Atlas of Signs and Findings in Crohn’s Diseaseeradiology.bidmc.harvard.edu/LearningLab/gastro/Priyadarshni.pdf · Atlas of Signs and Findings in Crohn’s Disease Shivani Priyadarshni,

Atlas of Signs and Findings in Crohn’s Disease

Shivani Priyadarshni, Kasturba Medical College, India

4th Year Medical Student

Gillian Lieberman, MD.

05/26/2015

Shivani Priyadarshni Gillian Lieberman, MD

Outline

2

1. Our Patient’s Clinical Features: History and

Physical Exam

2. Differential Diagnosis

3. Investigations of our patient

4. Crohn’s Disease

i. Clinical Manifestations

ii. Extraintestinal Manifestations

iii. Diagnostic Tests

iv. Radiological Findings

v. Crohn’s vs Ulcerative colitis

5. Conclusion

6. Summary


History

A 55 yo F with • 2-3 loose-formed nonbloody bowel

movements a day • Fleeting cramps prior to bowel movements • Came for follow up • No fever, chills, nausea, vomiting • No loss of appetite or weight change


3

Past History

• PMH: – Crohn’s Disease

– GERD

• PSH and Family History - Not significant for GI problems

• Social History: Smoked 2 PPD for 30 years, stopped 10 years ago


4

Physical Exam

• General: Well-developed, well-nourished female in no apparent distress

• Vital Signs WNL • HEENT: Unremarkable • Neck: Supple, no lymphadenopathy • Abdomen: Soft, mild tender below umbilicus

without guarding or rebound


5

Differential Diagnosis

• Crohn’s Disease • Ulcerative Colitis • Irritable Bowel Syndrome • Yersinia Ileitis • Ileocaecal Tuberculosis • Mesenteric Adenitis


6

Investigations of Our Patient

• CT scan done outside, 5 years ago, showed

inflammation in the proximal transverse

colon, with focal microperforations and some

abnormal thickening of the terminal ileum

• A repeat CT scan showed an ileocecal fistula

• Colonoscopy, 5 years back, showed a single

aphthous erosion in the terminal ileum and

an area in the transverse colon that looked

like a probable fistula site


7

Our Patient Past Coronal C+ T2 Weighted MR Enterography Image

Terminal ileum showing mural thickening and

mucosal enhancement BIDMC: PACS


8

Let us view another image of the same

study.

9


Abnormal inflammatory process between the terminal ileum and proximal transverse colon BIDMC: PACS


10

Our Patient Past Coronal C+ T2 Weighted MR Enterography Image

Let us move on to the report of the same

study.

11


• Abnormal wall thickening, mucosal enhancement and surrounding mesenteric inflammatory changes of the terminal ileum, consistent with terminal ileitis

• Abnormal inflammatory process between the

terminal ileum and proximal transverse colon without fluid collection or discrete tract, suggest early changes of fistulization or may represent changes related to recent perforation

• No lymphadenopathy, no evidence of abscess or

ascites


12

Our Patient Past C+ MR Enterography

Labs on Present Admission

• Hb - 13.8

• ESR -14

• CRP - 1.2 Hb, ESR and CRP are normal suggesting that there is no active disease.

13


Coronal C+ CT Enterography in Our Patient

BIDMC: PACS

Focal tethering of terminal ileum against proximal transverse colon Mild active inflammation and ulcerations in terminal ileum


14

Let us view another image of the same

study.

15


BIDMC: PACS Skip lesion proximal to the previous segment


16

Coronal C+ CT Enterography in Our Patient

Let us move on to the report of the same

study.

