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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Crohns Disease: Radiologic Crohns Disease: Radiologic FindingsFindings

Elissa Altin, Harvard Medical School Year IIIElissa Altin, Harvard Medical School Year IIIGillian Lieberman, MDGillian Lieberman, MD

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Our PatientOur Patient21 year21 year--old man with 7old man with 7--year history of Crohns year history of Crohns and medical nonand medical non--compliance presents with compliance presents with obstructive symptomsobstructive symptoms

History: bilious vomiting of undigested food, History: bilious vomiting of undigested food, abdominal pain, loose stoolsabdominal pain, loose stoolsPhysical Exam: orthostatic, Tmax to 101.7, abdomen Physical Exam: orthostatic, Tmax to 101.7, abdomen was soft, nonwas soft, non--distended with mild discomfort in the distended with mild discomfort in the epigastric region without peritoneal signs. epigastric region without peritoneal signs. Laboratory: WBC 11.3, Hct 39.1. PT and PTT were Laboratory: WBC 11.3, Hct 39.1. PT and PTT were 11.2 and 26.3. Electrolytes within normal limits. 11.2 and 26.3. Electrolytes within normal limits.

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Crohns Disease in OverviewCrohns Disease in OverviewDEFINITION:DEFINITION: disorder of transmural disorder of transmural discontinuous inflammation of any segment discontinuous inflammation of any segment of the GI tract from pharynx to perianal of the GI tract from pharynx to perianal areaareaETIOLOGY:ETIOLOGY: largely unknown but believed largely unknown but believed to be caused by destruction of immunologic to be caused by destruction of immunologic homeostasis of the GI tract secondary to homeostasis of the GI tract secondary to overover--expression of proexpression of pro--inflammatory inflammatory cytokines, undercytokines, under--expression of regulatory expression of regulatory cytokines, or bothcytokines, or both

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Crohns Disease in OverviewCrohns Disease in Overview

GENETICS:GENETICS: polygenic, but 10 times polygenic, but 10 times increased risk of having Crohns if a increased risk of having Crohns if a first degree relative suffers from itfirst degree relative suffers from it11

EPIDEMIOLOGY:EPIDEMIOLOGY: bimodal bimodal distribution with peak at 2distribution with peak at 2ndnd--44thth decade decade of life and again after 6of life and again after 6thth decade; decade; affects whites more, especially affects whites more, especially Ashkenazi Jews living in Europe and Ashkenazi Jews living in Europe and North AmericaNorth America

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Clinical Features of CrohnsClinical Features of CrohnsInflammatory SymptomsInflammatory Symptoms

RLQ pain, fever, diarrhea +/RLQ pain, fever, diarrhea +/-- blood, weight loss, blood, weight loss, palpable abdominal mass on physical exampalpable abdominal mass on physical exam

Obstructive SymptomsObstructive SymptomsPostPost--prandial abdominal pain, distension, nausea, prandial abdominal pain, distension, nausea, vomitingvomiting

Fistulous DiseaseFistulous DiseaseEnterovaginal, enterocutaneous, enteroentero, Enterovaginal, enterocutaneous, enteroentero, enterovesicular fistulae can form as a result of enterovesicular fistulae can form as a result of transmural inflammation with elaboration of sinus transmural inflammation with elaboration of sinus tracts that penetrate the mucosatracts that penetrate the mucosa

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Clinical Features of CrohnsClinical Features of Crohns

Perianal DiseasePerianal DiseaseAnal fissures, perianal abscess formation, Anal fissures, perianal abscess formation, anorectal fistula, pain and drainage from skin anorectal fistula, pain and drainage from skin tagstags

Extraintestinal ManifestationsExtraintestinal ManifestationsSeronegative arthritis (asymmetric, usually Seronegative arthritis (asymmetric, usually large joints), sacroiliitis, ankylosing large joints), sacroiliitis, ankylosing spondylitis, spondylitis, E. nodosumE. nodosum//Pyoderma Pyoderma gangrenosumgangrenosum, ocular manifestations , ocular manifestations (episcleritis, uveitis), hepatic complications (episcleritis, uveitis), hepatic complications (elevation of serum transaminases, primary (elevation of serum transaminases, primary sclerosing cholangitis)sclerosing cholangitis)

Image from Horton et al.Image from Horton et al. 77

Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Normal AnatomyNormal Anatomy

Image from Horton et al.Image from Horton et al. 88

Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Diagnosis of CrohnsDiagnosis of CrohnsClinical PresentationClinical PresentationEndoscopic featuresEndoscopic features

