imaging in inflammatory bowel disease
TRANSCRIPT
IMAGING IN INFLAMMATORY BOWEL DISEASE
Dr Ishfaq A Shad
PROTOCOL
INTRODUCTION
CLASSIFICATION
DEFINATIONS
ETIOPATHOLOGY
CLINICAL FEATURES
IMAGING MODALITIES
COMPLICATIONS
DIFFERENCES BETWEEN UC amp CD
DIFFERENTIAL DIAGNOSIS
CONCLUSION
INTRODUCTION
Inflammatory bowel disease (IBD) is a broad term
that describes conditions with chronic or recurring
immune response and inflammation of the GIT
These are chronic relapsing disorders that cause
inflammation within the gut which damages the gut
lining
CLASSIFICATION
Typical IBD (2 Major Types)
Ulcerative Colitis (Colitis Ulcerosa)
Crohnrsquos Disease (Regional Enteritis)
Atypical IBD
Lymphocytic Colitis
Collagenous Colitis
Ischaemic Colitis
Diversion Colitis
Indeterminate Colitis
Bachetrsquos Disease
ULCERATIVE COLITIS (UC)
Ulcerative colitis (UC)
the inflammatory response and mucosal damage are
localized in the colon and almost always involve the
rectum
The inflammation typically only occurs within the
mucosal layer of the colon wall but generally affects the
entire length of the colon
CROHNrsquoS DISEASE (CD)
Crohnrsquos disease (CD)
although it most commonly affects the bowel Crohnrsquos
disease can involve any part of the gastrointestinal tract
from the mouth to the anus
Diseased segments called ldquoskip areasrdquo are typically
separated by stretches of normal bowel
Tissue damage often extends past the mucosal layer
right through to the serosa
As the tissue heals it may produce an abnormal tunnel-
like connection known as a fistula which connects the
intestine to another organ or tissue
ANATOMY
AFFECTED AREAS
SUB TYPES OF CD amp UC
ETIOPATHOGENESIS
ETIOPATHOGENESIS
Environmental factors such as a lack of childhood exposure to germs diet or specific gastrointestinal infections may trigger the onset and reactivation of disease leads to damage of the mucosal barrier
Bacteria that are normally well tolerated stick to and invade the lining of the gut for example particular strains of Ecoli
Defective immune responses fail to clear invading bacteria which seems to activate other immune cells fuelling further inflammation
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
PROTOCOL
INTRODUCTION
CLASSIFICATION
DEFINATIONS
ETIOPATHOLOGY
CLINICAL FEATURES
IMAGING MODALITIES
COMPLICATIONS
DIFFERENCES BETWEEN UC amp CD
DIFFERENTIAL DIAGNOSIS
CONCLUSION
INTRODUCTION
Inflammatory bowel disease (IBD) is a broad term
that describes conditions with chronic or recurring
immune response and inflammation of the GIT
These are chronic relapsing disorders that cause
inflammation within the gut which damages the gut
lining
CLASSIFICATION
Typical IBD (2 Major Types)
Ulcerative Colitis (Colitis Ulcerosa)
Crohnrsquos Disease (Regional Enteritis)
Atypical IBD
Lymphocytic Colitis
Collagenous Colitis
Ischaemic Colitis
Diversion Colitis
Indeterminate Colitis
Bachetrsquos Disease
ULCERATIVE COLITIS (UC)
Ulcerative colitis (UC)
the inflammatory response and mucosal damage are
localized in the colon and almost always involve the
rectum
The inflammation typically only occurs within the
mucosal layer of the colon wall but generally affects the
entire length of the colon
CROHNrsquoS DISEASE (CD)
Crohnrsquos disease (CD)
although it most commonly affects the bowel Crohnrsquos
disease can involve any part of the gastrointestinal tract
from the mouth to the anus
Diseased segments called ldquoskip areasrdquo are typically
separated by stretches of normal bowel
Tissue damage often extends past the mucosal layer
right through to the serosa
As the tissue heals it may produce an abnormal tunnel-
like connection known as a fistula which connects the
intestine to another organ or tissue
ANATOMY
AFFECTED AREAS
SUB TYPES OF CD amp UC
ETIOPATHOGENESIS
ETIOPATHOGENESIS
Environmental factors such as a lack of childhood exposure to germs diet or specific gastrointestinal infections may trigger the onset and reactivation of disease leads to damage of the mucosal barrier
Bacteria that are normally well tolerated stick to and invade the lining of the gut for example particular strains of Ecoli
