INTRODUCTION DEFINATIONS IMAGING MODALITIES DIFFERENCE BETWEEN CHRON’S AND UC DIFFERENTIAL DIAGNOSIS CONCLUSION IMAGE GALLERY

1. IMAGING IN INFLAMMATORY
BOWEL DISEASE
DR.KHYATI VADERA REFERENCES: RADIOGRAPHICS
RESIDENT DOCTOR RUMACK
M.D RADIODIAGNOSIS RADIOLOGY ASSISTANT
MEDICAL COLLEGE BARODA
SSG HOSPITAL

2. • INTRODUCTION
• DEFINATIONS
• IMAGING MODALITIES
• DIFFERENCE BETWEEN CHRON’S AND UC
• DIFFERENTIAL DIAGNOSIS
• CONCLUSION
PROTOCOLS

3.  Group of chronic disorders that cause inflammation
and ulceration in small and large bowel.
 Mainly two most common diseases are –chron’s
disease and ulcerative colitis
INTRODUCTION

5.  Idiopathic, chronic, transmural inflammatory process
of bowel - affect whole GI system starting from
mouth to anus.
 Most commonly involved- terminal ileum, ileocaecal
valve and caecum with regional enteritis.
 SKIP LESIONS ARE PATHOGNOMIC
 Diagnosed typically between 15-25 years of age group.
 No gender predilection, runs in families.
 Smokers - more affected.
CHRON’S DISEASE

6. • Chron’s disease can be –Stricturing,Penetrating,Inflammatory
• Etiology – idiopathic, genetic(DR5 DQ1 alleles), immunologic, microbial,
psychosocial
• Clinical presentation- diarrhoea, abdominal pain, weight loss
• Intermittent attacks of active disease followed by periods of remission.
• Disease re-activation by triggers like stress, dietary factors, smoking.
• Risk of colonic adenocarcinoma is increased in long standing cases.

7. • on X-ray- plain radiograph of abdomen is usually helpful in cases of
obstruction secondary to chron’s or extraintestinal manifestations

8.  MUCOSAL ULCERS
 APHTHOUS ULCERS initially
 deeper transmural ulcers typically either longitudinal or circumferential in
orientation
 when severe leads to COBBLESTONE APPEARANCE
 may lead to sinus tracts and fistulae
 thickened folds due to oedema
 pseudodiverticula formation: due to contraction at the site of ulcer with
ballooning of the opposite site
 STRING SIGN: tubular narrowing due to spasm or stricture depending on
chronicity partial obstruction
Barium small bowel follow-through

9. APTHOUS ULCERS
First sign of chron’s
disease on barium

10. Cobblestone appearance:
due to deep fissuring
ulcers around inflammed
mucosa

11. Fissuring ulceration in Crohn's disease
- graphically called `raspberry thorn'
ulcers.

12. String sign: spasm/fibrosis
of bowel wall

13. ILEOILEAL FISTULA: long
standing chron’s

14. ULTRASOUND
 limited role, it has been evaluated as an initial screening tool
 Typically examination is limited to the small bowel and wall
thickness assessed:
Bowel wall thickness should be <3 mm, normally
 thickness < 3 mm helps exclude the disease in a low risk patient.
 thickness > 4 mm helps establish the diagnosis in a high risk patient.
 Ultrasound in the assessment of extraintestinal manifestations.

16. US image - stricture in a patient with active
Crohn's disease

17.  FAT HALO SIGN
 COMB SIGN
 Bowel wall enhancement
 Bowel wall thickening (1-2 cm) -terminal ileum
 strictures and fistulae
 mesenteric/intra-abdominal abscess or phlegmon
formation
CT FINDINGS

18. Fat halo sign in chron’s disease
Transverse CT scan shows the central fatty
submucosal layer of low attenuation (*)
surrounded by higher-attenuation inner (long
arrow) and outer(short arrow) layers grossly
corresponding to the mucosa and muscularis
propria and serosa of the descending colon,
respectively.

19. COMB SIGN:Hypervascular appearance of the mesentery in active Crohn's disease.
Fibrofatty proliferation and perivascular inflammatory infiltration outline the
distended intestinal arcades. This forms linear densities on the mesenteric side of
the affected segments of small bowel, which give the appearance of the teeth of a
comb.