Apthous ulcers, edema, Apthous ulcers, edema, erythema, exudate, friable erythema, exudate, friable mucosa with intercalated mucosa with intercalated normal mucosa called normal mucosa called ““skip skip lesionslesions””, linear ulcers with , linear ulcers with segments of uninvolved segments of uninvolved mucosa called mucosa called ““cobblestoningcobblestoning””

Histologic FeaturesHistologic FeaturesRadiologic Features: letRadiologic Features: let’’s s seesee……

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Radiographic options for Radiographic options for diagnosing Crohnsdiagnosing Crohns

Conventional XConventional X--rayrayWithout barium: good for obstruction to show dilated loops Without barium: good for obstruction to show dilated loops of bowel and stricturesof bowel and stricturesWith barium: not in the setting of obstruction, can show With barium: not in the setting of obstruction, can show details of the mucosa, including filling defects, ulcerations, details of the mucosa, including filling defects, ulcerations, and stricturesand strictures

CT ScanCT ScanCan show crossCan show cross--sections sections details of the bowel wall, details of the bowel wall, including edema, engorged ileal vasa recta, fistulous tract including edema, engorged ileal vasa recta, fistulous tract formation, abscess, stricture, dilation, formation, abscess, stricture, dilation, mural stratification, and mucosal and mural hyperenhancement

Courtesy of Kevin KnoblockCourtesy of Kevin Knoblock

Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Our Patient: A Natural History of Our Patient: A Natural History of Crohns on RadiographsCrohns on Radiographs

Barium swallow to rule out Barium swallow to rule out obstructing lesionobstructing lesion

No evidence of obstructing No evidence of obstructing lesions, but narrowed and lesions, but narrowed and diseased distal ileal loop diseased distal ileal loop ((““string signstring sign””) in pelvis ) in pelvis separate from other loops separate from other loops consistent with wall consistent with wall thickening without evidence thickening without evidence of proximal dilation to suggest of proximal dilation to suggest obstructionobstructionApthous ulceration: barium Apthous ulceration: barium collects in superficial collects in superficial ulceration, surrounded by ulceration, surrounded by edematous mucosa, herald edematous mucosa, herald future, larger ulcerationfuture, larger ulceration

String sign

Courtesy of Kevin KnoblockCourtesy of Kevin Knoblock 1111

Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

More findings from our patient: More findings from our patient: cobblestoning and ulcerationcobblestoning and ulceration

•Characteristic cobblestoning pattern formed by dispersal of barium between inflamed, edematous mucosa (thick arrow)

•Ulceration: barium collects in ulceration surrounded by thickened mucosa (thin arrow)

ulceration

cobblestoning

Courtesy of Kevin KnoblockCourtesy of Kevin Knoblock

Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

More findings from our patient: More findings from our patient: nodular filling defectsnodular filling defects

Nodular filling Nodular filling defects in folds of defects in folds of ileal mucosa are ileal mucosa are characteristic of characteristic of CrohnsCrohns

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Differential Diagnosis of Crohns ColitisDifferential Diagnosis of Crohns Colitis

Lactose intoleranceLactose intoleranceIBSIBSRadiation colitisRadiation colitisC. diffC. diff pseudomembranous colitispseudomembranous colitisIschemic colitisIschemic colitisAppendicitis, diverticulitis, perforating or Appendicitis, diverticulitis, perforating or obstructing carcinomaobstructing carcinomaInfection: Infection: ShigellaShigella, , SalmonellaSalmonella, , CampylobacterCampylobacter, , E. coliE. coli, , YersiniaYersinia (causes nearly identical small (causes nearly identical small bowel colitis to Crohns)bowel colitis to Crohns)Ulcerative ColitisUlcerative Colitis

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Crohns versus ulcerative colitisCrohns versus ulcerative colitisCharacteristics of Crohns not usually Characteristics of Crohns not usually found in UCfound in UC

Small bowel involvementSmall bowel involvementRectal sparingRectal sparingAbsence of gross bleedingAbsence of gross bleedingPerianal diseasePerianal diseaseDiscontinuous areas of diseaseDiscontinuous areas of disease

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Crohns versus ulcerative colitisCrohns versus ulcerative colitis

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

Courtesy of Kevin KnoblockCourtesy of Kevin Knoblock

Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Our patient: A few years laterOur patient: A few years later……Presents with fevers Presents with fevers to 103, abdominal to 103, abdominal pain pain –– barium studybarium study