Defective immune responses fail to clear invading bacteria which seems to activate other immune cells fuelling further inflammation
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
INTRODUCTION
Inflammatory bowel disease (IBD) is a broad term
that describes conditions with chronic or recurring
immune response and inflammation of the GIT
These are chronic relapsing disorders that cause
inflammation within the gut which damages the gut
lining
CLASSIFICATION
Typical IBD (2 Major Types)
Ulcerative Colitis (Colitis Ulcerosa)
Crohnrsquos Disease (Regional Enteritis)
Atypical IBD
Lymphocytic Colitis
Collagenous Colitis
Ischaemic Colitis
Diversion Colitis
Indeterminate Colitis
Bachetrsquos Disease
ULCERATIVE COLITIS (UC)
Ulcerative colitis (UC)
the inflammatory response and mucosal damage are
localized in the colon and almost always involve the
rectum
The inflammation typically only occurs within the
mucosal layer of the colon wall but generally affects the
entire length of the colon
CROHNrsquoS DISEASE (CD)
Crohnrsquos disease (CD)
although it most commonly affects the bowel Crohnrsquos
disease can involve any part of the gastrointestinal tract
from the mouth to the anus
Diseased segments called ldquoskip areasrdquo are typically
separated by stretches of normal bowel
Tissue damage often extends past the mucosal layer
right through to the serosa
As the tissue heals it may produce an abnormal tunnel-
like connection known as a fistula which connects the
intestine to another organ or tissue
ANATOMY
AFFECTED AREAS
SUB TYPES OF CD amp UC
ETIOPATHOGENESIS
ETIOPATHOGENESIS
Environmental factors such as a lack of childhood exposure to germs diet or specific gastrointestinal infections may trigger the onset and reactivation of disease leads to damage of the mucosal barrier
Bacteria that are normally well tolerated stick to and invade the lining of the gut for example particular strains of Ecoli
Defective immune responses fail to clear invading bacteria which seems to activate other immune cells fuelling further inflammation
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
Inflammatory bowel disease (IBD) is a broad term
that describes conditions with chronic or recurring
immune response and inflammation of the GIT
These are chronic relapsing disorders that cause
inflammation within the gut which damages the gut
lining
CLASSIFICATION
Typical IBD (2 Major Types)
Ulcerative Colitis (Colitis Ulcerosa)
Crohnrsquos Disease (Regional Enteritis)
Atypical IBD
Lymphocytic Colitis
Collagenous Colitis
Ischaemic Colitis
Diversion Colitis
Indeterminate Colitis
Bachetrsquos Disease
ULCERATIVE COLITIS (UC)
Ulcerative colitis (UC)
the inflammatory response and mucosal damage are
localized in the colon and almost always involve the
rectum
The inflammation typically only occurs within the
mucosal layer of the colon wall but generally affects the
entire length of the colon
CROHNrsquoS DISEASE (CD)
Crohnrsquos disease (CD)
although it most commonly affects the bowel Crohnrsquos
disease can involve any part of the gastrointestinal tract
from the mouth to the anus
Diseased segments called ldquoskip areasrdquo are typically
separated by stretches of normal bowel
Tissue damage often extends past the mucosal layer
right through to the serosa
As the tissue heals it may produce an abnormal tunnel-
like connection known as a fistula which connects the
intestine to another organ or tissue
ANATOMY
AFFECTED AREAS
SUB TYPES OF CD amp UC
ETIOPATHOGENESIS
ETIOPATHOGENESIS
Environmental factors such as a lack of childhood exposure to germs diet or specific gastrointestinal infections may trigger the onset and reactivation of disease leads to damage of the mucosal barrier
Bacteria that are normally well tolerated stick to and invade the lining of the gut for example particular strains of Ecoli
Defective immune responses fail to clear invading bacteria which seems to activate other immune cells fuelling further inflammation
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CLASSIFICATION
Typical IBD (2 Major Types)
Ulcerative Colitis (Colitis Ulcerosa)
Crohnrsquos Disease (Regional Enteritis)
