Intestinal Crohn’s Disease Classic Radiologic...

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


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


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


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Ulcerative Colitis - CT

Rectal involvement

Sigmoid

Descending colon

Splenic FlexureR Transverse Colon Uninvolved


From PACS, BIDMC

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Ulcerative Colitis – Barium Enema


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


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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


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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


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


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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.


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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


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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


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Management

• Medical– steroids– immunosuppressants– sulfasalazine– antibiotics

• Surgical– reserved for treatment

of severe complications

• obstruction• fistulas• hemorrhage• carcinoma• abscesses


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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


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


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



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


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


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




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



Ileocecal fistulae

Terminal ileum

Cecum

SBFT

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Fistulas


IliosigmoidIliosigmoid FistulaFistulaEnterovesicularEnterovesicular FistulaFistula


Courtesy of Linda Miles, 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


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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



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



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The End


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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.


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Acknowledgements

• Jonathan Kruskal, MD, PhD• Linda Miles, MD• Larry Barbaras• Cara Lyn D’amour


Intestinal Crohn’s Disease Classic Radiologic...

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