IMAGING OF COLITIS Ruedi...CrohnCrohn’s’s UCUC ULCERATIVE COLITIS VS. CROHN’S • Location Typ. right + TI Typ. left or diffuse • Wall of TI Thick Relatively thin • Terminal

IMAGING OF COLITIS

Ruedi F. Thoeni, M. D.University of California, San Francisco

IMAGING OF COLITISIMAGING OF COLITIS

Ruedi F. Thoeni, M. DRuedi F. Thoeni, M. D..University of California, San FranciscoUniversity of California, San Francisco

SCBT-MR Summer Practicum, Williamsburg, 2009SCBTSCBT--MRMR Summer Practicum, Williamsburg, 2009Summer Practicum, Williamsburg, 2009

OBJECTIVES: IMAGING OF COLITISOBJECTIVES: IMAGING OF COLITIS

• CT technique• Types of colitis• Imaging features of colitis

• Nonspecific• Specific

• Differential diagnosis & conclusion

•• CTCT techniquetechnique•• Types of colitisTypes of colitis•• Imaging features of colitis Imaging features of colitis

•• NonspecificNonspecific•• SpecificSpecific

•• Differential diagnosisDifferential diagnosis & conclusion& conclusion

DIAGNOSIS IN SUSPECTED COLITISDIAGNOSIS IN SUSPECTED COLITIS

• Clinical presentation• Laboratory tests• Detection by imaging• Clinical confirmation for specific

type without or with colonoscopy

•• Clinical presentationClinical presentation•• Laboratory testsLaboratory tests•• Detection by imagingDetection by imaging•• Clinical confirmation for specific Clinical confirmation for specific

type without or with colonoscopytype without or with colonoscopy

• Contrast Materials:– Oral contrast : 3 bottles of 450 ml of VoLumen

or 2.2% Gastrografin (3 x 10 mL/450 of water)– IV contrast: 3-4 cc/sec for 150 ml– Rectal contrast: water

• Important:– for suspected perforation use positive contrast

(40 cc of Conray 60% in 1000 mL normalsaline: use 500-1000 mL)

•• Contrast Materials:Contrast Materials:–– Oral contrast :Oral contrast : 33 bottles of 450 ml ofbottles of 450 ml of VoLumenVoLumen

or 2.2% Gastrografin (3 x 10 mL/450 of water)or 2.2% Gastrografin (3 x 10 mL/450 of water)–– IV contrast:IV contrast: 33--4 cc/sec for 150 ml4 cc/sec for 150 ml–– Rectal contrast: Rectal contrast: waterwater

•• Important:Important:–– for suspected perforation use positive contrastfor suspected perforation use positive contrast

(40 cc of(40 cc of Conray Conray 60% in 1000 mL normal60% in 1000 mL normalsaline: usesaline: use 500500--1000 mL)1000 mL)

ABD/PEL WITH MDCT FOR COLITISABD/PEL WITH MDCT FOR COLITIS

• 16 (64) - slice MDCT:Detector configuration: 16 (64) x 0.625 mm, axialreconstruction thickness and interval: 5 mm

• Scan delay:(enteric phase: 40 +) portal-venous 80 sec (smart prep),diaphragm to ischial tuberosity

• Important:• Coronal and sagittal MPRs: use 0.625 mm slices,

reconstruct at 3 mm and send to PACS• Delayed scans (5 min) optional: for possible perf.

•• 16 (64) 16 (64) -- slice MDCT:slice MDCT:Detector configuration: 16 (64) x 0.625 mm,Detector configuration: 16 (64) x 0.625 mm, axialaxialreconstruction thickness and interval: 5 mmreconstruction thickness and interval: 5 mm

•• Scan delay:Scan delay:(enteric phase: 40 +) portal(enteric phase: 40 +) portal--venous venous 80 sec80 sec (smart prep)(smart prep),,diaphragm to ischialdiaphragm to ischial tuberositytuberosity

•• Important:Important:•• Coronal and sagittal Coronal and sagittal MPRsMPRs:: use 0.625 mm slices,use 0.625 mm slices,

reconstruct at 3 mm and send to PACSreconstruct at 3 mm and send to PACS•• Delayed scans (5 min) optionalDelayed scans (5 min) optional: for possible : for possible perfperf..

