Transcript Review of Inflammatory Bowel Disease
Review of Inflammatory Bowel Disease
Crohn Disease Ulcerative Colitis Pseudomembranous Colitis
Crohn’s Disease
Transmural inflammation involving any part of the GI tract, from mouth to anus. Terminal Ileitius – 80% Ileocolic – 50% Colitis – 20% *Differentiate from UC—Crohn’s patients tend to have rectal sparing Perianal Disease – 30% Oral and Esophagus – small percentage.
Incidence: Most common 15-40, second peak between 50-80 (bimodal distribution) Signs/Symptoms: Typical history of prolonged diarrhea with abdominal pain, wt loss and fever +/- gross bleeding.
Characteristics: skip lesions, apthous ulcers, cobblestone appearance (submucosal thickening interspersed with mucosal ulceration) Treatment: Corticosteroids, aminosalicylates, immune modulators, infliximab (anti-TNF), metronizadole.
Surgery should be avoided if possible since Crohn’s disease is not curable unlike UC.
Complications: Abscess, fistula, obstruction, cancer, perianal disease
Imaging Crohn’s Disease
Small bowel contrast study vs CT SBFT useful for characterizing length of involvement and areas of stricture Characteristic Findings Mucosal nodularity Narrowed lumen Ulceration String sign Abscesses or fistula String Sign Term often applied to the appearance of any marked narrowing of the lumen, but originated as descriptor of reversible narrowing in Crohn disease.
Narrowing caused by incomplete filling as result of irritability/spasms associated with ulceration.
String Sign Masselli G. The gastrointestinal string sign. Radiology. 2007 Feb;242(2):632-3.
Ulcerative Colitis
Inflammation confined to mucosal layer of colon that extends from rectum proximally in continuous fashion Autoimmune process Incidence: Ages 15-40 or 50-80 (bimodal distribution) Signs/Symptoms: Rectal bleeding, loose bloody stools, passage of mucus from rectum, abdominal pain Complications: perforation, stricture, megacolon, cancer Treatment: Medical: Mild/moderate disease—5-ASA, corticosteroids Severe disease—IV steroids or immunosuppressants for refractory disease Surgical: Proctocolectomy (curative) Indications: Failure of medical therapy, increasing risk of cancer with long standing disease, bleeding, perforation Prognosis: Approximately 1-2% risk of cancer at 10 years, 1%/year thereafter
Imaging Ulcerative Colitis
Barium Enema vs. CT Barium Enema is no longer the test of choice Findings Continuous lesions from rectum proximally with circumferential involvement Lead Pipe Sign Repeated episodes of mucosal ulceration and marked muscularis hypertrophy results in shortening, narrowing and smoothing out of the normal haustral markings. “Lead pipe” appearance of colon due to chronic scarring and retraction/loss of haustra
Weinstein A et al. A super ‘lead pipe’ colon: radio-pathological correlation of long-standing ulcerative colitis. SA Journal of Radiology;2008 Oct:70-72
Pseudomembranous Colitis
An acute colitis characterized by formation of an adherent inflammatory exudate (pseudomembrane) overlying the site of mucosal injury Most commonly due to overgrowth of C.difficile, a gram positive, anaerobic spore forming bacilus Typically occurs after broad-spectrum antibiotics (especially clindamycin, ampicillin, or cephalosporins) eradicate normal intestinal flora Signs/Symptoms Self-limited diarrhea to invasive colitis with megacolon or perforation as possible complications Diagnosis Detection of C.diff toxin in stool, proctoscopy or colonoscopy Treatment Stop offending antibiotic and give flagyl or vancomycin Prognosis High rate of recurrence (20%) despite high response rate to treatment
CT findings
Colonic wall thickening Target sign Thickened bowel wall demonstrates three layers that comprise a contrast enhanced inner and outer layer of high attenuation between which is a layer of decreased attenuation. Indicates hyperemia in the mucosa and the muscularis propria, serosa, or both with submucosal edema or inflammation Accordion sign Alternating edematous haustral folds separated by transverse mucosal ridges filled with oral contrast material, simulating the appearance of an accordion.
Colonic dilatation Pneumatosis coli or portal venous gas Ahualli J. The target sign: bowel wall.
colonic edema. Radiology. 2005 Feb; 234(2):549-550 Macari M et al. The accordion sign at CT: a nonspecific finding in patients with Radiology. 1999 June;211(3):743-746
QUIZ
Case #1 23 yo male with h/o loose stools and abd pain Diagnosis?
3. Which inflammatory bowel disease is this most commonly associated with?
Case #2
1. What is the finding?
2. What is the diagnosis?
Case #3
60 year old female presents with abdominal pain, diarrhea, and weight loss.
1. What is the diagnosis?
2. Name three complications of this disease.
Case #4
65 yo male treated with intravenous vancomycin for osteomyelitis of the foot presents with diarrhea and elevated WBC Diagnosis?
1. What are the findings?
2. What is the diagnosis?
Case #5
Case #6
49 yo female on adjuvant chemotherapy for breast cancer with abd distension and diarrhea 1. What is the most likely diagnosis?
2. What are two CT imaging findings that can be seen with this?
ANSWERS
Case #1 23 yo male with h/o loose stools and abd pain Diagnosis?
Ulcerative Colitis
3. Which inflammatory bowel disease is this most commonly associated with?
Ulcerative Colitis
Case #2
1. What is the finding?
Increased periportal echogenicity 2. What is the diagnosis?
Sclerosing Cholangitis
Sclerosing Cholangitis
Classic sonographic finding is thickening (increased echogenicity) of intra and extra-hepatic bile ducts 75% of pts with PSC have inflammatory bowel dz (usually UC)
Sclerosing Cholangitis
Disease is characterized by inflammation, destruction and fibrosis of bile ducts Increased incidence of bacterial cholangitis and cholangiocarcinoma Definitive treatment is orthotopic liver transplant Secondary causes of SC include drugs, prior surgery, multiple opportunistic infections
Case #3
60 year old female presents with abdominal pain, diarrhea, and weight loss.
1. What is the diagnosis?
Crohns Disease 2. Name three complications of this disease.
Abscess, fistula, obstruction
Case #4
65 yo male treated with intravenous vancomycin for osteomyelitis of the foot presents with diarrhea and elevated WBC Diagnosis?
Pseudomembranous Colitis
Case #5 1. What are the findings?
Narrowing of bowel lumen with cobblestoning 2. What is the diagnosis?
Crohns Disease
Case #6
49 yo female on adjuvant chemotherapy for breast cancer with abd distension and diarrhea 1. What is the most likely diagnosis?
Pseudomembranous Colitis 1. What are two CT imaging findings that can be seen with this?
Target sign Accordion sign