Atypical IBD
Lymphocytic Colitis
Collagenous Colitis
Ischaemic Colitis
Diversion Colitis
Indeterminate Colitis
Bachetrsquos Disease
ULCERATIVE COLITIS (UC)
Ulcerative colitis (UC)
the inflammatory response and mucosal damage are
localized in the colon and almost always involve the
rectum
The inflammation typically only occurs within the
mucosal layer of the colon wall but generally affects the
entire length of the colon
CROHNrsquoS DISEASE (CD)
Crohnrsquos disease (CD)
although it most commonly affects the bowel Crohnrsquos
disease can involve any part of the gastrointestinal tract
from the mouth to the anus
Diseased segments called ldquoskip areasrdquo are typically
separated by stretches of normal bowel
Tissue damage often extends past the mucosal layer
right through to the serosa
As the tissue heals it may produce an abnormal tunnel-
like connection known as a fistula which connects the
intestine to another organ or tissue
ANATOMY
AFFECTED AREAS
SUB TYPES OF CD amp UC
ETIOPATHOGENESIS
ETIOPATHOGENESIS
Environmental factors such as a lack of childhood exposure to germs diet or specific gastrointestinal infections may trigger the onset and reactivation of disease leads to damage of the mucosal barrier
Bacteria that are normally well tolerated stick to and invade the lining of the gut for example particular strains of Ecoli
Defective immune responses fail to clear invading bacteria which seems to activate other immune cells fuelling further inflammation
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
Typical IBD (2 Major Types)
Ulcerative Colitis (Colitis Ulcerosa)
Crohnrsquos Disease (Regional Enteritis)
Atypical IBD
Lymphocytic Colitis
Collagenous Colitis
Ischaemic Colitis
Diversion Colitis
Indeterminate Colitis
Bachetrsquos Disease
ULCERATIVE COLITIS (UC)
Ulcerative colitis (UC)
the inflammatory response and mucosal damage are
localized in the colon and almost always involve the
rectum
The inflammation typically only occurs within the
mucosal layer of the colon wall but generally affects the
entire length of the colon
CROHNrsquoS DISEASE (CD)
Crohnrsquos disease (CD)
although it most commonly affects the bowel Crohnrsquos
disease can involve any part of the gastrointestinal tract
from the mouth to the anus
Diseased segments called ldquoskip areasrdquo are typically
separated by stretches of normal bowel
Tissue damage often extends past the mucosal layer
right through to the serosa
As the tissue heals it may produce an abnormal tunnel-
like connection known as a fistula which connects the
intestine to another organ or tissue
ANATOMY
AFFECTED AREAS
SUB TYPES OF CD amp UC
ETIOPATHOGENESIS
ETIOPATHOGENESIS
Environmental factors such as a lack of childhood exposure to germs diet or specific gastrointestinal infections may trigger the onset and reactivation of disease leads to damage of the mucosal barrier
Bacteria that are normally well tolerated stick to and invade the lining of the gut for example particular strains of Ecoli
Defective immune responses fail to clear invading bacteria which seems to activate other immune cells fuelling further inflammation
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ULCERATIVE COLITIS (UC)
Ulcerative colitis (UC)
the inflammatory response and mucosal damage are
localized in the colon and almost always involve the
rectum
The inflammation typically only occurs within the
mucosal layer of the colon wall but generally affects the
entire length of the colon
CROHNrsquoS DISEASE (CD)
Crohnrsquos disease (CD)
although it most commonly affects the bowel Crohnrsquos
disease can involve any part of the gastrointestinal tract
from the mouth to the anus
Diseased segments called ldquoskip areasrdquo are typically
separated by stretches of normal bowel
Tissue damage often extends past the mucosal layer
right through to the serosa
As the tissue heals it may produce an abnormal tunnel-
like connection known as a fistula which connects the
intestine to another organ or tissue
ANATOMY
AFFECTED AREAS
SUB TYPES OF CD amp UC
ETIOPATHOGENESIS
ETIOPATHOGENESIS