ABD/PEL WITH MDCT FOR COLITISABD/PEL WITH MDCT FOR COLITIS

MDCT TECHNIQUEMDCT TECHNIQUE

TYPES OF COLITISTYPES OF COLITIS

• IBD: UC and Crohn’s• Infectious colitis• Ischemic colitis• Diverticulitis (DDX: EA)• Neutropenic colitis• Drug-related colitis

•• IBD: UC and CrohnIBD: UC and Crohn’’ss•• Infectious colitisInfectious colitis•• Ischemic colitisIschemic colitis•• Diverticulitis (DDX: EA)Diverticulitis (DDX: EA)•• Neutropenic colitisNeutropenic colitis•• DrugDrug--related colitis related colitis

FEATURESFEATURES OF COLITISOF COLITIS

Nonspecific signs:• Wall thickening• Target sign• Hyperemia (comb sign)• Pericolonic stranding• Ascites

Nonspecific signs:Nonspecific signs:•• Wall thickeningWall thickening•• Target signTarget sign•• Hyperemia (comb sign)Hyperemia (comb sign)•• Pericolonic strandingPericolonic stranding•• AscitesAscites

COLITISCOLITIS


Specific signs:• Distribution• Lymph nodes• Fistulae• Sinus tracts

Specific signs:Specific signs:•• DistributionDistribution•• Lymph nodesLymph nodes•• FistulaeFistulae•• Sinus tractsSinus tracts


Distribution:• Right, left or diffuse• Skip areas• Rectum spared• Focal only

Distribution:Distribution:•• Right, left or diffuseRight, left or diffuse•• Skip areasSkip areas•• Rectum sparedRectum spared•• Focal onlyFocal only

DISTRIBUTION: IBD & INFECTIOUS COLITISDISTRIBUTION: IBD & INFECTIOUS COLITIS

Diffuse in Colon Right Colon (+TI) Left ColonDiffuse in Colon Diffuse in Colon Right Colon (+TI) Left ColonRight Colon (+TI) Left Colon

Ulcerative ColitisUlcerative ColitisCMV (or right)CMV (or right)E. coliE. coliPMC (or left)PMC (or left)CampylobacterCampylobacterCrohnCrohn’’ss

Ulcerative ColitisUlcerative ColitisShigellosisShigellosisSchistosomiasisSchistosomiasisHerpesHerpesLymphogranulomaLymphogranuloma(Drug(Drug--induced col.)induced col.)

CrohnCrohn’’ssTBTBYersiniaYersiniaSalmonellosisSalmonellosisAmebiasisAmebiasis(Typhlitis)(Typhlitis)

Crohn’s UCCrohnCrohn’’ss UCUC

ULCERATIVE COLITIS VS. CROHNULCERATIVE COLITIS VS. CROHN’’SS

• Location Typ. right + TI Typ. left or diffuse• Wall of TI Thick Relatively thin• Terminal ileum String sign Backwash ileitis• Ileocecal valve Strictured Gaping• Distribution Skip areas Continuous• Appearance Asymmetrical Symmetrical• Fistulae Present Absent• Rectum Spared Involved • Wall of colon 11 +/- 5.1 mm 7.8 +/- 1.9 mm• Peri-intestinal Creeping fat, nodes Perirectal fat↑

•• LocationLocation Typ. right + TITyp. right + TI Typ. left or diffuseTyp. left or diffuse•• Wall of TIWall of TI ThickThick Relatively thinRelatively thin•• Terminal ileumTerminal ileum String signString sign Backwash ileitisBackwash ileitis•• Ileocecal valve Ileocecal valve StricturedStrictured GapingGaping•• DistributionDistribution Skip areasSkip areas ContinuousContinuous•• AppearanceAppearance AsymmetricalAsymmetrical SymmetricalSymmetrical•• FistulaeFistulae PresentPresent AbsentAbsent•• RectumRectum SparedSpared Involved Involved •• Wall of colon Wall of colon 11 +/11 +/-- 5.1 mm5.1 mm 7.8 +/7.8 +/-- 1.9 mm1.9 mm•• PeriPeri--intestinalintestinal Creeping fat, nodes Perirectal fatCreeping fat, nodes Perirectal fat↑↑

CROHNCROHN’’S DISEASE: SMALL BOWELS DISEASE: SMALL BOWEL

ULCERATIVE COLITISULCERATIVE COLITIS

TI with hyperenhancing wallTI with TI with hyperenhancinghyperenhancing wallwall

CROHNCROHN’’S DISEASE: FIBROFATTY PROLIF.S DISEASE: FIBROFATTY PROLIF.





