45
Mahan Mathur Gillian Lieberman, MD CT evaluation of inflammatory conditions of the colon Mahan Mathur McGill Medicine Class of 2007 Advanced Clerkship in Radiology BIDMC, Harvard Medical School

CT Colitis

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Page 1: CT Colitis

Mahan Mathur

Gillian Lieberman MD

CT evaluation of inflammatory conditions

of the colon

Mahan MathurMcGill Medicine Class of 2007

Advanced Clerkship in RadiologyBIDMC Harvard Medical School

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Vascular (ischemic)bull Diverticulitisbull Appendicitisbull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Vascular (ischemic)bull Diverticulitisbull Appendicitisbull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Normal CT considerations of Bowel

bull Advantages ndash Ease of availability and performancendash Accurate delineation of anatomy ndash intestinal

and extraintestinal + complicationsndash Multidetector CT =gt short scan times thin

slices reformations

Normal Scout film PACS BIDMC Normal Axial CT slice PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Normal CT considerations of Bowel

bull Normal Colonndash Small Bowel 3 cmndash Large Bowel 6 cmndash Cecum 9 cm

bull Bowel wall thicknessndash Normal 3 mmndash Distended 1-2 mm

Normal Coronal CT reformation PACS BIDMC

Normal Sagittal CT reformation PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Vascular (ischemic)bull Diverticulitisbull Appendicitisbull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Patient 1 Scout and Axial Films

29 yo F with 3 wks of abdo pain anemia and increased WBCPACS BIDMC PACS BIDMC

Scout FilmAxial CT slice Note the Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

PACS BIDMC

Note the distal ileal distribution of Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Sagittal Reformations

Note the difference between small and large bowel wall (seen here is Transverse Colon) thickness

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

Note the difference between small and large bowel wall thickness

PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

IBD Crohnrsquos

bull Etiology unknownbull Involvement mouth to perianal

ndash 80 small bowel (distal ileum = most common)ndash 50 ileocolitisndash 20 limited to colon ndash sparing of rectum

bull Clinical Manifestationsndash Diarrhea Abdo pain Weight Loss Fever bleedingndash SBO (fibrotic strictures)ndash Fistula (entero-vaginalvesicalcutaneous)ndash Perforation sinus tracts with serosal penetration

Related to PathophysiologyOf Transmural Bowel Wall inflammation

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Extraintestinal Manifestations

Localized Episcleritis

Anterior uveitisiritis

Pyoderma gangrenosum

Erythema Nodosum

Apthous Stomatitis

Mintz et all Inflamm Bowel Dis 2004

Trost et all Postgrad Med J 2005

Mahan Mathur

Gillian Lieberman MD

ERCP showing Sclerosing Cholangitis

GallBladder

Common Bile Duct

Common Hepatic duct

RightLeft Hepatic ducts

Presti et all Dig Dis Sci 1997

Note Narrow CBD and stenotic CHD with prestenotic dilatation of Left Hepatic Duct + intraheptatic duct pruning

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 2: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Vascular (ischemic)bull Diverticulitisbull Appendicitisbull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Vascular (ischemic)bull Diverticulitisbull Appendicitisbull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Normal CT considerations of Bowel

bull Advantages ndash Ease of availability and performancendash Accurate delineation of anatomy ndash intestinal

and extraintestinal + complicationsndash Multidetector CT =gt short scan times thin

slices reformations

Normal Scout film PACS BIDMC Normal Axial CT slice PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Normal CT considerations of Bowel

bull Normal Colonndash Small Bowel 3 cmndash Large Bowel 6 cmndash Cecum 9 cm

bull Bowel wall thicknessndash Normal 3 mmndash Distended 1-2 mm

Normal Coronal CT reformation PACS BIDMC

Normal Sagittal CT reformation PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Vascular (ischemic)bull Diverticulitisbull Appendicitisbull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Patient 1 Scout and Axial Films

29 yo F with 3 wks of abdo pain anemia and increased WBCPACS BIDMC PACS BIDMC

Scout FilmAxial CT slice Note the Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

PACS BIDMC

Note the distal ileal distribution of Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Sagittal Reformations

Note the difference between small and large bowel wall (seen here is Transverse Colon) thickness

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

Note the difference between small and large bowel wall thickness

PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

IBD Crohnrsquos

bull Etiology unknownbull Involvement mouth to perianal

ndash 80 small bowel (distal ileum = most common)ndash 50 ileocolitisndash 20 limited to colon ndash sparing of rectum

bull Clinical Manifestationsndash Diarrhea Abdo pain Weight Loss Fever bleedingndash SBO (fibrotic strictures)ndash Fistula (entero-vaginalvesicalcutaneous)ndash Perforation sinus tracts with serosal penetration