Environmental factors such as a lack of childhood exposure to germs diet or specific gastrointestinal infections may trigger the onset and reactivation of disease leads to damage of the mucosal barrier
Bacteria that are normally well tolerated stick to and invade the lining of the gut for example particular strains of Ecoli
Defective immune responses fail to clear invading bacteria which seems to activate other immune cells fuelling further inflammation
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CROHNrsquoS DISEASE (CD)
Crohnrsquos disease (CD)
although it most commonly affects the bowel Crohnrsquos
disease can involve any part of the gastrointestinal tract
from the mouth to the anus
Diseased segments called ldquoskip areasrdquo are typically
separated by stretches of normal bowel
Tissue damage often extends past the mucosal layer
right through to the serosa
As the tissue heals it may produce an abnormal tunnel-
like connection known as a fistula which connects the
intestine to another organ or tissue
ANATOMY
AFFECTED AREAS
SUB TYPES OF CD amp UC
ETIOPATHOGENESIS
ETIOPATHOGENESIS
Environmental factors such as a lack of childhood exposure to germs diet or specific gastrointestinal infections may trigger the onset and reactivation of disease leads to damage of the mucosal barrier
Bacteria that are normally well tolerated stick to and invade the lining of the gut for example particular strains of Ecoli
Defective immune responses fail to clear invading bacteria which seems to activate other immune cells fuelling further inflammation
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ANATOMY
AFFECTED AREAS
SUB TYPES OF CD amp UC
ETIOPATHOGENESIS
ETIOPATHOGENESIS
Environmental factors such as a lack of childhood exposure to germs diet or specific gastrointestinal infections may trigger the onset and reactivation of disease leads to damage of the mucosal barrier
Bacteria that are normally well tolerated stick to and invade the lining of the gut for example particular strains of Ecoli
Defective immune responses fail to clear invading bacteria which seems to activate other immune cells fuelling further inflammation
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
AFFECTED AREAS
SUB TYPES OF CD amp UC
ETIOPATHOGENESIS
ETIOPATHOGENESIS
Environmental factors such as a lack of childhood exposure to germs diet or specific gastrointestinal infections may trigger the onset and reactivation of disease leads to damage of the mucosal barrier
Bacteria that are normally well tolerated stick to and invade the lining of the gut for example particular strains of Ecoli
Defective immune responses fail to clear invading bacteria which seems to activate other immune cells fuelling further inflammation
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
SUB TYPES OF CD amp UC
ETIOPATHOGENESIS
ETIOPATHOGENESIS
Environmental factors such as a lack of childhood exposure to germs diet or specific gastrointestinal infections may trigger the onset and reactivation of disease leads to damage of the mucosal barrier
Bacteria that are normally well tolerated stick to and invade the lining of the gut for example particular strains of Ecoli
Defective immune responses fail to clear invading bacteria which seems to activate other immune cells fuelling further inflammation
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ETIOPATHOGENESIS
ETIOPATHOGENESIS
Environmental factors such as a lack of childhood exposure to germs diet or specific gastrointestinal infections may trigger the onset and reactivation of disease leads to damage of the mucosal barrier
Bacteria that are normally well tolerated stick to and invade the lining of the gut for example particular strains of Ecoli
Defective immune responses fail to clear invading bacteria which seems to activate other immune cells fuelling further inflammation
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ETIOPATHOGENESIS
Environmental factors such as a lack of childhood exposure to germs diet or specific gastrointestinal infections may trigger the onset and reactivation of disease leads to damage of the mucosal barrier
Bacteria that are normally well tolerated stick to and invade the lining of the gut for example particular strains of Ecoli