17


• Terminal ileum demonstrating mild active inflammation and ulcerations, with focal tethering against the adjacent proximal transverse colon without patent fistula, similar in configuration to the past MR enterography. Tiny skip lesion just proximal to this segment appears new

• No new fistula or fluid collection • No obstruction • No lymphadenopathy or ascites


18

C+ CT Enterography in Our Patient

Crohn’s Disease

• Type of inflammatory bowel disease (IBD) • Etiology: Unknown, Possible environmental,

genetic and autoimmune factors

• Involvement: any segment from mouth to perianal region

• Distal ileum - most common


19

LOCATION SYMPTOMS COMMON DIAGNOSTIC TESTING

Ileum and colon Diarrhea, cramping, abdominal

pain, weight loss

Colonoscopy with ileoscopy, CT enterography,

biopsy

Colon only Diarrhea, rectal bleeding,

perirectal abscess, fistula,

perirectal ulcer


biopsy

Small bowel only Diarrhea, cramping, abdominal

pain, weight loss


capsule endoscopy, small bowel follow-through,

enteroscopy, biopsy, MR enterography

Gastroduodenal

region

Anorexia, weight loss, nausea,

vomiting

Esophagogastroduodenoscopy, small bowel

follow-through, enteroscopy

Clinical Manifestations Shivani Priyadarshni Gillian Lieberman, MD

20 Wilkins T, Jarvis K, Patel J.(2011). American Family Physician.84(12).

Extraintestinal Manifestations • Dermatological • Rheumatological - Migratory polyarthritis,

Ankylosing spondylitis • Ocular - Conjunctivitis, Anterior uveitis, Episcleritis • Urological - Nephrolithiasis • Hepatobiliary - Cholelithiasis, Hepatic steatosis,

Primary sclerosing cholangitis • Metabolic bone disorder - Osteoporosis,

osteonecrosis, pathological fracture • Venous and arterial thrombosis


21

Let us view some images of the same.

22


Schwartz and Nervi. Am Fam Physician. 2007.

Erythema nodosum Pyoderma gangrenosum

Brooklyn, et al. BMJ. 2006.

Superficial erosion of tongue

Sanderson, et al. Inflamm Bowel Dis. 2005. Mintz, et al. Inflammatory bowel diseases. 2004.

Anterior uveitis


23

Extraintestinal Manifestations

TEST COMMENT

Small bowel follow-

through/ enteroclysis/

enema

Visualization of lumen using contrast medium (barium)

radiation exposure, no wall and extraluminal visualization

Computed tomography

enterography

Permits visualization of the bowel wall and lumen;extraluminal sequelae

exposes patient to ionizing radiation.

Magnetic resonance

enterography

Similar to CT, no ionizing radiation

expensive

Endoscopy Direct visualization of mucosa - inflammation, fistula, or stricture of terminal ileum and colon; ability to

obtain biopsies.

extraluminal not seen.

Ultrasonography Detects increase in vascular flow, abscess, sinus tracts, and lymphadenopathy

operator dependant, obesity

Various Diagnostic Tests for Crohn's Disease

24 Wilkins T, Jarvis K, Patel J.(2011). American Family Physician.84(12).


Long narrow ileum with mucosal irregularity Koh, D. M., et al. (2001). American Journal of Roentgenology. 177(6) .


25

Barium Follow Through Image

of Companion Patient #1

Barium Enema Image of

Companion Patient #2

Wells, C.(1952). Annals of the Royal College of Surgeons of England .11(2).

String sign - severe narrowing of terminal ileum with

dilated proximal bowel


26

Axial C+ CT Abdomen of


Target sign

Periintestinal fat showing marked inflammatory change Gore, R.M., et al.(1996). American journal of roentgenology. 167(1).


27

Target Sign

Seen on contrast enhanced CT and MRI.

It consists of 3 concentric circles of bowel wall:

• Outer Layer: Inflamed muscularis propria (high

attenuation)

• Middle Layer: Intermediate edema/fat (low attenuation)

• Inner Layer: Inflamed mucosa (high attenuation)

Best seen during late arterial, early venous phase.

28




A D


29 Gore, R.M., et al.(1996). American journal of roentgenology. 167(1).

Luminal narrowing and mural thickening of distal ileum

Dilatation of fluid-filled small bowel proximally due to obstruction.