Related to PathophysiologyOf Transmural Bowel Wall inflammation

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Extraintestinal Manifestations

Localized Episcleritis

Anterior uveitisiritis

Pyoderma gangrenosum

Erythema Nodosum

Apthous Stomatitis

Mintz et all Inflamm Bowel Dis 2004

Trost et all Postgrad Med J 2005

Mahan Mathur

Gillian Lieberman MD

ERCP showing Sclerosing Cholangitis

GallBladder

Common Bile Duct

Common Hepatic duct

RightLeft Hepatic ducts

Presti et all Dig Dis Sci 1997

Note Narrow CBD and stenotic CHD with prestenotic dilatation of Left Hepatic Duct + intraheptatic duct pruning

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 3: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Vascular (ischemic)bull Diverticulitisbull Appendicitisbull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Normal CT considerations of Bowel

bull Advantages ndash Ease of availability and performancendash Accurate delineation of anatomy ndash intestinal

and extraintestinal + complicationsndash Multidetector CT =gt short scan times thin

slices reformations

Normal Scout film PACS BIDMC Normal Axial CT slice PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Normal CT considerations of Bowel

bull Normal Colonndash Small Bowel 3 cmndash Large Bowel 6 cmndash Cecum 9 cm

bull Bowel wall thicknessndash Normal 3 mmndash Distended 1-2 mm

Normal Coronal CT reformation PACS BIDMC

Normal Sagittal CT reformation PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Vascular (ischemic)bull Diverticulitisbull Appendicitisbull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Patient 1 Scout and Axial Films

29 yo F with 3 wks of abdo pain anemia and increased WBCPACS BIDMC PACS BIDMC

Scout FilmAxial CT slice Note the Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

PACS BIDMC

Note the distal ileal distribution of Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Sagittal Reformations

Note the difference between small and large bowel wall (seen here is Transverse Colon) thickness

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

Note the difference between small and large bowel wall thickness

PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

IBD Crohnrsquos

bull Etiology unknownbull Involvement mouth to perianal

ndash 80 small bowel (distal ileum = most common)ndash 50 ileocolitisndash 20 limited to colon ndash sparing of rectum

bull Clinical Manifestationsndash Diarrhea Abdo pain Weight Loss Fever bleedingndash SBO (fibrotic strictures)ndash Fistula (entero-vaginalvesicalcutaneous)ndash Perforation sinus tracts with serosal penetration

Related to PathophysiologyOf Transmural Bowel Wall inflammation

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Extraintestinal Manifestations

Localized Episcleritis

Anterior uveitisiritis

Pyoderma gangrenosum

Erythema Nodosum

Apthous Stomatitis

Mintz et all Inflamm Bowel Dis 2004

Trost et all Postgrad Med J 2005

Mahan Mathur

Gillian Lieberman MD

ERCP showing Sclerosing Cholangitis

GallBladder

Common Bile Duct

Common Hepatic duct

RightLeft Hepatic ducts

Presti et all Dig Dis Sci 1997

Note Narrow CBD and stenotic CHD with prestenotic dilatation of Left Hepatic Duct + intraheptatic duct pruning

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 4: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Normal CT considerations of Bowel

bull Advantages ndash Ease of availability and performancendash Accurate delineation of anatomy ndash intestinal

and extraintestinal + complicationsndash Multidetector CT =gt short scan times thin

slices reformations

Normal Scout film PACS BIDMC Normal Axial CT slice PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Normal CT considerations of Bowel

bull Normal Colonndash Small Bowel 3 cmndash Large Bowel 6 cmndash Cecum 9 cm

bull Bowel wall thicknessndash Normal 3 mmndash Distended 1-2 mm

Normal Coronal CT reformation PACS BIDMC

Normal Sagittal CT reformation PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Vascular (ischemic)bull Diverticulitisbull Appendicitisbull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Patient 1 Scout and Axial Films

29 yo F with 3 wks of abdo pain anemia and increased WBCPACS BIDMC PACS BIDMC

Scout FilmAxial CT slice Note the Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

PACS BIDMC

Note the distal ileal distribution of Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Sagittal Reformations

Note the difference between small and large bowel wall (seen here is Transverse Colon) thickness

