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Radiographic findings in Ulcerative Colitis and Crohn Disease. Amanda Wonnacott, MS3. Inflammatory Bowel Disease. Term applied to both ulcerative colitis and Crohn disease Causing chronic intestinal inflammation Idiopathic processes with unknown etiologies
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Radiographic findings in Ulcerative Colitis and Crohn Disease Amanda Wonnacott, MS3
Inflammatory Bowel Disease • Term applied to both ulcerative colitis and Crohn disease • Causing chronic intestinal inflammation • Idiopathic processes with unknown etiologies • Familial association with genetic predisposition • Auto-immune • Both can produce multiple radiographic changes • Incidence in US: 5-15 per 100,000
Ulcerative Colitis • Idiopathic inflammatory condition involving the superficial mucosal surface of the colon • 50% rectosigmoid • 30% left-sided colitis • 20% pancolitis • Signs and symptoms include bloody diarrhea with increased frequency of stools, abdominal cramps with fecal urgency, anemia
Crohn Disease • Chronic inflammation of gastrointestinal tract involving all layers of intestinal wall including mesentery and regional lymph nodes • 80% small bowel involvement with 1/3 having exclusive ileitis • 50% ileocolitis (both ileum and colon involvement) • 20% colonic involvement alone • Symptoms are more variable: Prolonged diarrhea (+/- bleeding), abdominal pain, weight loss, fever, fatigue • Other findings: fistulas, abscesses, fissures, strictures
Plain radiograph • Findings are not specific but are useful • Especially in determining bowel loop distension, obstruction Toxic megacolon; complication of ulcerative colitis
Plain radiograph Radiograph reveals “thumbprinting” as seen in ulcerative colitis Thumbprinting: symmetric thickening of haustral folds/edema in bowel walls
Plain radiograph • Dilatation of small bowel • Although not specific for crohn disease; still is useful information
Upper GI with small bowel follow through • String sign seen in Crohn disease reflecting narrowing in distal ileum • Cobblestone appearance seen in Crohn disease
Double contrast barium study • Study reveals inflammation and mucosal ulceration in colon consistent with acute ulcerative colitis
CT Findings • Both Ulcerative colitis and Crohn disease • Wall thickening • Increased in Crohn disease with average at 11-13 mm compared to 7-8 mm in UC • Proliferation of perirectal fat can be seen in both UC, Crohn disease and other conditions • Inflammatory stranding
CT Findings • Findings more likely with Crohn disease: • Small intestine and right colon involvement • Proliferation of mesenteric fat and mesenteric lymphadenopathy • Eccentric wall thickening with skip regions • Findings more likely with UC: • Left colon involvement • Symmetric wall thickening • Halo sign: low attenuation ring in bowel due to deposition of submucosal fat
Crohn disease Moderate thickening of terminal ileum Thickening of cecum
Crohn Disease • CT reveals lymph nodes (arrow) in mesentery in a patient with Crohn disease
Ulcerative Colitis • CT reveals diffuse thickening of sigmoid colon with minimal inflammatory stranding
Ulcerative Colitis • CT reveals a deposition of fat in the submucosa around referred to as a “halo sign” • Also fatty proliferation in perirectal area
CT Findings • Although CT does play a limited role in diagnosis of UC or Crohn disease, findings can be useful for evaluating complications • Abscesses • Fistulas • Colorectal carcinoma/Hepatobiliary carcinoma • Extraintestinal manifestations
Fistulas • Fistulas are a common complication of Crohn disease • Barium enhanced study showing fistulas from terminal ileum (arrowheads) converging into mesenteric cavity (*) and communicating back to more proximal ileum
Abscesses Abscess (arrowheads) seen in lower right quadrant extending out from inflamed terminal ileum (arrow)
Extraintestinal Complications • Eye involvement: uveitis and episcleritis • Skin disorders: erythema nodosum and pyoderma gangrenosum • Bone and joints: Large joint arthritis and ankylosing spondylitis • Primary sclerosing cholangitis • Thromboembolism
Extraintestinal Complications • The percentage of patients with inflammatory bowel disease and extraintestinal complications varies in the literature from 21 to 41% • Incidence increases with the duration of disease • More patients with Crohn disease experience extraintestinal manifestations than patients with ulcerative colitis