Ulcerative ColitisUlcerative ColitisCMV (or right)CMV (or right)E. coliE. coliPMC (or left)PMC (or left)CampylobacterCampylobacterCrohnCrohn’’ss

CYTOMEGALOVIRUS COLITIS (CMV)CYTOMEGALOVIRUS COLITIS (CMV)

AIDS and other immunosuppressive conditionAIDS and other immunosuppressive conditionAIDS and other immunosuppressive condition

Ulcerative ColitisUlcerative ColitisCMVCMVE. coliE. coliPMC (or left)PMC (or left)CampylobacterCampylobacterCrohnCrohn’’ss





COLITIS WITH SMALL BOWEL (TI)COLITIS WITH SMALL BOWEL (TI)

• Crohn’s colitis• Tb colitis• Yersinia colitis• Salmonellosis• Typhlitis• CMV colitis• Campylobacteriosis

•• CrohnCrohn’’s colitiss colitis•• Tb colitisTb colitis•• Yersinia colitisYersinia colitis•• SalmonellosisSalmonellosis•• TyphlitisTyphlitis•• CMV colitisCMV colitis•• CampylobacteriosisCampylobacteriosis

TERMINAL ILEITISTERMINAL ILEITISTB COLITISTB COLITIS

Hx: previous exposure, abd. pain, weight lossHxHx: previous exposure, : previous exposure, abdabd. pain, weight loss. pain, weight loss

THICKENED RIGHT COLONTHICKENED RIGHT COLONPASSIVE CONGESTION IN CIRRHOSISPASSIVE CONGESTION IN CIRRHOSIS

Ulcerative ColitisUlcerative ColitisCMVCMVE. coliE. coliPMC (or left)PMC (or left)CampylobacterCampylobacterCrohnCrohn’’ss





DRUGDRUG--INDUCED COLITISINDUCED COLITIS

Drug hypersensitivity, antihypertensive drugs, NSAIDsDrug hypersensitivity, antihypertensive drugs, Drug hypersensitivity, antihypertensive drugs, NSAIDsNSAIDs

COLITIS WITH SKIP AREASCOLITIS WITH SKIP AREAS

• Crohn’s disease• Tuberculous (ileo)colitis• Pseudomembranous colitis• Amebiasis• Caustic colitis (spasms) • Shigellosis colitis (healing)

•• CrohnCrohn’’s diseases disease•• TuberculousTuberculous ((ileo)colitisileo)colitis•• Pseudomembranous colitisPseudomembranous colitis•• AmebiasisAmebiasis•• Caustic colitis (spasms) Caustic colitis (spasms) •• Shigellosis colitis (healing) Shigellosis colitis (healing)

COLITIS WITH RECTUM SPAREDCOLITIS WITH RECTUM SPARED

• Crohn’s disease (two age peaks)• Ischemic colitis (< 3% involved)• C. difficile colitis (PM), amebiasis • UC treated with steroid enemas

•• CrohnCrohn’’s disease (two age peaks)s disease (two age peaks)•• Ischemic colitis (Ischemic colitis (<< 3% involved)3% involved)•• C. difficile colitis (PM), amebiasis C. difficile colitis (PM), amebiasis •• UC treated with steroid enemasUC treated with steroid enemas

INVOLVEMENT OF RECTUMINVOLVEMENT OF RECTUM

Crohn’s: TI + nl. rectumCrohnCrohn’’s: TI + s: TI + nlnl. rectum. rectum UC: thickened rectumUC: thickened rectumUC: thickened rectum

ISCHEMIC COLITIS: ASSOCIATED FINDINGSISCHEMIC COLITIS: ASSOCIATED FINDINGS

• Infarcts in liver, spleen, kidneys• Occlusion of SMA or branches• Thrombosis of mesenteric vessels • Air in mesenteric vessels, hepatic

portal veins

•• Infarcts in liver, spleen, kidneysInfarcts in liver, spleen, kidneys•• Occlusion of SMA or branchesOcclusion of SMA or branches•• Thrombosis of mesenteric vessels Thrombosis of mesenteric vessels •• Air in mesenteric vessels, hepatic Air in mesenteric vessels, hepatic

portal veinsportal veins

FOCAL COLITISFOCAL COLITIS

• Crohn’s Colitis• Typhlitis (neutropenic colitis)• Diverticulitis (DDx: ca)• Anisakiasis• DDx: Epiploic Appendagitis

(incidence: 8.8/million/year)

•• CrohnCrohn’’s Colitiss Colitis•• Typhlitis (neutropenic colitis)Typhlitis (neutropenic colitis)•• Diverticulitis (DDx: ca)Diverticulitis (DDx: ca)•• AnisakiasisAnisakiasis•• DDx: DDx: Epiploic AppendagitisEpiploic Appendagitis

(incidence: 8.8/million/year)(incidence: 8.8/million/year)

DIVERTICULITISDIVERTICULITIS

LLQ or RLQ pain, fever, leukocytosis, diarrheaLLQ or RLQ pain, fever, LLQ or RLQ pain, fever, leukocytosisleukocytosis, diarrhea, diarrhea