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

Note the difference between small and large bowel wall thickness

PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

IBD Crohnrsquos

bull Etiology unknownbull Involvement mouth to perianal

ndash 80 small bowel (distal ileum = most common)ndash 50 ileocolitisndash 20 limited to colon ndash sparing of rectum

bull Clinical Manifestationsndash Diarrhea Abdo pain Weight Loss Fever bleedingndash SBO (fibrotic strictures)ndash Fistula (entero-vaginalvesicalcutaneous)ndash Perforation sinus tracts with serosal penetration

Related to PathophysiologyOf Transmural Bowel Wall inflammation

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Extraintestinal Manifestations

Localized Episcleritis

Anterior uveitisiritis

Pyoderma gangrenosum

Erythema Nodosum

Apthous Stomatitis

Mintz et all Inflamm Bowel Dis 2004

Trost et all Postgrad Med J 2005

Mahan Mathur

Gillian Lieberman MD

ERCP showing Sclerosing Cholangitis

GallBladder

Common Bile Duct

Common Hepatic duct

RightLeft Hepatic ducts

Presti et all Dig Dis Sci 1997

Note Narrow CBD and stenotic CHD with prestenotic dilatation of Left Hepatic Duct + intraheptatic duct pruning

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 5: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Normal CT considerations of Bowel

bull Normal Colonndash Small Bowel 3 cmndash Large Bowel 6 cmndash Cecum 9 cm

bull Bowel wall thicknessndash Normal 3 mmndash Distended 1-2 mm

Normal Coronal CT reformation PACS BIDMC

Normal Sagittal CT reformation PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Vascular (ischemic)bull Diverticulitisbull Appendicitisbull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Patient 1 Scout and Axial Films

29 yo F with 3 wks of abdo pain anemia and increased WBCPACS BIDMC PACS BIDMC

Scout FilmAxial CT slice Note the Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

PACS BIDMC

Note the distal ileal distribution of Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Sagittal Reformations

Note the difference between small and large bowel wall (seen here is Transverse Colon) thickness

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

Note the difference between small and large bowel wall thickness

PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

IBD Crohnrsquos

bull Etiology unknownbull Involvement mouth to perianal

ndash 80 small bowel (distal ileum = most common)ndash 50 ileocolitisndash 20 limited to colon ndash sparing of rectum

bull Clinical Manifestationsndash Diarrhea Abdo pain Weight Loss Fever bleedingndash SBO (fibrotic strictures)ndash Fistula (entero-vaginalvesicalcutaneous)ndash Perforation sinus tracts with serosal penetration

Related to PathophysiologyOf Transmural Bowel Wall inflammation

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Extraintestinal Manifestations

Localized Episcleritis

Anterior uveitisiritis

Pyoderma gangrenosum

Erythema Nodosum

Apthous Stomatitis

Mintz et all Inflamm Bowel Dis 2004

Trost et all Postgrad Med J 2005

Mahan Mathur

Gillian Lieberman MD

ERCP showing Sclerosing Cholangitis

GallBladder

Common Bile Duct

Common Hepatic duct

RightLeft Hepatic ducts

Presti et all Dig Dis Sci 1997

Note Narrow CBD and stenotic CHD with prestenotic dilatation of Left Hepatic Duct + intraheptatic duct pruning

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 6: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Vascular (ischemic)bull Diverticulitisbull Appendicitisbull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Patient 1 Scout and Axial Films

29 yo F with 3 wks of abdo pain anemia and increased WBCPACS BIDMC PACS BIDMC

Scout FilmAxial CT slice Note the Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

PACS BIDMC

Note the distal ileal distribution of Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Sagittal Reformations

Note the difference between small and large bowel wall (seen here is Transverse Colon) thickness

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

Note the difference between small and large bowel wall thickness

PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

IBD Crohnrsquos

bull Etiology unknownbull Involvement mouth to perianal

ndash 80 small bowel (distal ileum = most common)ndash 50 ileocolitisndash 20 limited to colon ndash sparing of rectum

bull Clinical Manifestationsndash Diarrhea Abdo pain Weight Loss Fever bleedingndash SBO (fibrotic strictures)ndash Fistula (entero-vaginalvesicalcutaneous)ndash Perforation sinus tracts with serosal penetration

Related to PathophysiologyOf Transmural Bowel Wall inflammation

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Extraintestinal Manifestations

