intestinal crohn’s disease classic radiologic...
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Intestinal Crohn’s Disease Classic Radiologic Findings
Elizabeth Austen, Harvard Medical School Year IIIGillian Lieberman, MD
Elizabeth AustenGillian Lieberman, MD May 2001
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Our Patient
• 25 yo F presented w/persistent fever, nausea, postprandial abdominal cramping, diarrhea x6 wks
• 13 lb weight loss• PE - T 100.7; abd soft, mild bilateral LQ
tenderness; no peritoneal signs; no masses; normal bowel sounds; guaiac neg
• Labs - WBC 12.1; ESR 31; otherwise unremarkable
• Micro - Blood, urine cx negative
Elizabeth AustenGillian Lieberman, MD
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Our Patient: Imaging
UGI w/SBFT CT
Elizabeth AustenGillian Lieberman, MD
From PACS, BIDMC
Terminal ileumTerminal ileum
Cecum
Ascending Colon
Narrowed terminal ileum w/ Narrowed terminal ileum w/ thickened wallthickened wall
Cecum
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Ddx of bowel wall thickening
• Hemorrhage• Ischemia• Infection• IBD• Radiation• Neoplasm
Elizabeth AustenGillian Lieberman, MD
In this patient, thickening in In this patient, thickening in iliocecaliliocecal region is highly region is highly suggestive of suggestive of Crohn’sCrohn’s– age– classic sx: diarrhea, abd
pain, fever– common sx: weight loss,
nausea– labs: ↑
WBC, ↑
ESR– ileocecal distribution
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Inflammatory Bowel Disease (IBD): Crohn’s vs. Ulcerative Colitis (UC)
Crohn’s• transmural• skip areas• rectal sparing• may involve any
region of GI tract
UC• mucosal• continuous• involves rectum• usually limited to
colon
Elizabeth AustenGillian Lieberman, MD
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Ulcerative Colitis - CT
Rectal involvement
Sigmoid
Descending colon
Splenic FlexureR Transverse Colon Uninvolved
Elizabeth AustenGillian Lieberman, MD
From PACS, BIDMC
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Ulcerative Colitis – Barium Enema
Elizabeth AustenGillian Lieberman, MD
From Peppercorn, M, Clinical Manifestations and Diagnosis of Ulcerative Colitis. UpToDate, 2001.
Images courtesy of Jonathan Kruskal, MD, PhD
Acute UC w/extensive mucosal ulceration, inflammation
Chronic UC w/pipestem appearance, loss of haustral markings
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Patient’s course• Colonoscopy revealed patchy erythema, apthoid
ulcers in distal ileum, bx c/w chronic active ileitis• In light of clinical presentation and imaging
findings, she was given dx of Crohn’s disease• She was started on corticosteroids• Fevers, nausea, abdominal cramping resolved;
diarrhea improved
Elizabeth AustenGillian Lieberman, MD
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Crohn’s Disease - The Basics•• Definition Definition - Transmural granulomatous inflammatory
disease of GI tract•• EpidemiologyEpidemiology - 10-70 cases/100,000; peak age 15-25, 55-65•• EtiologyEtiology - genetic, environmental, infectious, immunologic,
psychologic factors•• Clinical presentationClinical presentation - diarrhea, abdominal pain/tenderness,
weight loss, fever– Complications: fistulae, abscesses, strictures, obstruction,
malignancy, malabsorption, bleeding– Extraintestinal: Hepatobiliary, urinary, joint, eye, skin
•• Labs Labs - ↑WBC, ↑ESR, ↓HCT•• Endoscopy Endoscopy - patchy erythema, apthoid ulcerations, linear
ulcers, skip lesions
Elizabeth AustenGillian Lieberman, MD
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Distribution
• May involve entire GI tract
• 80% small bowel involvement, most often distal ileum
• 30% exclusive ileitis• 50% ileocolitis• 20% limited to colon
Elizabeth AustenGillian Lieberman, MD
IleumJohn’s Hopkins Medical Institutions website, Crohn’s Disease. John’s Hopkins University 2000.
