Elissa Altin, HMSIII May 2005

Gillian Lieberman, MD

Crohns Disease: Radiologic

Findings
Elissa Altin, Harvard Medical School Year III
Gillian Lieberman, MD

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 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Our Patient
z 21 year-old man with 7-year history of Crohns
and medical non-compliance presents with
obstructive symptoms
z History: bilious vomiting of undigested food,
abdominal pain, loose stools
z Physical Exam: orthostatic, Tmax to 101.7, abdomen
was soft, non-distended with mild discomfort in the
epigastric region without peritoneal signs.
z Laboratory: WBC 11.3, Hct 39.1. PT and PTT were
11.2 and 26.3. Electrolytes within normal limits.

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 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Crohns Disease in Overview

z DEFINITION: disorder of transmural
discontinuous inflammation of any segment
of the GI tract from pharynx to perianal
area
z ETIOLOGY: largely unknown but believed
to be caused by destruction of immunologic
homeostasis of the GI tract secondary to
over-expression of pro-inflammatory
cytokines, under-expression of regulatory
cytokines, or both 3
 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Crohns Disease in Overview

z GENETICS: polygenic, but 10 times
increased risk of having Crohns if a
first degree relative suffers from it1
z EPIDEMIOLOGY: bimodal
distribution with peak at 2nd-4th decade
of life and again after 6th decade;
affects whites more, especially
Ashkenazi Jews living in Europe and
North America 4
 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Clinical Features of Crohns

z Inflammatory Symptoms
z RLQ pain, fever, diarrhea +/- blood, weight loss,
palpable abdominal mass on physical exam
z Obstructive Symptoms
z Post-prandial abdominal pain, distension, nausea,
vomiting
z Fistulous Disease
z Enterovaginal, enterocutaneous, enteroentero,
enterovesicular fistulae can form as a result of
transmural inflammation with elaboration of sinus
tracts that penetrate the mucosa
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 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Clinical Features of Crohns

z Perianal Disease
z Anal fissures, perianal abscess formation,
anorectal fistula, pain and drainage from skin
tags
z Extraintestinal Manifestations
z Seronegative arthritis (asymmetric, usually
large joints), sacroiliitis, ankylosing
spondylitis, E. nodosum/Pyoderma
gangrenosum, ocular manifestations
(episcleritis, uveitis), hepatic complications
(elevation of serum transaminases, primary
sclerosing cholangitis) 6
Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Normal Anatomy

Image from Horton et al. 7

 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Diagnosis of Crohns
z Clinical Presentation
z Endoscopic features
z Apthous ulcers, edema,
erythema, exudate, friable
mucosa with intercalated
normal mucosa called skip
lesions, linear ulcers with
segments of uninvolved
mucosa called cobblestoning
z Histologic Features
z Radiologic Features: lets
see

Image from Horton et al. 8

 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Radiographic options for

diagnosing Crohns
z Conventional X-ray
z Without barium: good for obstruction to show dilated loops
of bowel and strictures
z With barium: not in the setting of obstruction, can show
details of the mucosa, including filling defects, ulcerations,
and strictures
z CT Scan
z Can show cross-sections details of the bowel wall,
including edema, engorged ileal vasa recta, fistulous tract
formation, abscess, stricture, dilation, mural stratification,
and mucosal and mural hyperenhancement
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 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Our Patient: A Natural History of

Crohns on Radiographs
z Barium swallow to rule out
obstructing lesion
z No evidence of obstructing
lesions, but narrowed and
diseased distal ileal loop
(string sign) in pelvis
separate from other loops
consistent with wall
thickening without evidence
of proximal dilation to suggest
obstruction
z Apthous ulceration: barium
collects in superficial
ulceration, surrounded by
edematous mucosa, herald
future, larger ulceration
String sign

Courtesy of Kevin Knoblock

 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

More findings from our patient:

cobblestoning and ulceration
Characteristic
cobblestoning pattern
formed by dispersal of
barium between
inflamed, edematous
mucosa (thick arrow)
ulceration Ulceration: barium
collects in ulceration
surrounded by thickened
mucosa (thin arrow)
cobblestoning
Courtesy of Kevin Knoblock 11
 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