Distal jejunum shows at Distal jejunum shows at least 5 segments of least 5 segments of narrowing with interspersed narrowing with interspersed dilationdilationMore distally, there is More distally, there is sacculationsacculation of the terminal of the terminal ileum in between areas of ileum in between areas of luminal narrowingluminal narrowingSegmental areas of Segmental areas of disease with intervening disease with intervening normal bowelnormal bowel

sausage sign

sacculation

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Our patient: After surgeryOur patient: After surgery

Status post Status post segmental resection segmental resection of jejunum, of jejunum, stricturoplastystricturoplasty of of ileum, and ileum, and ileoascendingileoascendingcolostomycolostomyNo evidence of No evidence of obstruction or obstruction or recurrencerecurrence

Image from PACS, BIDMCImage from PACS, BIDMC 1818

Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Our patient: Obstructed AgainOur patient: Obstructed Again……

Partial obstruction seen Partial obstruction seen two ways, with distended two ways, with distended small bowel loops on small bowel loops on KUB and dilated loops of KUB and dilated loops of fluid filled small bowel on fluid filled small bowel on CTCT

Image from Rollandi et al.Image from Rollandi et al. 1919

Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Other radiologic signs in a comparison Other radiologic signs in a comparison patient: fistulae and abscesspatient: fistulae and abscess

Fistulous tract connecting Fistulous tract connecting bowel wall to surrounding bowel wall to surrounding abscess abscess Seen above without Seen above without contrast and below with contrast and below with contrast showing contrast showing enhancing abscess wallenhancing abscess wall

Presence of contrast in Presence of contrast in abscess confirms abscess confirms communication between communication between abscess and bowel wall via abscess and bowel wall via fistulafistula

fistula

abscess

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Medical Management of Medical Management of CrohnsCrohns

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

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

ImmunomodulatoryImmunomodulatory TreatmentTreatmentActive IleitisActive Ileitis

55--ASA (ASA (PentasaPentasa, , AsacolAsacol), ABX (ciprofloxacin, ), ABX (ciprofloxacin, clarithromycinclarithromycin), ), steroidssteroids

MaintenanceMaintenance55--ASAASA

Refractory DiseaseRefractory DiseaseAzathioprineAzathioprine and 6and 6--mercaptopurinemercaptopurine

Both Both purinepurine mimic mimic antimetabolitesantimetabolitesCan help to induce remission in steroid resistant patients as Can help to induce remission in steroid resistant patients as well as for remission maintenancewell as for remission maintenance

MethotrexateMethotrexateStructural analog of Structural analog of folatefolate and competitive inhibitor of and competitive inhibitor of dihydrofolatedihydrofolate bindingbinding

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

Review of Radiologic FindingsReview of Radiologic Findings

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

ReferencesReferencesBrzezinkskiBrzezinkski, Aaron. , Aaron. ““Inflammatory Bowel Disease.Inflammatory Bowel Disease.”” Cecil Essential of Cecil Essential of MedicineMedicine. Ed. Thomas . Ed. Thomas AndreoliAndreoli. . Philadelphia: Saunders, 2001. 345Philadelphia: Saunders, 2001. 345--50.50.Horton, K Horton, K et alet al. . ““CT Evaluation of the Colon: Inflammatory Disease.CT Evaluation of the Colon: Inflammatory Disease.””RadiographicsRadiographics: 2000 Mar: 2000 Mar--Apr;20(2):399Apr;20(2):399--418. 418. OrholmOrholm, M , M et al. et al. ““Familial occurrence of inflammatory bowel disease.Familial occurrence of inflammatory bowel disease.””NEJM: 1991 Jan 10;324(2):84NEJM: 1991 Jan 10;324(2):84--8. 8. RollandiRollandi, G , G et alet al. . ““Spiral CT of the abdomen after distention of small bowel Spiral CT of the abdomen after distention of small bowel loops with transparent enema in patients with loops with transparent enema in patients with Crohn'sCrohn's disease.disease.”” Abdominal Abdominal ImagingImaging: 1999; 24:544: 1999; 24:544––549.549.WoldWold, P , P et alet al. . ““Assessment of Small Bowel Crohn Disease: Noninvasive Peroral CT Enterography Compared with Other Imaging Methods and Endoscopy—Feasibility Study.” Radiology: 2003; 229:275–281.Uptodate.comUptodate.comPACS, BIDMCPACS, BIDMC

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Elissa Altin, HMSIIIGillian Lieberman, MD

May 2005

AcknowledgementsAcknowledgementsKevin Kevin KnoblockKnoblockPamela Pamela LepkowskiLepkowskiLarry BarbarasLarry BarbarasGillian Lieberman, MDGillian Lieberman, MD