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Anatomy of colon
Hepatic flexure
Ascending colon
Ileocecal valve
Cecum
Appendix
Terminal Ileum
Splenic flexure
Descending colon
Transverse colon
Sigmoid
Pernkopf, E, Atlas of Topographical and Applied Human Anatomy. Ferner, H (Ed). Urban & Schwarzenberg Baltimore-Munich 1980, p. 275.
Double contrast barium enema
Elizabeth AustenGillian Lieberman, MD
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Small bowel distribution
• Frontal image– peripheral colon– central small
bowelDuodenum
Ileum Jejunum
Meschan, I, An Atlas Basic to Radiology. WB Saunders Company, Philadelphia 1975, p. 843.
Elizabeth AustenGillian Lieberman, MD
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Anatomy of small bowel
Pernkopf, E, Atlas of Topographical and Applied Human Anatomy. Ferner, H (Ed). Urban & Schwarzenberg Baltimore-Munich 1980, p. 269.
Duodenum
IleumJejunum
Roentgenogram w/barium
Elizabeth AustenGillian Lieberman, MD
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Standard Imaging Modalities
• Barium studies– along w/endoscopy, choice for dx– visualization of mucosa, abnormal surface patterns, caliber– barium enema for colitis– UGI w/SBFT for disease proximal to colon
• CT– double contrast – oral barium, IV iodinated contrast– visualization of transmural inflammation and extraintestinal
manifestations
Elizabeth AustenGillian Lieberman, MD
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Management
• Medical– steroids– immunosuppressants– sulfasalazine– antibiotics
• Surgical– reserved for treatment
of severe complications
• obstruction• fistulas• hemorrhage• carcinoma• abscesses
Elizabeth AustenGillian Lieberman, MD
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Early Mucosal Changes
• Not seen on CT• Best seen on barium studies• Apthous ulcerations
– lymphoid follicle enlargement, ulceration of overlying mucosa
– barium crater c/surrounding halo
Elizabeth AustenGillian Lieberman, MD
From Peppercorn, MA. Clinical Manifestations and diagnosis of Crohn’s Disease. UptoDate 2001. Image courtesy of Jonathan Kruskal, MD, PhD
Apthous ulcer
Double contrast BE
From Peppercorn, MA. Clinical Manifestations and diagnosis of Crohn’s Disease. UptoDate 2001. Image courtesy of James B. McGee, MD
Colonoscopy
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Cobblestoning
• Apthae enlarge, merge• interspersed w/
edematous mucosa• Deep ulcers lead to
fistulas
Elizabeth AustenGillian Lieberman, MD
From Peppercorn, MA. Clinical Manifestations and diagnosis of Crohn’s Disease. UptoDate 2001. Image courtesy of Norman Joffe, MD
SBFT
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Pseudopolyps
• Inflammatory– cobblestoning– nodular filling defects– edematous mucosa
surrounded by ulcerations
• Postinflammatory– mucosal overgrowth
during healing process– filiform
Elizabeth AustenGillian Lieberman, MD
From Peppercorn, MA. Clinical Manifestations and diagnosis of Crohn’s Disease. UptoDate 2001. Image courtesy of Jonathan Kruskal, MD, PhD
Inflammatory pseudopolyps
SBFT
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Intramural sinuses
• Transmural inflammation
• Ulceration• Leads to sinus tracts
within wall, through wall to form fistulas
Courtesy of Jonathan Kruskal, MD, PhD
Elizabeth AustenGillian Lieberman, MD
Sinus tract
Lumen
SBFT
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Transmural disease
• Best seen on CT• Normal wall thickness
on CT is 2-3 mm• Wall thickening,
inflammation– Stratified attenuation
• Progresses to fibrosis– homogenous attenuation
of thickened wall
Elizabeth AustenGillian Lieberman, MD
Courtesy of Linda Miles, MD