Defective immune responses fail to clear invading bacteria which seems to activate other immune cells fuelling further inflammation
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ETIOPATHOGENESIShellip
Damage to the intestinal mucosa caused by a
prolonged inflammatory response leads to lesions
and ulcers This increases exposure to intestinal
microbes
Loss of immunological tolerance to the normal gut
microflora
A combination of these factors typically contribute
to the development of inflammatory bowel disease
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CLINICAL FEATURES
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CLINICAL FEATURES (IBD)
Abdominal PainCramping
Diarrhea often with Blood in the Stool
Weight Loss
Fever amp Fatigue
Reduced Appetite
Weight Loss
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CLINICAL FEATURES (UC)
Bloody Diarrhea
Urgency
Abdominal Pain (Left Sided)
Fever
Nocturnal Diarrhea
Frequent small volume bowel movements
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CLINICAL FEATURES (CD)
Persistent Diarrhea
Loss of Appetite amp Weight Loss
May have Rectal Bleeding
Abdominal PainCramping
Steatorrhea
Fatigue
Fever
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
EXTRA INTESTINAL FEATURES
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
INVESTIGATIONS
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ABDOMINAL X RAY
Helpful in cases of
Obstruction secondary to Crohnrsquos Disease
Extra Intestinal Manifestations
To Assess
Intestinal Obstruction
Pneumoperitoneum
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ABDOMINAL X RAY
Small Bowel Obstruction
Multiple Air fluid levels gt2
Wide Air fluid levels gt25 cm
Differential Air fluid levels
Small bowel Colon ratio gt 05
Pneumoperitoneum
Air under Diaphragm
Rigler signDouble Wall sign
(Air on both sides of the bowel)
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ABDOMINAL X RAYhellip
Step Ladder configuration of Small Bowel loops
String of Pearl sign
Thumb printing appearance
Toxic Megacolon
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
SBO
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
SBO
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION
FROM LUQ TO RLQ)
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
TOXIC MEGACOLON THE COLON (TYPICALLY TRANSVERSE COLON) BECOMES DILATED TO ATLEAST 6 CM (USUALLY
GREATER)
THERE IS ADDITIONAL LOSS OF HAUSTRAL MARKINGS WITH PSEUDOPOLYPS EXTENDING INTO LUMEN
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
BOWEL WALL THUMBPRINTING (THE APPEARANCE OF THUMBPRINT-SHAPED PROJECTIONS) IS A RADIOLOGICAL
SIGN OF THICKENING OF THE COLONIC WALL IT OCCURS SECONDARY TO SUBMUCOSAL HAEMORRHAGE AND
OEDEMA FROM CAPILLARY LEAKAGE1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL
WALL
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
FLUOROSCOPY
Features on barium small bowel follow-through include
mucosal ulcers
o aphthous ulcers initially
o deep ulcers (more than 3mm depth)
o longitudinal fissures
o transverse stripes
o when severe leads to cobblestone appearance
o may lead to sinus tracts and fistulae
widely separated loops of bowel due to fibro-fatty proliferation (creeping fat) 2
thickened folds due to oedema
pseudodiverticula formation due to contraction at the site of ulcer with ballooning of the opposite site
string sign tubular narrowing due to spasm or stricture depending on chronicity
partial obstruction
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
APHTHOUS ULCERS ARE SMALL DISCRETE LESIONS amp ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS
MUCOSA BARIUM COLLECTS IN THE CENTRAL DEPRESSION WITH THE SURROUNDING ELEVATION APPEARING AS A
RADIOLUCENT HALO
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
APHTHOUS ULCER
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
APHTHOUS ULCER
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
APHTHOUS ULCER
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA RESULTS IN
CHARACTERISTIC COBBLESTONE APPEARANCE
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