EPIPLOIC APPENDAGITISEPIPLOIC APPENDAGITIS

LLQ or RLQ pain, no leukocytosis, no guardingLLQ or RLQ pain, no LLQ or RLQ pain, no leukocytosisleukocytosis, no guarding, no guarding

COLITIS WITH ADENOPATHYCOLITIS WITH ADENOPATHY

• Crohn’s disease• Tuberculosis• Histoplasmosis• Yersinia colitis• Exclude:

- HIV- Tumor

•• CrohnCrohn’’s diseases disease•• TuberculosisTuberculosis•• HistoplasmosisHistoplasmosis•• Yersinia colitisYersinia colitis•• Exclude:Exclude:

-- HIVHIV-- TumorTumor

COLITIS WITH FISTULAE/SINUS TRACTSCOLITIS WITH FISTULAE/SINUS TRACTS

• Crohn’s disease (right)• Tuberculosis• Diverticulitis (left)• Actinomycosis• Histoplasmosis• Strongyloidiasis• UC (anal sinus tracts)

•• CrohnCrohn’’s disease (right)s disease (right)•• TuberculosisTuberculosis•• Diverticulitis (Diverticulitis (leftleft))•• ActinomycosisActinomycosis•• HistoplasmosisHistoplasmosis•• StrongyloidiasisStrongyloidiasis•• UC (anal sinus tracts)UC (anal sinus tracts)

TUBERCULOUS COLITISTUBERCULOUS COLITIS

COLONOSCOPY FOR COLONIC COLONOSCOPY FOR COLONIC THICKENING ON CT (THICKENING ON CT (N = 107)N = 107)

• 8 (7.4%) with new Dx of colonic carcinoma• 10 (9.3%) had a new Dx of IBD• 16 (15%) had infectious colitis• 39 (36.4%) had ischemic colitis • 6 (5.6%) had miscellaneous (diverticulitis,

proctitis, appendicitis)• 28 (26.1%) no abnormality found

•• 8 (7.4%) with new 8 (7.4%) with new DxDx of colonic carcinomaof colonic carcinoma•• 10 (9.3%) had a new 10 (9.3%) had a new DxDx of IBDof IBD•• 16 (15%) had infectious colitis16 (15%) had infectious colitis•• 39 (36.4%) had ischemic colitis 39 (36.4%) had ischemic colitis •• 6 (5.6%) had miscellaneous (diverticulitis,6 (5.6%) had miscellaneous (diverticulitis,

proctitis, appendicitis)proctitis, appendicitis)•• 28 (26.1%) no abnormality found28 (26.1%) no abnormality found

Wolff JH, Rubin A, Potter JD, Wolff JH, Rubin A, Potter JD, LattimoreLattimore W, W, ResnickResnick MB, Murphy BL, Moss SF. Clinical significance of MB, Murphy BL, Moss SF. Clinical significance of colonoscopiccolonoscopic findings findings associated with colonic thickening on computed tomography: is coassociated with colonic thickening on computed tomography: is colonoscopy warranted when thickening is detected? J lonoscopy warranted when thickening is detected? J ClinClinGastroenterolGastroenterol 2008; 42: 4722008; 42: 472--475.475.

TAKE HOME MESSAGETAKE HOME MESSAGE

• Wall thickening nonspecific• Ascites favors infectious or ischemic colitis• UC + most infectious colitis:

continuous, rectum involved• Crohn’s: skip (Tb, PMC, Ameb, Shig.),

asymmetry, rectum often spared• Fistulae: • Crohn’s • Tb colitis

• Actinomycosis • Strongyloidiasis• Ischemia: vascular pattern + rectum spared

•• Wall thickening nonspecificWall thickening nonspecific•• Ascites favors infectious or ischemic colitisAscites favors infectious or ischemic colitis•• UC + most infectious colitis:UC + most infectious colitis:

continuous,continuous, rectum involvedrectum involved•• CrohnCrohn’’s: s: skip skip (Tb, PMC, (Tb, PMC, AmebAmeb, , ShigShig.), .),

asymmetry, asymmetry, rectum often sparedrectum often spared•• Fistulae: Fistulae: •• CrohnCrohn’’ss •• Tb colitisTb colitis

•• ActinomycosisActinomycosis •• StrongyloidiasisStrongyloidiasis•• Ischemia: Ischemia: vascular pattern vascular pattern + rectum spared+ rectum spared

Documents

IMAGING OF COLITIS Ruedi...CrohnCrohn’s’s UCUC ULCERATIVE COLITIS VS. CROHN’S • Location Typ. right + TI Typ. left or diffuse • Wall of TI Thick Relatively thin • Terminal