Thickened wall Normal wall
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Stricturing
• Active disease– “string sign”– edema, spasm
• Fibrotic disease– irreversible strictures– lead to obstruction,
fistulas
Elizabeth AustenGillian Lieberman, MD
Courtesy of Jonathan Kruskal, MD, PhD
From Peppercorn, MA. Clinical Manifestations and diagnosis of Crohn’s Disease. UptoDate 2001. Image courtesy of Jonathan Kruskal, MD, PhD
SBFT
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Fistulas• Barium studies
– kissing lesion of prefistulas
– premature filling w/enteroenteric fistulas
• CT– useful in defining
fistulas, particularly enterocutaneous, rectovaginal, enterovesical,abscesses
Elizabeth AustenGillian Lieberman, MD
From Peppercorn, MA. Clinical Manifestations and diagnosis of Crohn’s Disease. UptoDate 2001. Image courtesy of Jonathan Kruskal, MD, PhD
Ileocecal fistulae
Terminal ileum
Cecum
SBFT
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Fistulas
Courtesy of Jonathan Kruskal, MD, PhD
IliosigmoidIliosigmoid FistulaFistulaEnterovesicularEnterovesicular FistulaFistula
Courtesy of Jonathan Kruskal, MD, PhD
Courtesy of Linda Miles, MD
Elizabeth AustenGillian Lieberman, MD
Bladder
Fistula
Ileum
Cecum
SBFT
SBFT w/contrast SBFT w/contrast filling sigmoidfilling sigmoid
Sigmoid
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Creeping Fat
• Mesentary thickened, edematous, fibrotic
• CT– increased attenuation of
mesenteric fat due to inflammatory cells, fluid
– separation of bowel loopsCourtesy of Linda Miles, MD
Elizabeth AustenGillian Lieberman, MD
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Abscesses
• 2º to sinus tracts, fistulas, perforations, surgery
• Barium, endoscopy may suggest abscess by mass effect, fistula
• CT is imaging modality of choice– Circumscribed, round/oval
water-density mass– Capsule may enhance– Air 2º to gas-forming bacteria
or sinus to skin, GI tract
Elizabeth AustenGillian Lieberman, MD
Courtesy of Jonathan Kruskal, MD, PhD
R Rectus Abdominus Abscess
Fistula
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Abscesses
CT-guided drainage• CT used
therapeutically• CT guided drainage
plus abx• May obviate need for
surgery
Gas in abscessDrain
Courtesy of Jonathan Kruskal, MD, PhD
Elizabeth AustenGillian Lieberman, MD
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The End
Elizabeth AustenGillian Lieberman, MD
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References• Gore, RM. CT of Inflammatory Bowel Disease. Radiologic Clinics of North America
1989; 27:717-729.
• Gore, RM, Balthazar, EJ, Ghahremani, GG, Miller, FH. CT Features of Ulcerative Colitis and Crohn’s Disease. AJR 1996; 167:3-15.
• John’s Hopkins Medical Institutions website, Crohn’s Disease. John’s Hopkins University 2000.
• Meschan, I, An Atlas Basic to Radiology. WB Saunders Company, Philadelphia 1975.
• Peppercorn, MA. Clinical Manifestations and diagnosis of Crohn’s Disease. UptoDate 2001.
• Peppercorn, M, Clinical Manifestations and Diagnosis of Ulcerative Colitis. UpToDate 2001.
• Pernkopf, E, Atlas of Topographical and Applied Human Anatomy. Ferner, H (Ed). Urban & Schwarzenberg Baltimore-Munich 1980.
• Simpkins, KC, Gore, RM. Crohn’s Disease. In Gore, Levine, Laufer (eds) Textbook of Gastrointestinal Radiology, WB Saunders Company, Philadelphia 1994.
• Wills, JS, Lobis, IF, Denstman, FJ. Crohn Disease: State of the Art. Radiology 1997; 202:597-610.
Elizabeth AustenGillian Lieberman, MD
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Acknowledgements
• Jonathan Kruskal, MD, PhD• Linda Miles, MD• Larry Barbaras• Cara Lyn D’amour
Elizabeth AustenGillian Lieberman, MD