Localized Episcleritis

Anterior uveitisiritis

Pyoderma gangrenosum

Erythema Nodosum

Apthous Stomatitis

Mintz et all Inflamm Bowel Dis 2004

Trost et all Postgrad Med J 2005

Mahan Mathur

Gillian Lieberman MD

ERCP showing Sclerosing Cholangitis

GallBladder

Common Bile Duct

Common Hepatic duct

RightLeft Hepatic ducts

Presti et all Dig Dis Sci 1997

Note Narrow CBD and stenotic CHD with prestenotic dilatation of Left Hepatic Duct + intraheptatic duct pruning

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 7: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Patient 1 Scout and Axial Films

29 yo F with 3 wks of abdo pain anemia and increased WBCPACS BIDMC PACS BIDMC

Scout FilmAxial CT slice Note the Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

PACS BIDMC

Note the distal ileal distribution of Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Sagittal Reformations

Note the difference between small and large bowel wall (seen here is Transverse Colon) thickness

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

Note the difference between small and large bowel wall thickness

PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

IBD Crohnrsquos

bull Etiology unknownbull Involvement mouth to perianal

ndash 80 small bowel (distal ileum = most common)ndash 50 ileocolitisndash 20 limited to colon ndash sparing of rectum

bull Clinical Manifestationsndash Diarrhea Abdo pain Weight Loss Fever bleedingndash SBO (fibrotic strictures)ndash Fistula (entero-vaginalvesicalcutaneous)ndash Perforation sinus tracts with serosal penetration

Related to PathophysiologyOf Transmural Bowel Wall inflammation

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Extraintestinal Manifestations

Localized Episcleritis

Anterior uveitisiritis

Pyoderma gangrenosum

Erythema Nodosum

Apthous Stomatitis

Mintz et all Inflamm Bowel Dis 2004

Trost et all Postgrad Med J 2005

Mahan Mathur

Gillian Lieberman MD

ERCP showing Sclerosing Cholangitis

GallBladder

Common Bile Duct

Common Hepatic duct

RightLeft Hepatic ducts

Presti et all Dig Dis Sci 1997

Note Narrow CBD and stenotic CHD with prestenotic dilatation of Left Hepatic Duct + intraheptatic duct pruning

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 8: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

PACS BIDMC

Note the distal ileal distribution of Bowel Wall thickness

Mahan Mathur

Gillian Lieberman MD

Patient 1 Sagittal Reformations

Note the difference between small and large bowel wall (seen here is Transverse Colon) thickness

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

Note the difference between small and large bowel wall thickness

PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

IBD Crohnrsquos

bull Etiology unknownbull Involvement mouth to perianal

ndash 80 small bowel (distal ileum = most common)ndash 50 ileocolitisndash 20 limited to colon ndash sparing of rectum

bull Clinical Manifestationsndash Diarrhea Abdo pain Weight Loss Fever bleedingndash SBO (fibrotic strictures)ndash Fistula (entero-vaginalvesicalcutaneous)ndash Perforation sinus tracts with serosal penetration

Related to PathophysiologyOf Transmural Bowel Wall inflammation

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Extraintestinal Manifestations

Localized Episcleritis

Anterior uveitisiritis

Pyoderma gangrenosum

Erythema Nodosum

Apthous Stomatitis

Mintz et all Inflamm Bowel Dis 2004

Trost et all Postgrad Med J 2005

Mahan Mathur

Gillian Lieberman MD

ERCP showing Sclerosing Cholangitis

GallBladder

Common Bile Duct

Common Hepatic duct

RightLeft Hepatic ducts

Presti et all Dig Dis Sci 1997

Note Narrow CBD and stenotic CHD with prestenotic dilatation of Left Hepatic Duct + intraheptatic duct pruning

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 9: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Patient 1 Sagittal Reformations

Note the difference between small and large bowel wall (seen here is Transverse Colon) thickness

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

Note the difference between small and large bowel wall thickness

PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

IBD Crohnrsquos

bull Etiology unknownbull Involvement mouth to perianal

ndash 80 small bowel (distal ileum = most common)ndash 50 ileocolitisndash 20 limited to colon ndash sparing of rectum

bull Clinical Manifestationsndash Diarrhea Abdo pain Weight Loss Fever bleedingndash SBO (fibrotic strictures)ndash Fistula (entero-vaginalvesicalcutaneous)ndash Perforation sinus tracts with serosal penetration

Related to PathophysiologyOf Transmural Bowel Wall inflammation

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Extraintestinal Manifestations

