Radiographic findings in Ulcerative Colitis and Crohn Disease - PowerPoint PPT Presentation

Radiographic findings in Ulcerative Colitis and Crohn Disease

Amanda Wonnacott, MS3

• 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

• 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

• 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

• Findings are not specific but are useful
• Especially in determining bowel loop distension, obstruction

Toxic megacolon; complication of ulcerative colitis

Radiograph reveals “thumbprinting” as seen in ulcerative colitis

Thumbprinting: symmetric thickening of haustral folds/edema in bowel walls

• Dilatation of small bowel
• Although not specific for crohn disease; still is useful information

• String sign seen in Crohn disease reflecting narrowing in distal ileum

• Cobblestone appearance seen in Crohn disease

• Study reveals inflammation and mucosal ulceration in colon consistent with acute ulcerative colitis

• 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

• 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

Moderate thickening of terminal ileum

Thickening of cecum

• CT reveals lymph nodes (arrow) in mesentery in a patient with Crohn disease

• CT reveals diffuse thickening of sigmoid colon with minimal inflammatory stranding

• CT reveals a deposition of fat in the submucosa around referred to as a “halo sign”
• Also fatty proliferation in perirectal area

• 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 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

Abscess (arrowheads) seen in lower right quadrant extending out from inflamed terminal ileum (arrow)

• 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

• 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

• 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)

• Radiograph reveals early sacroiliitis in ankylosing spondylitis

• Fusion of SI joints in late ankylosing spondylitis with complete obliteration of the joint spaces

• 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

• CT shows volume loss at bilateral lung apices

• 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

• Erythema nodosum
• Painful red or violet subcutaneous nodules found usually in the pretibial region
• Pyoderma gangrenosum
• Ulcerative painful lesion found usually on lower extremities

• 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)

• Histology section reveals periductal sclerosis in a portal bile duct

• Image during ERCP showing multifocal strictures and irregularity of the right intrahepatic bile ducts.

• 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

• Image shows severe lobulation of liver in patient with PSC

• Ultrasound picture in patient with UC and PSC revealing thickened wall of the common bile duct (large arrows) with narrowed lumen (small arrows)

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