21. CECT image, coronal section,
venous phase - enterocecal
fistula with secondary
traction of the cecum and
right psoas muscle abscess

22. CT AND MR ENTEROGRAPHY
 Useful for both mural and extramural spread of
disease.
 Inflammed bowel loops show thickening and contrast
enhancement.
 Extramural spread: fibrofatty proliferation-thickening
of extramural fat
:vascular engorgement(comb sign)
 Stenosis and strictures

24.  MRI enteroclysis - placement of a nasojejunal catheter
through which 1.5-2 L of contrast solution (e.g. water
with polyethylene glycol and electrolytes) are
injected.
 When disease is transmural, with cobblestone
appearance, the abnormalities are evident as high T2
signal linear regions.
CT AND MR ENTEROCLYSIS

25.  Introduction of the 12 to 14-F enteroclysis tube (under
fluoroscopy or through duodenoscope).
 Contrast is administered either on the fluoroscopy table or after
transferring the the patient to the CT unit for commencement
of the CT scan (usually 1.5-2L of oral contrast).
 In the CT unit, the position of the enteroclysis tube is checked in
the topogram.
 In case negative oral contrast will be used, intravenous contrast
injection will be given (approximately 100-150ml).
CT ENTEROCLYSIS

27.  placement of a nasoduodenal tube under fluoroscopic guidance
 the small-bowel is distended with 1-3L of methylcellulose (0.5%)
and water solution or isosmotic water solution through an
electric infusion pump infusion rate: 80-200 mL/min.
 multislice HASTE(half-Fourier acquisition single-shot turbo spin-
echo) images with fat saturation and unenhanced and
enhanced (0.1 mmol/kg gadolinium) T1 coronal and axial fast
low-angle shot (FLASH) 2D images with fat saturation are
obtained 60 seconds after contrast injection
MR ENTEROCLYSIS

30. Perirectal phlegmon on axial T2 Single Shot TSE (left) and T1 contrast
enhanced (right) sequences. Rectal wall thickening with avid contrast
uptake due to active disease. Perirectal phlegmon surrounded by a
hyperenhancing perirectal fascia, displaces the rectum anteriorly.

31.  For extraintestinal disease:
 Perianal fistula/abscess
 Hepatobiliary manifestations
 Sacroiliac joints
ROUTINE MRI

32.  Causes superficial ulceration of colon and rectum.
 It starts from rectum and retrogradely involves whole colon
continuously.
 In total colitis- back wash ileitis.
 More common in DR2 related genes.
 More female predilection, age group 30-40 yrs.
 Clinical symtoms- diarrhoea, tenesmus, bleeding per rectum, passage
of mucus, crampy abdominal pain.
ULCERATIVE COLITIS

33.  MILD DISEASE: fine granularity
 MODERATE: marked erythema, coarse granularity, contact bleeding
and no ulceration.
 SEVERE: spontaneous bleeding,edematous and ulcerated
 Long standing cases epithelial regeneration- pseudopolyps, pre
cancerous condition
 Eventually shortening and narrowing of colon
 FULMINANT DISEASE: toxic colitis/megacolon
PATHOGENESIS

34. Acute UC – descending colon
has irregular outline. No fecal
residue in colon S/O total colitis

35.  Mucosal inflammation-granular appearance to the surface of
the bowel.
 Mucosal ulcers are undermined -button-shaped ulcers
 Islands of mucosa remain giving it a pseudo-polyp appearance
 In chronic cases the bowel becomes featureless with loss of
normal haustral markings, luminal narrowing and bowel
shortening- lead pipe sign
BARIUM ENEMA

36. FINE MUCOSAL
GRANULARITY- FIRST SIGN
NARROWING OF LUMEN

37. COLLAR
BUTTON
ULCERS

39. LEAD PIPE COLON

40. Back wash ileitis : patulous
IC valve and dilated granular
terminal ileum

41. CT FINDINGS
 Inflammatory pseudopolyps
 Inflamed and thickened bowel - target appearance, due concentric
rings of varying attenuation- mural stratification
 In chronic cases, submucosal fat deposition is seen particularly in the
rectum fat halo sign
 Extramural deposition of fat, leads to thickening of the perirectal
fat, widening of the presacral space
 Marked muscularis mucosa hypertrophy-lead pipe sign.