Localized Episcleritis

Anterior uveitisiritis

Pyoderma gangrenosum

Erythema Nodosum

Apthous Stomatitis

Mintz et all Inflamm Bowel Dis 2004

Trost et all Postgrad Med J 2005

Mahan Mathur

Gillian Lieberman MD

ERCP showing Sclerosing Cholangitis

GallBladder

Common Bile Duct

Common Hepatic duct

RightLeft Hepatic ducts

Presti et all Dig Dis Sci 1997

Note Narrow CBD and stenotic CHD with prestenotic dilatation of Left Hepatic Duct + intraheptatic duct pruning

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 10: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Patient 1 Coronal Reformation

Note the difference between small and large bowel wall thickness

PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

IBD Crohnrsquos

bull Etiology unknownbull Involvement mouth to perianal

ndash 80 small bowel (distal ileum = most common)ndash 50 ileocolitisndash 20 limited to colon ndash sparing of rectum

bull Clinical Manifestationsndash Diarrhea Abdo pain Weight Loss Fever bleedingndash SBO (fibrotic strictures)ndash Fistula (entero-vaginalvesicalcutaneous)ndash Perforation sinus tracts with serosal penetration

Related to PathophysiologyOf Transmural Bowel Wall inflammation

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Extraintestinal Manifestations

Localized Episcleritis

Anterior uveitisiritis

Pyoderma gangrenosum

Erythema Nodosum

Apthous Stomatitis

Mintz et all Inflamm Bowel Dis 2004

Trost et all Postgrad Med J 2005

Mahan Mathur

Gillian Lieberman MD

ERCP showing Sclerosing Cholangitis

GallBladder

Common Bile Duct

Common Hepatic duct

RightLeft Hepatic ducts

Presti et all Dig Dis Sci 1997

Note Narrow CBD and stenotic CHD with prestenotic dilatation of Left Hepatic Duct + intraheptatic duct pruning

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 11: CT Colitis

Mahan Mathur

Gillian Lieberman MD

IBD Crohnrsquos

bull Etiology unknownbull Involvement mouth to perianal

ndash 80 small bowel (distal ileum = most common)ndash 50 ileocolitisndash 20 limited to colon ndash sparing of rectum

bull Clinical Manifestationsndash Diarrhea Abdo pain Weight Loss Fever bleedingndash SBO (fibrotic strictures)ndash Fistula (entero-vaginalvesicalcutaneous)ndash Perforation sinus tracts with serosal penetration

Related to PathophysiologyOf Transmural Bowel Wall inflammation

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Extraintestinal Manifestations

Localized Episcleritis

Anterior uveitisiritis

Pyoderma gangrenosum

Erythema Nodosum

Apthous Stomatitis

Mintz et all Inflamm Bowel Dis 2004

Trost et all Postgrad Med J 2005

Mahan Mathur

Gillian Lieberman MD

ERCP showing Sclerosing Cholangitis

GallBladder

Common Bile Duct

Common Hepatic duct

RightLeft Hepatic ducts

Presti et all Dig Dis Sci 1997

Note Narrow CBD and stenotic CHD with prestenotic dilatation of Left Hepatic Duct + intraheptatic duct pruning

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 12: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Extraintestinal Manifestations

Localized Episcleritis

Anterior uveitisiritis

Pyoderma gangrenosum

Erythema Nodosum

Apthous Stomatitis

Mintz et all Inflamm Bowel Dis 2004

Trost et all Postgrad Med J 2005

Mahan Mathur

Gillian Lieberman MD

ERCP showing Sclerosing Cholangitis

GallBladder

Common Bile Duct

Common Hepatic duct

RightLeft Hepatic ducts

Presti et all Dig Dis Sci 1997

Note Narrow CBD and stenotic CHD with prestenotic dilatation of Left Hepatic Duct + intraheptatic duct pruning

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 13: CT Colitis

Mahan Mathur

Gillian Lieberman MD

ERCP showing Sclerosing Cholangitis

GallBladder

Common Bile Duct

Common Hepatic duct

RightLeft Hepatic ducts

Presti et all Dig Dis Sci 1997

Note Narrow CBD and stenotic CHD with prestenotic dilatation of Left Hepatic Duct + intraheptatic duct pruning

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 14: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Crohnrsquos Imaging Options

ndash Colonoscopyndash Barium studies ndash CT (sens 94-100 spec 95) sens 70

early stage disease

Disadvantage Limited evaluation of extramural extension + extraintestinal complications

