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
4.
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
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.
15.
16. US image - stricture in a patient with active
Crohn's disease
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.
20.
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
23.
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
26.
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
28.
29.
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.
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
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.
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
47.
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.
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
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
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
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.
76. Accordion sign
The sign is described as alternating edematous
haustral folds separated by mucosal ridges filled with
oral contrast material
77.
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