42. INFLAMMATORY PSEUDOPOLYPS

45.  Wall Thickening- median wall thickeness of colon
ranges from 4.7 to 9.8 mm, more severe the disease
more thicken the wall
 Increased Enhancement- enhancement of the mucosa
with no or less enhancement of the submucosa
 Loss of haustral markings
MRI

46. Mri image reveals thickening
of colon with loss of haustral
markings

48. DIFFERENCE
CHRON’S DISEASE
 70-80%Small bowel involvement
 Skip lesions
 Fat halo sign seen in 8%
 Apthous ulcers are seen
 Bowel wall more thicker
 Irregular serosal surface
 Perianal fistula/sinus/abscess
more common
 Creeping fat and abscess are
very common in chronic cases
ULCERATIVE COLITIS
 95% cases rectal involvement
 Continuous spread from rectum
upwards
 Fat halo sign is commonly seen
 Collar button ulcers are seen.
 Smooth serosal surface
 Perianal disease rare
 Mesenteric creeping fat and abscess
are uncommon.
 Carcinoma is more common in long
standing cases.

49.  Ileocaecal tuberculosis
 Acute appendicitis
 Mesenteric adenitis
 Malignancy
 Acute diverticulitis
 Acute epiploic appendagitis
 Ischaemic colitis
 Pseudomembranous colitis
DIFFERENTIAL DIAGNOSIS

50.  On BMFT:
 Mucosal irregularity and rapid emptying
 Stiffened and thickened folds.
 Luminal stenosis(hour glass stenosis)
 Dilated loops and strictures.
 Aderent fixed and matted loops
Ileocaecal tuberculosis

51. BMFT:partially contracted
caecum with coarse nodular
mucosal thickening and a
stricture of terminal ileum

52. TB: narrowing & irregularity of the
terminal ileum and rt side of
colon.

54. Increased ileocaecal angle:
obtuse
Goose neck deformity:
fibrosed and retracted
caecum

57. Thickening of ileocaecal
junction with
surrounding necrotic
lymph nodes

58. Peritoneal thickening in intestinal tuberculosis

59. • Lymph nodes with peripheral
rim enhancement giving
multilocular appearance
• Bowel wall thickening

60. TB CROHN’S
Involvement of
terminal ileum
shorter longer
Features Narrowed,
thickened, rigid
terminal ileum with
pulled up ceacum
Asymmetry and
cobblestoning
Longitudinal
Ulceration
absent present
TUBERCULOSIS VS CHRON’S

61. Acute appendicitis

62. Mesenteric adenitis
3 or more nodes with a short-axis diameter of at least 5
mm clustered in the right lower quadrant

63. Lymphoma
bowel wall thickening: 1-7cm and aneurysmal dilatation:

65. Lymphoma on ultrasound: hypoechoic
vascular mass with multiple pre para
aortic lymph nodes

66. COLORECTAL CARCINOMA

67. Acute diverticulitis
 Pericolic stranding- disproportionate to the amount of bowel
wall thickening
 segmental thickening of the bowel wall
 enhancement of the colonic wall
 diverticular perforation - air and fluid into the pelvis and
peritoneal cavity
 abscess formation (seen in up to 30% of cases)
 may contain fluid, gas or both
 fistula formation-gas in the bladder/direct visualisation of
fistulous tract

69. Diverticulum of colon
In acute diverticulitis:
barium studies are
contraindicated

70. Ischemic colitis
 On CT:
 segmental region of abnormality
 submucosal oedema may produce low-density ring bordering
lumen (target sign)
 intramural or portal venous gas
 mesenteric oedema WITH NON ENHANCING BOWEL WALL
 superior mesenteric artery or vein thrombus/occlusion may be
demonstrated

73. Ischemic colitis(thumb printing ): edematous
thickened bowel wall will cause indentations
into the air-filled colonic lumen

74. Pseudomembranous colitis
 Pseudomembranous colitis-caused by the bacterium
Clostridium difficile due to bacterial overgrowth of
the colon in patients who are treated with broad-
spectrum antibiotics.
 ascites and hyper enhancement of the bowel wall
with submucosal edema and edema in the
mesocolon.

75. Ct findings:
• Circumferential and
diffuse mural
thickening with
submucosal edema.
• Prominent haustrae.
• Eccentric polypoid wall
thickening.
• Shaggy luminal
contour.

76. Accordion sign
 The sign is described as alternating edematous
haustral folds separated by mucosal ridges filled with
oral contrast material

78. CONCLUSION
 Inflammatory bowel diseases are chronic group of disorders which have a long
course of disease with intermittent periods of active disease and remission.
 They can be easily diagnosed by multimodality approach combining clinical
symptoms , colonoscopy, and radiology.
 Conventional radiological investigations like barium studies are still necessary for
diagnosis of characteristic intramural changes.
 However the CT and MRI investigations are nowadays frequent and less
invasive, useful for detection of extraintestinal manifestations of IBD.
 Colonoscopy at regular intervals is also must to look for progression of disease
and malignancy in long standing cases

79. THANKS