Collapsed ascending colon (A) and descending colon (D)



Creeping fat of mesentery

Homogeneously thickened walls of ileum and ascending colon

Separation of normal small-bowel loop from these diseased segments

caused by abnormal mesenteric fat


30 Gore, R.M., et al.(1996). American journal of roentgenology. 167(1).

*

*

Creeping Fat of Mesentery

Fibrofatty proliferation with hypertrophied

mesenteric fat between inflamed intestinal

segments.

31


Perirectal abscesses with sinus tract

extending into right buttock.

Presacral abscess attributable to

fistula from rectum (R).

Axial C- CT Pelvis of Companion

Patient #6 and Patient #7

R


32

Gore, R.M., et al.(1996). American journal of roentgenology. 167(1).

* * *

Mucosal enhancement with narrowing of lumen of terminal ileum

Dilation of proximal bowel

Coronal C+ MRI of Companion

Patient #8


33 Albert, J.G., et al.(2005). Gut. 54(12).

Terminal ileum shows Two aphthous ulcers with

Wall thickening and cobblestoning. Gourtsoyiannis, et al. (2006). European radiology.16(9).


34

Coronal C+MRE(a) and Conventional

Enteroclysis(b) in Companion Patient #9

Coronal T1 Fat Suppressed C+ MRI

of Companion Patient #10

Comb sign

J. Panés, et al. (2011). Aliment Pharmacol Ther. 34(2).


35

Comb Sign


36

Shaft of comb - Mural hyper enhancement

and thickening in the distal ileum

Bristles of comb - Prominent engorged

vasa recta in the mesentery

Axial 3D FLASH C+ MRI of


Mesenteric lymphadenopathy


37 Gourtsoyiannis, et al. (2006). European radiology. 16(9).

Mesenteric Lymphadenopathy

38

Mesenteric lymphadenopathy <1 cm may be

seen in Crohn’s disease.

If >1 cm, then rule out other causes,

especially lymphoma.


Crohn’s vs Ulcerative Features CD UC

Mucosal Granularity + ++

Aphthoid ulcers ++ -

Deep ulceration ++ -

Discontinuous ulceration/ Skip lesion

++ -

Rectal sparing + -

Colonic shortening + ++

39 Halligan and Robinson.(2003). In Sutton, D. (Ed.), A Textbook of Radiology and Imaging, Volume 1.

7th edition.


Let us see some more features that

differentiate the two diseases.

40


CD UC

Haustral obliteration + ++

Pseudodiverticula ++ -

Enteric fistulae ++ -

Abscess ++ -

Small bowel disease/ Anal disease

++ -

Toxic megacolon + ++

41

Halligan and Robinson.(2003). In Sutton, D. (Ed.), A Textbook of Radiology and Imaging, Volume 1.

7th edition.


Crohn’s vs Ulcerative

Conclusion

Based on the clinical features and radiological

findings of our patient, a diagnosis of Crohn’s

disease was arrived upon.

Patient counselled and does not want to take

medications, but is willing for follow up.

Plan of follow up:

- ESR, CRP

- Repeat CT Enterography


42

Summary

• Crohn’s disease is a type of IBD which can affect any

part of GIT, most commonly ileum

• Clinical features include abdominal pain, diarrhea,

weight loss, abscess, fistula, etc

• Extraintestinal manifestations may also be present as

already mentioned

• Various investigations for evaluation include small

bowel follow through, enteroclysis, enema with

barium contrast, CT enterography, MR enterography,

endoscopy and ultrasonography 43


Summary

Radiological findings include:

● Aphthous ulcers, eccentric bowel wall thickening

● Skip lesions

● String sign, creeping fat of mesentery

● Target sign

● Comb sign

● Abscesses and Fistulae 44


Summary

Treatment:

● Symptomatic OR to induce remission

● Medical

○ Steroids

○ 5-ASA derivatives

○ Immunomodulators

● Surgical

45



46

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47

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Acknowledgements


Dr. G. Lieberman, MD Dr. Jonathan Kim

48

Thank You


49

Documents

Atlas of Signs and Findings in Crohn’s Diseaseeradiology.bidmc.harvard.edu/LearningLab/gastro/Priyadarshni.pdf · Atlas of Signs and Findings in Crohn’s Disease Shivani Priyadarshni,