestinal tract seen in 4% of the cases [2]. As granulomatous disease with ulceration and scarring manifests in the stomach, doublecontrast studies can reveal gastric narrowing and ulcerated appearance of the mucosa. Pliability of the stomach decreases with progressive scarring, specifically in the gastric antrum. Fluoroscopy may reveal limited distensibility, poor peristalsis, and moderate outlet obstruction [1]. Further scarring across the pylorus can create a tubular appearance to the duodenal bulb and result in distention of the proximal stomach [3] (Fig. 2a). While thus far, the shofar sign has only been described on fluoroscopy, analogous findings can also be seen on CT or MR enterography. As on fluoroscopy, CT shows narrowing extending from the gastric antrum across the pylorus into the duodenum (Fig. 2b). Although more difficult to appreciate on cross-sectional imaging, mucosal ulceration may also be apparent.
Although the shofar sign is fairly specific to gastroduodenal Crohn disease and rarely reported in secondary syphilis [4], the differential for tubular narrowing of the gastric antrum is broad including tuberculosis, sarcoidosis, Zollinger–Ellison syndrome, lymphoma, and peptic ulcer disease [5]. Antral narrowing is also associated with linitis plastica, a phenotype seen most often in late-stage gastric adenocarcinoma [6]. Contiguous extension of scarring and narrowing past the pylorus is much more common in Crohn (reported in as high as 22% of cases [7]) than linitis plastica (observed in as few as 5% of cases [6]). Furthermore, linitis plastica is classically described as a uniform narrowing of the gastric lumen such as in the “leather bottle” sign [8] rather than the segmental stricturing seen in the shofar sign.
* Naiim Ali [email protected] Liam du Preez Liam.du‑[email protected] Dmitriy Akselrod [email protected] Robert D’Agostino [email protected] 1
University of Vermont Medical Center, Burlington, Vermont, USA
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Vol.:(0123456789)
Abdominal Radiology
Fig. 1 A shofar formed from a ram’s horn, used to signal the beginning of Rosh Hashanah in traditional Judaic customs (https://commons.wikimedia. org/wiki/File:Shofar-16-Zachi -Evenor.jpg). Accessed May 6, 2020
Fig. 2 Fluoroscopic upper gastrointestin
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