Crohns disease

Dr. Naveed AshrafRadiologic Pictorial Review
Crohn’s Disease
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Dr. Naveed AshrafRadiologic Pictorial Review2

Dr. Naveed AshrafRadiologic Pictorial Review3

Double-contrast barium enema in different patients demonstrates
aphthoid lesions (arrows) of varying sizes in the cecum , transverse colon ,
and sigmoid colon .
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Cobblestone mucosa. Longitudinal and transverse ulcers of the transverse
colon produce a cobblestone appearance.
5

Deep ulcerations. Double-contrast image of the splenic flexure
demonstrates deep ulcers (arrow), a large ileocecal valve, and sparing of
the sigmoid colon. The appendix is subhepatic in location.
Deep ulcerations of fistulizing-perforating Crohn’s disease. Radiograph
shows two deep ulcerations (arrows) penetrating into the fat of the small
bowel mesentery.
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Crohn’s disease: fistulas and sinus tracts. A. Fistula (arrow) between the
sigmoid colon and adjacent small bowel is demonstrated on barium
enema study. B. Barium enema examination shows fistula between
transverse colon and duodenum. C. Paracolic sinus tract (arrow) is
demonstrated in a patient with previous resection of transverse colon and
an ascending-descending colon anastomosis.
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Sacculations in Crohn’s disease. A. There is straightening of the mesenteric
border (arrows) of the terminal ileum because of fibrofatty proliferation of
the mesentery. B. Multiple segments of small bowel show straightening
and shortening of the mesenteric border (white arrows) with a redundant
antimesenteric border forming sacculations (yellow arrows).
Crohn’s disease involves primarily the mesenteric side (arrows) of the gut,
leading to fibrosis and ballooning of the antimesenteric border. Crohn’s
disease is typically discontinuous, patchy, and asymmetric.
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Mesenteric border ulceration and ileoileal fistula. Image from an air
double-contrast enteroclysis study demonstrates typical straightening of
the mesenteric border, a finding that indicates linear ulceration or ulcer
scar. A relatively long segment of the bowel is affected at several sites, and
multiple stenoses are also identified. A fistula (arrow) extends from the
ileum to the adjacent ileal loop.
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Fibrostenotic Crohn’s disease. These four patients demonstrate the string sign of
Crohn’s disease with narrowing and rigidity of the involved segments because of
cicatrizing Crohn’s disease. A. The terminal ileum is narrowed (arrows) and there
is minimal proximal dilation. B. There is a sacculation (arrow) identified along the
antimesenteric border of this very narrowed ileum. C. A segment of marked
luminal narrowing (arrows) is identified in the distal jejunum. D. Specimen
radiograph shows narrowing of the lumen of the terminal ileum (white arrow)
associated with mural thickening (red arrows). Note the creeping fat (yellow
arrows) on the mesenteric side of the distal ileum. E. Recurrent, stricturing
Crohn’s disease is evident on both sides of the ileocolic anastomosis (arrow).
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Fistulizing-perforating Crohn’s disease. A. Multiple ileocolic and ileoileal
fistulae are shown on this small bowel series. B. Specimen radiograph
shows an ileoileal fistula (yellow arrow). Note the cobblestone mucosa and
deep ulcerations (red arrow) associated with mural thickening. C. Fistulae
between the proximal small bowel and colon (arrow) are demonstrated on
this radiograph.
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Barium enema study shows a sinus tract (arrow) into the right perianal
soft tissues.
Coronal, fat-suppressed T2-weighted MRI scan of the anorectum shows
multiple high signal intensity fistulas (arrows) into the perianal and
mesorectal fat.
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Crohn’s disease: Sonographic features. A. Mural thickening is the
sonographic hallmark of Crohn’s disease. B. In acute disease, mural
stratification is maintained. Yellow arrow, mucosa–muscularis mucosae;
white arrow, submucosa; red arrow, muscularis mucosae. C. In chronic
Crohn’s disease, mural stratification is lost. D. The density of vessels seen
on color flow Doppler ultrasound correlates with the degree of disease
activity.
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Fistulizing-perforating subtype Crohn’s disease: Deep ulcerations. An
affected segment scanned longitudinally (A) and axially (B) shows mural
thickening with deep ulcerations (arrows) and lumen stenosis. C. A fistula
(red arrow) is seen extending from a diseased segment of the ileum (white
arrow) to a small abscess cavity (yellow arrow).
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Active Crohn’s disease. Axial contrast-enhanced CT images in three
different patients ( a - c ) show mural stratification (closing parenthesis in c
) with visualization of wall layers;
1. Mucosal hyper-enhancement ( white arrows ),
2. Submucosal edema ( transparent arrow ) and
3. Enhancing serosa ( arrowhead ),
4. Surrounding mesenteric fat stranding, and
5. Prominent mesenteric vascularity