Ankylosing Spondylitis • Chronic inflammatory disease of axial skeleton manifested by back pain and progressive stiffness of the spine resulting in decreased ROM • Worse with inactivity and improvement with exercise • Limitation in chest expansion when compared to population of similar age and sex • Early onset (20-30 years old) and male : female 3:1 • 2.6% in UC; 6.0% in Crohn disease • Association with HLA-B27 • Findings include: • Enthesitis: inflammation around the enthesis (the site of ligament insertion into bone) • Sacroiliitis: sclerosis and erosions at SI joints; may even lead to fusion (either grade III or IV)
Ankylosing Spondylitis • Radiograph reveals early sacroiliitis in ankylosing spondylitis
Ankylosing Spondylitis • Fusion of SI joints in late ankylosing spondylitis with complete obliteration of the joint spaces
Ankylosing Spondylitis • Lung findings associated with ankylosing spondylitis • 1.2% of pts with AS • Peripheral interstitial lung disease • Bronchiectasis • Paraseptal emphysema • Apical fibrosis • PA Chest radiograph shows: • Severe bilateral scarring in upper lobes
Ankylosing Spondylitis • CT shows volume loss at bilateral lung apices
Ocular complications • Less than 10% of patients with IBD • Episcleritis-inflammation of the area directly under the conjunctiva • Scleritis • Uveitis-inflammation of the vascular coat of the eye
Skin manifestations • Erythema nodosum • Painful red or violet subcutaneous nodules found usually in the pretibial region • Pyoderma gangrenosum • Ulcerative painful lesion found usually on lower extremities
Primary Sclerosing Cholangitis • Chronic cholestatic liver disease, which often progresses to bile duct obliteration, biliary cirrhosis and portal hypertension • Inflammation with obliterative fibrosis of medium and large extra- and intra-hepatic ducts • Seen more often with UC than with Crohn disease • Symptoms include: fatigue, pruritus, jaundice • Diagnosis: • Cholangiography or ERCP: characteristic multi-focal stricturing and dilation of ducts • Dilated ducts may also be seen on ultrasound • Magnetic resonance cholangiopancreatography (MRCP)
Primary Sclerosing Cholangitis • Histology section reveals periductal sclerosis in a portal bile duct
Primary Sclerosing Cholangitis • Image during ERCP showing multifocal strictures and irregularity of the right intrahepatic bile ducts.
Primary Sclerosing Cholangitis • Using MRCP: arrows show multiple strictures of the right hepatic ducts • MRCP may be utilized as a non-invasive alternative to ERCP in the diagnosis of PSC
Primary Sclerosing Cholangitis • Image shows severe lobulation of liver in patient with PSC
Primary Sclerosing Cholangitis • Ultrasound picture in patient with UC and PSC revealing thickened wall of the common bile duct (large arrows) with narrowed lumen (small arrows)
Works Cited • Bernstein CN, Blanchard JF, Rawsthorne P, et al. The prevalence of extraintestinal diseases in inflammatory bowel disease: a population-based study. American Journal of Gastroenterology. 2001; 96(4):1116-22. • Dodd GD, Baron RL, Oliver JH, et al. End-Stage Primary sclerosing cholangitis: CT findings of hepatic morphology in 36 patients. Radiology. 1999; 211:357-362. • Horton KM, Corl FM, Fishman EK. CT evaluation of the colon: inflammatory disease. Radiographics. 2000;20:399-418. • Macari M, Hines J, Balthazar E, et al. Mesenteric adenitis: CT diagnosis of primary versus secondary causes, incidence, and clinical significance in pediatric and adult patients. American Journal of Roentgenology. 2002; 178:853-858 • Manaster BJ. Adult Chronic Hip Pain: Radiographic Evaluation. Radiographics. 2000; 20:S3-S25. • Mayberry JP, Primack SL, Muller NL. Thoracic manifestations of systemic autoimmune diseases: radiographic and high-resolution CT Findings. Radiographics. 2000; 20:1623-1635.
Works Cited 7. Palm O, Moum B, Ongre A, et al. Prevalence of ankylosing spondylitis and other spondyloarthropathies among patients with inflammatory bowel disease: a population study. Journal of Rheumatology. 2002; 29(3):511-5. • Pickhardt PJ, Bhalla S, Balfe DM. Acquired gastrointestinal fistulas: classification, etiologies, and imaging evaluation.Radiology 2002 224: 9-23. • Storch I, Sachar D, Katz S. Pulmonary manifestations of inflammatory bowel disease. Inflammatory Bowel Diseases. 2003; 9(2): 104-115. • Tung BY, Kowdley KV. Clinical manifestations and diagnosis of primary sclerosing cholangitis. Up to Date Online. 2004. • Vitellas KM, Keogan MT, Freed KS, et al. Radiologic manifestations of sclerosing cholangitis with emphasis on MR cholangiopancreatography. Radiographics. 2000;20:959-975.