Colonoscopy showing Cobblestone Mucosa

Lee et all Endoscopy 2006

Barium study demonstrating a crohns induced bowel Fistula

Maconi et all Am J Gastroenterol 2003

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 15: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Crohns Findings on CTbull Small bowel terminal ileum left sided colitis rare rectal sparingbull Eccentric Wall thickening with contrast enhancement

ndash 11mm +- 51bull Homogenous or Stratifiedsegmental appearance (ldquoskiprdquo lesions)

ndash Psedodiverticulabull Luminal Narrowing with prestenotic dilatation (ldquostring signrdquo)bull Fibrofatty proliferation adjacent to small bowel segments

(ldquoCreeping fatrdquo) -gt separation of small bowel loopsbull Mesenteric Lymphadenopathy (3-8mm) ifgt1cm -gt consider

lymphomabull Water Halo and Target Signs =gt acute bowel injurybull Engorged Mesenteric Vessel (ldquocomb signrdquo) =gt acute bowel injurybull Abscess Fistulas

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 16: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Close-up Axial and Sagittal views of Patient 1rsquos abdomen

Bowel Wall Thickening (gt1cm) Comb Sign + Fibrofatty proliferation

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 17: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Close-up Axial view of patient 1rsquos Abdomen

Mesenteric Lymphadenopathy Note sizelt1cm

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 18: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Close-up Coronal View of Patient 1rsquos Abdomen Target Sign

Target Sign

1 Outer later for high attenuation inflamed muscularis propria

2 Middle layer intermediate (edema)low attenuation (fat)

3 Inner later inflamed muscosaPACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 19: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 1

bull Combination of Clinical and Radiological Findings point to diagnosis of Crohnrsquos Disease in our patient

bull Radiological Findings Distal Ileal Bowel wall thickening with Target sign Comb sign fibrofatty proliferation and Mesenteric Lymphadenopathy

bull Patient had subsequent follow-up with Gastroenterology and a c-scope with biopsies confirming the diagnosis of Crohns

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 20: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Patient 2 Scout and Axial images of Abdomen

57yo M with history of Ulcerative Colitis presents with 4 days of watery diarrhea afebrile normal WBC Previous allergic reaction to IV Iodine (thus no IV contrast given)

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 21: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Two Coronal Reformations in different planes for Patient 2

PACS BIDMC PACS BIDMC

Note Involvement of Hepatic Flexure Note Ahaustral thickened bowel

transverse colon

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 22: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Sagittal and Axial slices in Patient 2

PACS BIDMC PACS BIDMC

Ahaustal rectosigmoid colon =gt likely chronic UCTransverse Colon involvement

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 23: CT Colitis

Mahan Mathur

Gillian Lieberman MD

IBD Ulcerative Colitis

bull Etiology unknownbull Involvement Rectum -gt Large Bowel

ndash Beware of ldquobackwash Ilietisrdquobull Clinical Manifestations

ndash Abdo pain bloody diarrhea weight loss feverndash Increased risk of colon cancer (increased with duration

and extent of colonic involvement)ndash Toxic megacolon with muscle layer infiltrationndash Strictures Abscess

bull Extraintestinal Manifestations (see Crohnrsquos)

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 24: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Ulcerative Colitis Imaging Options

bull Imagingndash Flexible Sigmoidoscopyndash Colonoscopyndash Barium enema ndash rare use low sensitivity in mild

disease risk of bowel perforation in severe diseasendash CT

bull Rectal involvement + Left sidedpancolitis ndash occasional backwash ileitis

bull Symmetric wall thickening 78mm +- 19bull Proliferation of perirectal fatbull Target sign Comb Sign in large bowelbull Colon cancer Toxic Megacolon

Tests of choice

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 25: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3)

with UC

Ahaustral Transverse colon

Sigmoid Colon involvement in a different patient with known Ulcerative colitis and possible rectal stricture

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 26: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Axial Slices for patient 3

Stricture note the increase in bowel wall thickness along the horizontal plane versus the vertical plane

Rectal Wall Thickening

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 27: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Coronal and Sagittal Views of Patient 3

Target Sign + sparing of small bowel at rectosigmoid junction

Rectosigmoid involvement

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 28: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 2

bull Again Combination of Clinical and Radiological Findings point to the diagnosis of UC exacerbation in our patient

bull Radiological Findings Rectal wall thickness + exclusive large bowel involvement perirectal fatty proliferation target sign in rectosigmoid junction

bull Subsequent Colonoscopy confirmed the diagnosis in this patient

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 29: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Patient 4 Scout and Axial images of Abdomen

