Apple Core Sign Causes Mnemonic: “IDEAL”

I still remember the day when Dr. Basit Khan (our Consultant General Medicine and walking-talking UpToDate) looked at a barium enema and declared:
“Apple core sign. Adenocarcinoma until proven otherwise.”
Then walked off like Sherlock Holmes after solving a murder mystery. 🕵️‍♂️

But the truth is — not every apple core is malignant. 🍏

So if you’re staring at a colonic stricture on imaging that looks like it’s been chewed by a dyspeptic fruit bat, here’s your lifeline: the mnemonic IDEAL — because spotting the apple core is half the battle; knowing the differentials wins the war.

🧠 Mnemonic Table: “IDEAL” — Causes of Apple Core Sign 🍎

Letter	Cause	Explanation
I	Ischemic/IBD	Chronic ischemia or long-standing Inflammatory Bowel Disease (esp. Crohn’s) can lead to segmental narrowing and mural thickening. A bit like the colon’s version of “long COVID.”
D	Diverticulitis	Chronic scarring from repeated episodes leads to luminal narrowing — apple core in disguise. Usually left-sided. Often confused for cancer. Ask me how I know.
E	Extrinsic compression	Scalloped lumen due to endometriotic deposits, peritoneal carcinomatosis, or fibrotic bands. Not truly intraluminal — more of a “squish” than a stricture.
A	Adenocarcinoma	The most classic cause. Concentric, irregular, and rigid narrowing — the OG apple core. Seen a case in a 60-year-old man from Mashkel with classic symptoms. Textbook stuff.
L	Lymphoma	Usually causes long, smooth narrowing — but can occasionally mimic the apple core. Remember, lymphoma breaks the rules like Dr. Behroz Rahim breaks ward silence with psychiatry quotes. 🧠💬

🩺 Clinical Insight From Panjgur

We had a patient from Panjgur, 65 years old, chronic altered bowel habits, mild weight loss. CT showed an apple core lesion in descending colon.
Everyone jumped to cancer. Even Dr. Danish Ramzan started discussing resection margins.

But biopsy? Benign fibrotic stricture from chronic diverticulitis.
Lesson: If you see apple core, IDEAL should be your reflex. Don’t be that intern who screams “malignancy!” louder than the suction in endoscopy suite. 🎤

Happy learning! 🙂

Dr. Aurangzaib Qambrani
MBBS, PLAB, MRCP-UK
General Medicine | Gastroenterology | CCU
Sheikh Khalifa Bin Zayed Hospital, Quetta (Balochistan)