COBBLESTONE- LONGITUDNAL amp CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA GIVING
IT AN APPEARANCE REMINISCENT OF COBBLESTONES
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
A SMALL BOWEL ENEMA SHOWING EXTENSIVE JEJUNAL DISEASE CHARACTERIZED BY LOSS OF
DISTENSIBILITY (THE CAPABILITY OF BEING STRETCHED OR DISTENDED) THICKENING OF THE SMALL-BOWEL WALL
AND GROSS DISRUPTION OF THE CIRCULAR HAUSTRAL FOLD PATTERN WHICH IS LARGELY REPLACED BY A MARKED
COBBLESTONE EFFECT CD OF THE JEJUNUM
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
COBBLESTONE CROHN DISEASE THIS IS A MAGNIFIED IMAGE FROM THE RIGHT ILIAC FOSSA PERFORMED AS PART
OF A SMALL BOWEL FOLLOW THROUGH IT SHOWS THE CLASSIC APPEARANCE OF CROHN DISEASE IN THE TERMINAL
ILEUM ndash SO-CALLED lsquoCOBBLESTONINGrsquo THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN
AREAS OF INTACT BUT OEDEMATOUS MUCOSA RESEMBLING COBBLESTONES (ARROWS)
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ROSE THORN THE DEEP LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL
ILEUM ARE KNOWN AS lsquoROSE-THORN ULCERSrsquo AND ARE TYPICAL OF CROHN DISEASE
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
RASPBERRY THORN
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
STRING SIGN OF KANTOUR IN THIS CASE THERE IS SEVERE STRICTURING OF A LONG SEGMENT OF THE TERMINAL
ILEUM (ARROWS) THIS IS CALLED RATHER OMINOUSLY THE lsquoSTRING SIGN OF KANTORrsquo THIS IMAGE ALSO
DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE ndash THE AFFECTED BOWEL LOOP
SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
STRING SIGN AP RADIOGRAPHIC IMAGE OF THE ABDOMEN SHOWING DIFFUSE NODULAR MUCOSAL THICKENING AND
NARROWING OF A SEGMENT OF DISTAL ILEUM WITH ADJACENT SIMILAR CHANGES IN THE CECUM (ARROWS)
INCIDENTALLY NOTED IS A NORMAL APPENDIX (ARROWHEAD)
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
STRING SIGN
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
COLLAR BUTTON ULCERS- CLASSICALLY SEEN IN THE COLON ASSOCIATED WITH ACTIVE UC THE COLLAR BUTTON
APPEARANCE IS FORMED BY MUCOSAL ULCERATION WITH ASSOCIATED UNDERMINING OF THE EDGE BY LATERAL
SUBMUCOSAL EXTENSION
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE
COLITIS CASE SHOWS CLASSIC lsquoLEAD PIPErsquo SIGN THE IMAGE DEMONSTRATES
DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH
LACK OF HAUSTRA AND NARROWING
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
PSEUDOPOLYPS THIS DOUBLE CONTRAST BARIUM ENEMA REVEALS AN IRREGULAR MUCOSA AND NUMEROUS
SMALL FILLED NODULES OR POLYPOIDS THROUGHOUT THE ENTIRE COLON REPRESENTATIVE
OF INFLAMMATORY PSEUDOPOLYPS IN LONG STANDING ULCERATIVE COLITIS
ALSO VISIBLE ARE SMALL WORM LIKE STRUCTURES THAT ARE SMALL GROUPS OF RESIDUAL
MUCOSA CALLED FILIFORM POLYPS
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ILEO ILEAL FISTULA
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CT
CT examination can be carried out with both intravenous and intraluminal contrast (positive or negative) 5
fat halo sign
comb sign
bowel wall enhancement
bowel wall thickening (1-2 cm) which is most frequently seen in the terminal ileum (present in up to 83 of patients) 8
strictures and fistulae
mesentericintra-abdominal abscess or phlegmonformation 8
abscesses are eventually seen in 15-20 of patients
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT BW THE MUSCULARIS PROPRIA AND THE MUCOSA
CHARACTERISED BY AN INNER (MUCOSA) amp OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING
BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA)
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
FAT HALO SIGN
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY FIBROFATTY PROLIFERATION amp PERIVASCULAR
INFLAMMATORY INFILTRATION OUTLINE THE DISTENDED INTESTINAL ARCADES
THIS FORMS THE LINEAR DENSITIES ON THE MESENTRIC SIDE OF AFFECTED SEGMENTSOF SMALL BOWEL WHICH
GIVES THE APPEARANCE OF THE TEETH OF A COMB
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
COMB SIGN
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
TARGET SIGN- 3 CONSECUTIVE CIRCLES FORMED BY THE LAYERS OF THE BOWEL WALL