86 yo F with Fever Abdo Pain watery diarrhea x 2days

Multiple recent hospitalizations Last June 2006 for pneumonia

PACS BIDMCPACS BIDMC

Note the irregular looking Bowel wall appearance

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 30: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Sagittal and Coronal Reformation of Patient 4rsquos Abdomen

PACS BIDMC PACS BIDMC

Reformations indicate pancolitisSigmoid Wall thickness

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 31: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis

bull Etiology C Difficilendash Nosocomial sp antibiotics

bull Involvement Pancolitisisolated colitisbull Clinical Manifestations

ndash Asymptomatic carrier watery diarrhea abdo pain fever high WBC 5-10d sp Antibiotics (penicillin clindamycin cephalosporins)

ndash Toxic Megacolon colonic dilatationgt7cm

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 32: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis Imaging

bull Imagingndash SigmoidoscopyColonoscopy

bull Pseudomembrane plaquesndash CT

Often not necessary Clinical Diagnosis

Kawamoto et all Radiographics 1999 Kawamoto et all Radiographics 1999

Pathology specimen showcasing plaques (straight arrows) + erythema edema (curved arrow)

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 33: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Pseudomembranous Colitis CT Findings

ndash Bowel Wall thickening 3-32mm (mean 147mm)bull Irregular ldquoshaggyrdquo

ndash Target Signndash Accordion Sign alternating bands of high and low

attenuation (contrast trapped between thickened folds) non-specific (also found in other infectious colitis ischemic colitis)

ndash Ascites Important in differentiating from IBD (but again non-specific)

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 34: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Close up Axial and normal Axial images of abdomen in Patient 4

Accordion Sign

PACS BIDMC PACS BIDMC

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 35: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Follow-up + Summary for Patient 4

bull Clinical history particularly important in this case although as demonstrated by the radiographic findings P Colitis demonstrates an irregular (ldquoshaggyrdquo) wall appearance with an accordion sign +- ascites that allow for a reasonably distinct appearance

bull Stool for C Diff confirmed the diagnosis of P Colitis Antibiotic treatment was started for this patient

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 36: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Complication of P colitis + UC

bull Toxic Megacolon bowel wallgt 7cm

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 37: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Outline

1 Normal CT considerations of Bowel2 Disease Spectrum

bull IBD (Crohns Ulcerative Colitis)bull Infectious ( Pseudomembranous Colitis

typhlitis)bull Appendicitis bull Diverticulitisbull Vascular (ischemic)bull Epiploic Appendagitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 38: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Typhlitis

ndash Terminal ileum Cecal Asc colon involvement ndash Neutropenic patientsndash Fever waterybloody diarrheandash Unknown etiologyndash Txt conservative ndash resolution with return of functioning

neutrophilsAxial image of abdomen showing circumferential thickening of the cecal wall + pericecal inflammation

Horton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 39: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Appendicitis

ndash Luminal occlusion with venous congestion ischemia inflammation

ndash RLQ painndash CT thickened wall with

dilated appendix (gt6mm) + pericecal inflammation

ndash Txt Surgery (risk of perforation)

Axial Image of Abdomen showing inflamed appendix and periappendiceal fat strandingHorton et all Radiographics 2000

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 40: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Diverticulitis

ndash Outpouchings of colonic musocasubmucosa at site where vessels exit

ndash Etiology Obstruction by stoolfoodinflammation

ndash CT descendingsigmoid colon wall thickening with pericolic inflammation in patient with diverticulae

PACS BIDMC

Diverticulae

Axial Image of Abdomen demonstrating mild fat stranding and fascial thickening in 60 yo M with LLQ pain

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 41: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Ischemic Colitis

ndash Older populationndash Ischemia (MI Arrhythmia embolus)ndash Colonic mucosal changes due to restoration

of blood flow (free radical damage)ndash ldquoWatershedrdquo area distal transverse colon

(splenic flexure) + distal descending colon (rectosigmoid junction)

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 42: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Epiploic Appendagitis

ndash 1ndash4-cm oval fatty pericolic lesion with surrounding mesenteric inflammation

ndash Associated with torsionthrombosisndash Can be confused clinically with appendicitisndash Conservative management

Axial image of Abdomen showing peripheral enhancement of fatty epiploic appendage with surrounding mesenteric inflammation Note the sparing of the large bowel