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Mixed fibrostenotic and active inflammatory small bowel Crohn’s disease
of the distal ileum with penetrating disease: Bilaminar
hyperenhancement. CT enterography in axial (A) and coronal (B)
reconstructions show bilaminar hyperenhancement, severe wall thickening
(>1 cm) (white arrow), and a fistulous tract extending cephalad
(arrowhead ) toward an abscess (black arrow).
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Active inflammatory small bowel Crohn’s disease of the distal ileum with
mild luminal narrowing: Bilaminar hyperenhancement. MRE using HASTE
(A, B) and postcontrast VIBE (C, D). A, B. HASTE images show increased
signal because of edema and/ or lymphatic distention (black arrow). C, D.
Postcontrast VIBE images show a bilaminar hyperenhancement pattern,
moderate wall thickening (5-10 mm), and vasa recta distention
(arrowheads). There is also colitis (white arrow).
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Active inflammatory small bowel Crohn’s disease of the terminal ileum
with luminal narrowing: Trilaminar hyperenhancement. Axial CTE (A) and
Coronal CTE (B) images show moderate wall thickening, a trilaminar
hyperenhancement pattern, and mural fat (arrow). Postcontrast axial (C)
and coronal (D) VIBE images from MRE confirm the trilaminar
hyperenhancement pattern (arrow).
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Active Crohn’s disease with characteristic skip lesions. Axial contrast-
enhanced CT images ( a , b ) in the same patient at two different levels
show involvement of the small bowel at two segments ( arrows ) with
active disease. Note, intervening segments of small bowel dilatation
indicating partial small bowel obstruction
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Active and fibrotic strictures complicating Crohn’s disease. Axial ( a ) and
coronal reconstructed ( b ) contrast enhanced CT images demonstrating
long segment stricture of the terminal ileum with active disease indicated
by bowel wall thickening with mural stratification causing luminal
narrowing ( white arrow ). Note proximal small bowel dilatation indicating
small bowel obstruction ( black arrow ). Axial contrast-enhanced CT ( c ) in
a different patient demonstrates a homogenously enhancing wall
suggestive of fibrotic stricture ( arrow in c )
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Active Crohn’s disease with comb sign. Coronal reconstructed CT images in
two different patients ( a , b ) show prominent vasa recta -comb sign (
arrows ), which is the most specific sign of active Crohn’s disease, that
correlates with disease activity and elevated CRP levels.
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MR enterography in active Crohn’s disease. Axial T2-weighted fat-
suppressed ( a ), axial diffusion-weighted ( b ) and axial post-contrast fat-
suppressed T1-weighted ( c )images show mural thickening, with impeded
diffusion and hyper-enhancement in a long segment of distal ileum
consistent with active inflammatory bowel disease ( white arrows ), with
enlarged reactive lymph node along the left iliac chain ( black arrows ).
Coronal T2-wighted image- HASTE ( d ) demonstrates marked fibrofatty
proliferation ( white arrows ) adjacent to the distal ileum
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Submucosal fat deposition in the bowel wall associated with longstanding
Crohn’s disease. Axial contrast enhanced CT images ( a , b ) show low
attenuation of the submucosa secondary to submucosal fat deposition
within the bowel wall ( arrows )
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Enterocutaneous fi stula in Crohn’s disease. Axial contrast enhanced CT of
the abdomen shows extravasation of oral contrast from an ileal loop
through a hyperattenuating fistulous tract ( white arrow ) communicating
with the skin. Note perienteric inflammatory changes soft tissue thickening
( black asterisks )
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Entero-enteric fi stulae in Crohn’s disease. Ileo-ileal and ileocolic fistulas
in active Crohn’s disease: Coronal ( a - c and e ), axial ( d ) and Sagittal ( f )
contrast enhanced CTE images show various examples of ileo-ileal and
ileocolic fistulae in patients with Crohn’s disease appearing as hyper-
enhancing tracts connecting adjacent bowel loops ( arrows )
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ileocolic fi stulae in patients with Crohn’s disease appearing as
hyperenhancing tracts connecting adjacent bowel loops ( arrows )
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ileocolic fi stulae in patients with Crohn’s disease appearing as
hyperenhancing tracts connecting adjacent bowel loops ( arrows )
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MR in active Crohn’s disease with an ileo-vesical fi stula. Gradient echo
coronal ( a ) image shows nodular thickening along the urinary bladder
dome ( black arrow ). Non-contrast 3D T1W gradient echo ( b ) image
shows oral enteric contrast containing fistulous tract ( black arrow )
between the thick inflamed ileum and bladder dome. Post-contrast 3D
T1W gradient echo ( c ) image shows an enhancing fistulous tract ( black
arrow )
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MRI in active Crohn’s disease with an ileal fistula and iliacus abscess.