INNER LAYER OF SOFT TISSUE ATTENUATION (MUCOSA)
MIDDLE LAYER OF FATTY ATTENUATION
OUTER LAYER OF SOFT TISSUE ATTENUATION (MUSCULARIS PROPRIA amp SEROSA)
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
TARGET SIGN
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
MRI
MRI enterography has no ionising radiation and an
ability to evaluate both mural and extramural
involvement It has become an increasingly
important part of management of patients with
Crohn disease
MRI enteroclysis may be attempted in select
patients
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
MRI ENTEROGRAPHY (MRE)
MR enterography can be a useful technique for
evaluation of the bowel Inflamed loops of bowel
demonstrate thickening and contrast enhancement
Extramural disease is where MRI excels
fibrofatty proliferation
o thickening of extramural fat which separates
bowel loops
o equivalent to the fat halo sign on CT
vascular engorgement comb sign
stenoses and strictures
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ACTIVE CROHNS DISEASE
LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING DISTINGUISHING
FEATURES OF INFLAMMATION (CROHNS DISEASE) ARE ULCERATIONS INCREASED MESENTERIC VESSELS (COMB
SIGN) SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT)
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
TERMINAL ILEITIS INFLAMED MUCOSA
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
MURAL THICKENING WITH MUCOSAL IRREGULARITY ULCERS AND ENHANCEMENT
(A) CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA
MIMICKING ldquoCOBBLE STONE APPEARANCErdquo WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW)
(B) FIESTA MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD)
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
DISTAL ILEUM MURAL THICKENING AND LAYERING
T2-W (A) AND T1-W POST-GADOLINIUM INJECTION (B) MURAL THICKENING (ARROWHEAD) AND STRATIFICATION
(ARROW) NOTICE MUCOSAL ENHANCEMENT (BRIGHT) SUBMUCOSAL EDEMA (DARKER) AND MUSCULARIS PROPRIA
ENHANCEMENT (BRIGHT)
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
COMB SIGN REPRESENTING CONGESTED MESENTERIC VESSEL ADJACENT TO THE DISEASED JEJUNAL LOOP
(ARROWHEAD) T1-W WITH FAT SUPPRESSION NOTICE MURAL THICKENING AND ENHANCEMENT POST-GADOLINIUM
INJECTION
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW)
(A) FIESTA CORONAL VIEW (B) FIESTA AXIAL VIEW
NOTICE CHOLELITHIASIS (ARROWHEAD)
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
MRI ENTEROCLYSIS
MRI enteroclysis requires the placement of a
nasojejunal catheter through which 15-2 L of
contrast solution (eg water with polyethylene
glycol and electrolytes) are injected 2
Spatial resolution is not as good as with
conventional fluoroscopic enteroclysis and thus
minor mucosal changes are not apparent When
disease is transmural with cobblestone
appearance the abnormalities are evident as high
T2 signal linear regions provided adequate
distension is achieved 2
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
A LOSS OF HAUSTRAL MARKINGS AND A THICKENING OF THE TRANSVERSE AND DESCENDING COLON (ARROWS)
INCREASED VASCULARITY ADJACENT TO THE AFFECTED BOWEL SEGMENT IS NOTED
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CD WITH FISTULAE
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ROUTINE MRI
Routine MRI can also give valuable information
perianal disease
liver disease
sacroiliac joints and spine
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ULTRASOUND
Ultrasound has a limited role but due to it being
cheap and available and not involving ionizing
radiation it has been evaluated as an initial screening
tool for active disease and also for follow-up and to
assess complications 420 Typically examination is
limited to the small bowel and wall thickness
assessed
bowel wall thickness should be lt3 mm
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ULTRASOUND
Other features on ultrasound20
non compressible rigid fixed bowel wall
perienteric fluid
creeping fat - echogenic area (representing proliferation
of adipose tissue that extends around active
inflammation) separating bowel loops