Thoeni et all Radiology 2006

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 43: CT Colitis

Mahan Mathur

Gillian Lieberman MD

Summary clinical history is paramount

Thoeni et all Radiology 2006

bull Crohns Right sided distal ileum left sided (rare) with rectal sparing

bull UC Rectal involvement +- large bowel involvement occasional ileitis

bull P colitis pancolitis accordion sign ascites Hx of antibiotic use

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 44: CT Colitis

Mahan Mathur

Gillian Lieberman MD

References

1 Trost LB McDonnell JK Important cutaneous manifestations of inflammatory bowel disease Postgrad Med J 2005 Sep81(959)580-5 Review

2 Mintz R Feller ER Bahr RL Shah SA Ocular manifestations of inflammatory bowel disease Inflamm Bowel Dis 2004 Mar10(2)135-9 Review

3 Presti ME Neuschwander-Tetri BA Vogler CA Janney CG Roche JK Sclerosing cholangitis inflammatory bowel disease and glomerulonephritis a case report of a rare triad Dig Dis Sci 1997 Apr42(4)813-6 Review

4 Furukawa A Saotome T Yamasaki M Maeda K Nitta N Takahashi M Tsujikawa T Fujiyama Y Murata K Sakamoto T Cross-sectional imaging in Crohn disease Radiographics 2004 May-Jun24(3)689-702 Review

5 Lee YJ Yang SK Byeon JS Myung SJ Chang HS Hong SS Kim KJ Lee GH Jung HY Hong WS Kim JH Min YI Chang SJ Yu CS Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohns disease Endoscopy 2006 Jun38(6)592-7 Epub 2006 Apr 27

6 Maconi G Sampietro GM Parente F Pompili G Russo A Cristaldi M Arborio G Ardizzone S Matacena G Taschieri AM Bianchi Porro G Contrast radiology computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohns disease a prospective comparative study Am J Gastroenterol 2003 Jul98(7)1545-55

7 Kawamoto S Horton KM Fishman EK Pseudomembranous colitis spectrum of imaging findings with clinical and pathologic correlation Radiographics 1999 Jul-Aug19(4)887-97 Review

8 Thoeni RF Cello JP CT imaging of colitis Radiology 2006 Sep240(3)623-38 Review

9 Horton KM Corl FM Fishman EK CT evaluation of the colon inflammatory disease Radiographics 2000 Mar-Apr20(2)399-418

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45
Page 45: CT Colitis

Mahan Mathur

Gillian Lieberman MD

bull Acknowledgements

ndash Dr V Raptopoulosndash Dr J Kruskalndash Dr A Hochbergndash Dr K Manindash Dr G Liebermanndash George Lynskeyndash Pamela Lepkowskindash Larry Barbaras Chisasibi Northern Quebec

summer 2003

  • CT evaluation of inflammatory conditions of the colon
  • Outline
  • Outline
  • Normal CT considerations of Bowel
  • Normal CT considerations of Bowel
  • Outline
  • Patient 1 Scout and Axial Films
  • Patient 1 Coronal Reformation
  • Patient 1 Sagittal Reformations
  • Patient 1 Coronal Reformation
  • IBD Crohnrsquos
  • Crohnrsquos Extraintestinal Manifestations
  • ERCP showing Sclerosing Cholangitis
  • Crohnrsquos Imaging Options
  • Crohns Findings on CT
  • Close-up Axial and Sagittal views of Patient 1rsquos abdomen
  • Close-up Axial view of patient 1rsquos Abdomen
  • Close-up Coronal View of Patient 1rsquos Abdomen Target Sign
  • Follow-up + Summary for Patient 1
  • Patient 2 Scout and Axial images of Abdomen
  • Two Coronal Reformations in different planes for Patient 2
  • Sagittal and Axial slices in Patient 2
  • IBD Ulcerative Colitis
  • Ulcerative Colitis Imaging Options
  • Coronal Slice of Patient 2 and Axial Slice of another patient (patient 3) with UC
  • Axial Slices for patient 3
  • Coronal and Sagittal Views of Patient 3
  • Follow-up + Summary for Patient 2
  • Patient 4 Scout and Axial images of Abdomen
  • Sagittal and Coronal Reformation of Patient 4rsquos Abdomen
  • Pseudomembranous Colitis
  • Pseudomembranous Colitis Imaging
  • Pseudomembranous Colitis CT Findings
  • Close up Axial and normal Axial images of abdomen in Patient 4
  • Follow-up + Summary for Patient 4
  • Complication of P colitis + UC
  • Outline
  • Typhlitis
  • Appendicitis
  • Diverticulitis
  • Ischemic Colitis
  • Epiploic Appendagitis
  • Summary clinical history is paramount
  • References
  • Slide Number 45