Upload
vankhuong
View
232
Download
0
Embed Size (px)
Citation preview
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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