More findings from our patient:

nodular filling defects
z Nodular filling
defects in folds of
ileal mucosa are
characteristic of
Crohns

Courtesy of Kevin Knoblock

 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Differential Diagnosis of Crohns Colitis

z Lactose intolerance
z IBS
z Radiation colitis
z C. diff pseudomembranous colitis
z Ischemic colitis
z Appendicitis, diverticulitis, perforating or
obstructing carcinoma
z Infection: Shigella, Salmonella, Campylobacter,
E. coli, Yersinia (causes nearly identical small
bowel colitis to Crohns)
z Ulcerative Colitis 13
 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Crohns versus ulcerative colitis

z Characteristics of Crohns not usually
found in UC
z Small bowel involvement
z Rectal sparing
z Absence of gross bleeding
z Perianal disease
z Discontinuous areas of disease

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 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Crohns versus ulcerative colitis

z Why do we care to differentiate?
z Colectomy with ileoanal anastomosis is
essentially curative in UC, but in Crohns
disease can recur in small bowel
z Crohns is treated with segmental resection,
but in UC, disease can recur in non-
resected colon

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 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Our patient: A few years later

z Presents with fevers
to 103, abdominal
pain barium study
z Distal jejunum shows at
least 5 segments of sausage sign
narrowing with interspersed
dilation
z More distally, there is
sacculation of the terminal
ileum in between areas of
luminal narrowing
z Segmental areas of
disease with intervening
normal bowel sacculation

Courtesy of Kevin Knoblock

Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Our patient: After surgery

z Status post
segmental resection
of jejunum,
stricturoplasty of
ileum, and
ileoascending
colostomy
z No evidence of
obstruction or
recurrence
Courtesy of Kevin Knoblock
 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Our patient: Obstructed Again

z Partial obstruction seen

two ways, with distended
small bowel loops on
KUB and dilated loops of
fluid filled small bowel on
CT
Image from PACS, BIDMC 18
Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Other radiologic signs in a comparison

patient: fistulae
fistula
and abscess
z Fistulous tract connecting
bowel wall to surrounding
abscess
z Seen above without
contrast and below with
contrast showing
enhancing abscess wall
z Presence of contrast in
abscess confirms
communication between
abscess and bowel wall via
fistula
abscess
Image from Rollandi et al. 19
 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Medical Management of Crohns

z From our patient, we have seen the
progression of disease from small scale
ulceration to painful climax resulting in surgical
resection
z How do we treat patients medically to hopefully
avoid or postpone surgery, keeping in mind
that up to 80% of patients will require surgery
eventually?

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 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Immunomodulatory Treatment
z Active Ileitis
z 5-ASA (Pentasa, Asacol), ABX (ciprofloxacin, clarithromycin),
steroids
z Maintenance
z 5-ASA
z Refractory Disease
z Azathioprine and 6-mercaptopurine
z Both purine mimic antimetabolites
z Can help to induce remission in steroid resistant patients as
well as for remission maintenance
z Methotrexate
z Structural analog of folate and competitive inhibitor of
dihydrofolate binding
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Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Review of Radiologic Findings

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 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

References
z Brzezinkski, Aaron. Inflammatory Bowel Disease. Cecil Essential of
Medicine. Ed. Thomas Andreoli. Philadelphia: Saunders, 2001. 345-50.
z Horton, K et al. CT Evaluation of the Colon: Inflammatory Disease.
Radiographics: 2000 Mar-Apr;20(2):399-418.
z Orholm, M et al. Familial occurrence of inflammatory bowel disease.
NEJM: 1991 Jan 10;324(2):84-8.
z Rollandi, G et al. Spiral CT of the abdomen after distention of small bowel
loops with transparent enema in patients with Crohn's disease. Abdominal
Imaging: 1999; 24:544549.
z Wold, P et al. Assessment of Small Bowel Crohn Disease: Noninvasive
Peroral CT Enterography Compared with Other Imaging Methods and
EndoscopyFeasibility Study. Radiology: 2003; 229:275281.
z Uptodate.com
z PACS, BIDMC

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 Elissa Altin, HMSIII May 2005
Gillian Lieberman, MD

Acknowledgements
z Kevin Knoblock
z Pamela Lepkowski
z Larry Barbaras
z Gillian Lieberman, MD

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