Crohn’s disease
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Crohn’s disease

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Crohn’s disease Crohn’s disease Presentation Transcript

  • Dr / Hytham Nafady
  • Definition • Crohn’s disease is an idiopathic inflammatory bowel disease chracterized by transmural non caseating granulomatous inflammation.
  • Demographics • Age onset: 15-30, another peak at 60-70. • Sex: M=F
  • C.P
  • Location Any where in the gut from mouth to anus. Most common: • Ileo-colic (50%). • Terminal ileum (30%). • Right colon (20%). Distribution: • Segmental distribution with skip lesions.
  • • Systemic complications: • Arthritis. • Ankylosing spondylitis. • Sclerosing cholangitis. • Uveitis. • Erythema nodosum. • Pyoderma gangrenosum. • Malabsorption. • Oxalate stones.
  • Postoperative complications • Normal ileocolic anastomosis
  • Anastomotic recurrence
  • Anastomotic fibro-stenosis
  • Plain radiography • The role of plain radiography is limited and only done for 2 reasons: • To assess intestinal obstruction. • To diagnose pneumoperitoneum.
  • SBO 1. Multiple air fluid levels > 2. 2. Wide air fluid levels > 2.5 cm. 3. Differential air fluid levels (2 air fluid levels of different height > 2 cm in the same bowel loop). 4. Small bowel / colon diameter ratio > 0.5. 5. Step ladder configuration of small bowel loops from LUQ to RLQ. 6. String of pearls sign (trapped air between the valvulae conniventes along the superior wall of the dilated bowel).
  • Step ladder configuration LUQ RLQ
  • String of pearls sign
  • Pneumo-peritoneum • Air under diaphragm (erect). • Air on both sides of the bowel wall (Rigler sign). • Air around the falciform ligament (supine).
  • Signs of pneumo-peritoneum
  • Barium studies • Ulcers. • Nodular pattern. • Ulcero-nodular pattern. • Stricture. • Straightening of the mesenteric border. • Sacculation of the ante-mesenteric border. • Wide separation. • Fistula.
  • Ulcers
  • Aphthoid ulcers (target sign) • Pathology: mucosal ulcers with surrounding translucent mound of edema.
  • Fissure ulcers (Rose thorn appearance) • Pathology: transmural ulcers
  • Nodular pattern •Pathology: Submucosal edema of the villi.
  • Ulcero-nodular pattern (Cobble stone appearance) • Pathology: transverse & longitudinal fissure ulcers with intervening edematous mucosa.
  • Straightening of the mesenteric border & sacculation of the ante-mesenteric border
  • Stricture (String sign of Kantor) • Pathology: edema &/or fibrosis with ulcerated mucosa (resembling frayed string).
  • DD of stricture Crohn’s disease: Terminal ileum. Ulcerated mucosa. Multiple strictures. Ischemic stricture Watershed areas. Smooth non ulcerated. Gradually tapering. Usually single. Malignancy Shouldering Radiation enteropathy Thick folds.
  • Wide separation Pathology: • Circumferential mural thickening. • Creeping fat. • Mesenteric lymphadenopathy.
  • Fistula
  • Entero-enteric & entero-colic fistulas Terminal ileum Cecum Proximal ileum
  • Entero-enteric fistula • Between the terminal ileum & right colon. • Double tracking of the ileocecal valve.
  • Entero-cutaneous fistula
  • Entero-vesical fistula
  • U/S
  • Mural thickening
  • Mural hyper-vascularity
  • Loss of layering •Pathology: transmural edema, inflammation or fibrosis. The bowel wall is formed of 5 alternating hyper & hypoechoic layers AKA the gut signature).
  • Mesenteric creeping fat • Uniform hyper-echoic mesenteric fat. • (usually at the cephalic margin of terminal ileum).
  • Mesenteric lymphadenopathy • Multiple oval hypoechoic masses in the mesentery.
  • Obstruction • Dilated hyperperistaltic fluid filled segments.
  • Abscess • Fluid collection with thickened wall • containing air or echogenic debris
  • Fistula • bright echoes with distal acoustic shadows outside the boundaries of bowel loops.
  • Phlegmon • Heterogenous hypoechoic mass with irregular borders. • No identifiable wall or fluid.
  • CT CT is less sensitive than barium studies in detection of early mucosal changes (i.e ulceration). CT is more sensitive than barium studies in detection of extraluminal changes (mural or extraintestinal).
  • CT
  • Circumferential mural thickening In acute non cicatrizing phase: Mural thickening with preserved stratification and minimal luminal narrowing. In chronic cicatrizing phase: Mural thickening, with loss of mural stratification and increased luminal narrowing.
  • • Normally the bowel wall measures less than 2 mm if well distended). • The mean diameter in Crohn’s disease is 10 mm. • If > 10 mm suspect pseudomembranous enterocolitis.
  • Mural hyper-enhancement. • Segmental hyper-attenuation of distended small bowel loops relative to nearby normal-appearing loops • Mural hyper-enhancement indicates active disease.
  • Stricture • Sometimes associated with proximal dilatation due to partial obstruction.
  • Mesenteric fibro-fatty proliferation (Creeping fat): • Adjacent to the actively inflamed segment. • Of high density than the normal fat. • Produce mass effect with displacement of the adjacent bowel loops (DD with T.B).
  • Mesenteric hypervascularity (Comb sign) • Pathology: engorged vasa recta.
  • Phlegmon • ill-defined inflamed mass of mixed attenuation
  • Abscess • Well defined mass of fluid attenuation, • Thick enhancing wall • Containing air or contrast material.
  • Obstruction • Proximal dilatation of small bowel loop > 2.5 cm.
  • Perforation • Pneumoperitoneum.
  • Fistula • The track of the fistula is better demonstrated on barium studies while the sequelae of these tracks are better demonstrated on CT (e.g air in the urinary bladder in entero-vesical fistula).