gut signature - lost or preserved
strictures - fibrotic (maintains gut signature) or
inflammatory (loss of gut signature)
abscess
fistula
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
ULTRASOUNDhellip
Ultrasound does of course have a significant role to
play in the assessment of
perianal disease rectal ultrasound
hepatobiliary disease
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
STRICTURE
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
THICKENED BOWEL WALL- CROSS SECTIONAL AND LONGITUDINAL IMAGES OF THE TERMINAL ILEUM SHOW THICKEND
BOWEL WALL AND INFLAMMATORY ECHOGENIC FAT IN A PATIENT WITH ACUTE CD OF THE TERMINAL ILEUM
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
Complications Of IBD
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
Malnutrition
Colon Cancer
Fistulas
Intestinal Rupture Perforation
Bowel Obstruction
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
DIFFERENCES BETWEEN UC amp CD
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CROHN DISEASE VS ULCERATIVE COLITIS
Due to the overlap in clinical presentation of Crohndisease (CD) and Ulcerative colitis (UC) imaging often has a role to play in distinguishing the two Distinguishing features include
bowel involved
CD small bowel 70-80 only 15-20 have only colonic involvement
UC rectal involvement 95 with terminal ileum only involved in pancolitis (backwash ileitis)
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CD VS UC
distribution
CD skip lesions typical
UC continuous disease from rectum up
gender
CD no gender preference
UC male predilection
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CD VS UChellip
colonic wall
fat halo sign seen in 61 of chronic UC cases
but only in 8 of CD 2
bowel wall is thicker in CD than in UC (when
colon involved) 2
serosal surface smooth in UC (95) irregular in
CD (80) 2
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CD VS UC
perianal involvement
UC although rectal involvement is very common
perianal complication are not as frequently seen
CD common seen in 82 of patients 2
stranding of ischiorectal fossaperirectal fat (73)
fistulassinus tracts (22)
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CD VS UChellip
mesenteric creeping fat
CD common in chronic cases
UD not seen as small bowel not involved
abscess formation
CD common eventually seen in 15-20 of
patients
UC uncommon
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CD VS UC
extraintestinal complications
gallstones seen in 30-50 of CD patients 2
primary sclerosing cholangitis more common in
UC
hepatic abscess seen in CD
pancreatitis more common in CD
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
Differential Diagnosis
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
The differential diagnosis depends on the
presenting symptom
When terminal ileitis is the main presentation then
differentials (adjusted for patients age) include 1
acute appendicitis
Yersinia ileitis
mesenteric adenitis
ileocaecal tuberculosis 9
malignancy
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
When colonic involvement is the predominant
feature then other considerations include
ulcerative colitis
acute diverticulitis
acute epiploic appendagitis
ischaemic colitis
pseudomembranous colitis
infectious colitis
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
CONCLUSION
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
Inflammatory bowel diseases are chronic group of
disorders which have a long course of disease with
intermittent periods of active disease and
remission
They can be easily diagnosed by multimodality
approach combining clinical symptoms
colonoscopy and radiology
Conventional radiological investigations like barium
studies are still necessary for diagnosis of
characteristic intramural changes
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
However the CT and MRI investigations are
nowadays frequent and less invasive useful for
detection of extra intestinal manifestations of IBD
Colonoscopy at regular intervals is also must to
look for progression of disease and malignancy in
long standing cases
THANKShellip
THANKShellip