Axial T2-weighted HASTE ( a ), diffusion-weighted ( b ) and post-contrast
3D T1-weighted fat-suppressed ( c ) images show bowel wall thickening
and enhancement of the distal ileum with surrounding fibrofatty
proliferation compatible with active Crohn’s disease ( white arrows ). Note
the ileal fistulous tract leading to iliacus muscle abscess, with the
characteristic impeded diffusion ( black arrows )
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CT in active Crohn’s disease with a peri-ileal collection. Fluid collection in
active Crohn’s disease. Axial ( a ) and coronal ( b ) CTE demonstrating a
fluid collection ( arrows ). Note that though the contents of the collection
demonstrate attenuation similar to enteric contrast, the lack of
communication with bowel and caliber discrepancy confirms its
extraluminal location
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Active Crohn lesions at the distal ileum. (a) Image from an air double-contrast
enteroclysis study demonstrates deformity of the distal ileum associated with
linear (arrows) and aphthoid (arrowheads) ulcers. (b) Fat-suppressed single-shot
fast spin-echo MR image (70-mm section thickness) demonstrates similar
deformity at the distal ileum (black arrowhead) as well as the entire course of the
intestine (white arrowheads). (c) Coronal non-fat-suppressed single-shot fast
spin-echo MR image (5-mm section thickness) clearly demonstrates bowel wall
thickening at the involved segment (arrowheads). (d) On a gadolinium-enhanced
spoiled gradient-echo MR image, the bowel wall demonstrates intense
enhancement.
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Inactive Crohn lesion at the terminal ileum. (a) Image from a barium
study demonstrates typical straightening of the mesenteric border at the
terminal ileum. (b) Non-fat-suppressed single-shot fast spin-echo MR
image clearly shows asymmetric bowel deformity at the terminal ileum.
No bowel wall thickening is seen at the involved segment.
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High-grade small bowel obstruction at the distal ileum caused by Crohn
disease. Contrast-enhanced axial (a, b) and coronal reformatted (c) CT
scans demonstrate luminal narrowing at the distal ileum in a relatively long
bowel segment (straight arrows) associated with prominent dilated
proximal loops (curved arrow in c). The wall of the involved segment has a
stratified appearance associated with an increased number of adjacent
mesenteric vessels (comb sign) (arrowheads in a and c).
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Fibrofatty proliferation. Contrast-enhanced CT scan of the lower abdomen
shows a proliferation of fat tissue around the ascending colon. The tissue
has a heterogeneous appearance with increased attenuation. The wall of
the ascending colon is thickened and demonstrates intense enhancement
(arrow).
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Abscess in the small bowel mesentery. Contrast-enhanced CT scan of the
pelvis shows a loculated fluid collection in the mesentery surrounded by a
thin wall. (14) Abscess in the abdominal wall. Contrast-enhanced CT scan
shows the right abdominal rectus muscle and subcutaneous fat tissue with
increased enhancement. Air bubbles are seen within the abdominal wall.
(15) Iliopsoas muscle abscess. Contrast-enhanced CT scan of the pelvis
shows an air-containing abscess in the right iliopsoas muscle (arrow). (16)
Perianal abscess. Contrast-enhanced CT scan obtained at the bottom of
the pelvis demonstrates a fluid-containing abscess around the anus.
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Enterocutaneous fistula. Conventional fistulogram (a) and fat-suppressed
single-shot fast spin-echo MR fistulogram (b) clearly demonstrate an
enterocutaneous fistula (arrows).
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Duodenocolic fistula. Single-shot fast spin-echo MR image demonstrates a
fistula (arrow) between the duodenum and the ascending colon.
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Sinus tracts. (a) Image from a barium enema study shows sinus tracts at
the descending colon (arrowheads). (b) Coronal single-shot fast spin-echo
MR image demonstrates the descending colon with wall thickening and
containing a tract (arrowhead).
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Mural stratification. Contrastenhanced CT scan of the pelvis shows Crohn
disease involvement of the distal ileum. The thickened bowel wall has low
attenuation owing to fluid in the lumen and is surrounded by alternating
layers of higher or lower attenuation in a concentric pattern.
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Comb sign. Contrast-enhanced CT scan of the lower pelvis shows a
diseased segment of the distal ileum (arrowheads) with prominently
dilated adjacent mesenteric vessels.
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Prominent wall thickening. Contrast-enhanced CT scan demonstrates
prominent, strongly enhanced wall thickening with a stratified appearance
at the ascending colon. An inflammatory lesion extends beyond the wall to
the adjacent region.
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Crohns disease

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