role of ct enterography in chronic diarrhea...

Role of CT enterography in chronic

diarrhea patients

Thesis

Submitted for partial fulfillment of the MD degree in

Radiodiagnosis

By

Rasha Mostafa Mohamed Ali

MSc. Of radiodiagnosis, Cairo University

Supervisors

Prof.Dr. Reda Saad A.ELlatif Professor of radiodiagnosis

Faculty of medicine

Cairo University

Dr. Marwa Shaker A.Elfattah Lecturer of radiodiagnosis

Faculty of medicine

Cairo University

Dr.Tamer Mahmoud Elbaz Lecturer of endemic hepatogastroenterology

Faculty of medicine

Cairo University

Faculty of Medicine

Cairo University

2014

ACKNOWLEDGMENT

I

Acknowledgment

First and foremost, my deep gratefulness and indebtedness are to

Allah, the most gracious and the most merciful.

I wish to express my deep gratitude and respect to Prof. Dr. Reda

Saad A.ELlatif , professor of Radiodiagnosis, Faculty of Medicine,

Cairo University, for his profound suggestion, valuable advices,

continuous encouragement and judicious guidance.

I would like to express my great thanks to Dr. Marwa Shaker

A.Elfattah, lecturer of Radiodiagnosis, Faculty of Medicine, Cairo

University, for her patience, sincere advice and kind support throughout

this study.

Also, I would like to thank Dr. Tamer Mahmoud Elbaz, lecturer

of endemic hepatogastroenterology, Faculty of Medicine, Cairo

University for his support and generous help.

I would also like to thank all my professors and my colleagues at

Radiodiagnosis Department, Kasr El Aini Hospital, Faculty of Medicine.

Cairo University for their continuous encouragement, help and support.

Last but not least, I send my deepest love to my parents, my family

and my husband for their care and support.

ABSTRACT

Chronic diarrhea is a common patient complaint and is defined as

lasting more than 4 weeks. A wide range of problems can cause chronic

diarrhea; some of the most common causes include, inflammatory bowel

disease (Crohn's disease and ulcerative colitis), malabsorption syndromes,

and chronic infections. (Juckett et al, 2011)

CT enterography is a new non-invasive imaging technique that

offers superior small bowel visualization compared with standered

abdomino-pelvic CT, and provides complementary diagnostic

information to capsule endoscopy and MRI enterography . CT

enterography is well tolerated by patients and enables accurate ,efficient

assessment of pathology arising from the small bowel wall or surrounding

organs. (Ilangovan et al, 2012).

The greatly improved spatial and temporal resolution provided by

multidetector CT scanners, combined with good luminal distention

provided by negative oral contrast agents and with good bowel wall

visualization, have made CT enterography the main imaging modality not

only for investigating proved or suspected inflammatory bowel disease

but also for detecting occult gastrointestinal tract bleeding, small bowel

neoplasms, and mesenteric ischemia .(Elsayes et al, 2010).

Although capsule endoscopy provides better mucosal visualization,

it does not allow visualization of abnormalities outside the bowel lumen.

Moreover, capsule endoscopy cannot be performed when the presence of

a stricture is suspected; the endoscopic capsule may become lodged at the

diseased segment and cause obstruction. CT enterography allows

excellent visualization of the entire thickness of the bowel wall and

depicts extraenteric involvement as well, providing more detailed and

comprehensive information about the extent and severity of the disease

process. (Elsayes et al, 2010)

KEY WORDS

Multi-slice computed tomography, enterography, chronic diarrhea.

LIST OF ABBREVIATIONS

II

List of Abbreviations

2D : Two Dimensional

3D : Three Dimensional

CARD 15 : Capase activation and recruitment domain

CD : Crohn’s Disease

CT : Computed Tomography

CTA : Computed Tomographic Angiography

CTE : CT Enterography

ERCP : Endoscopic retrograde cholangiopancreatography

EUS : Endoscopic Ultrasound

GISTs : Gastro Intestinal Stromal Tumours

GIT : Gastro Intestinal Tract

HIV : Human immunodeficiency virus

HU : Housfield unit

IBDs : Inflammatory Bowel Diseases

IMA : Inferior Mesenteric Artery

IV : Intra-Venous

MABP : Malabsorption pattern

MDCT : Multi-Detector Computed Tomography

MR : Magnetic Resonance

MRI : Magnetic Resonance Imaging

MSCT : Multi-Slice Computed Tomography

MSCTE : Multi-Slice Computed Tomographic Enterography

ROI : Region of interest

SBFT : Small bowel follow through

SMA : Superior Mesenteric Artery

SMV : Superior Mesenteric Vein

UC : Ulcerative colitis

US : Ultra Sonography

LIST OF TABLES

III

List of Tables

Table page

Table(1) Comparison between jejunum and ileum

Table(2) Classification of chronic diarrhea

Table(3) Radiographic findings in chronic diarrhea and

malabsorption Syndromes

Table(4) Demographic features of the studied group.

percentile prevalence of lymph node among

different pathological findings

Table(5) Age subgroups in the studied patients.

Table(6) Gender distribution among studied patients.

Table(7) Clinical presentation of the studied group.

Table(8) Radiological findings of the studied group.

Table(9) The total number and percentage of different

pathological intestinal lesions.

Table(10) Distribution of the lesions at different intestinal

segments & their percentage.

Table(11) Mucosal thickening in different pathological

findings

Table(12) percentile prevalence of mucosal hyper

enhancement among different pathological

findings

Table(13) percentile prevalence of adhesions among


Table(14) Bowel dilatation in different pathological

findings.

Table(15) percentile prevalence of lymph node among


LIST OF FIGURES

IV

List of Figures

Page Figure

Loop of small intestine and mesentery Figure(1)

Ileoc-ecal valve, interior of cecam and lower end

of ascending colon

Figure(2)

The position in which the appendix may lie Figure(3)

A diagram showing the anatomy of large bowel

loops.

Figure(4)

A diagram showing blood supply of the colon Figure(5)

Transverse CT images of normal anatomy and

relations of the duodenal bulb

Figure (6A&B)


relations of the 2nd part of the duodenum

Figure (7A&B)


relations of 2nd and 3rd parts of the duodenum

Figure (8A&B)

Transverse CT images of normal anatomy of

jejunal and ileal loops

Figure (9A&B)

Transverse CT images of normal CT appearance

of the mesentery of jejunum and ileum

Figure (10A&B)


terminal ileum and ileocecal junction

Figure (11A&B)


parts of the colon

Figure (12A&B)

Transverse CT images of normal CT appearance

of the mesentery of colon

Figure (13)


sigmoid colon and cecum

Figure (14A&B)

Transverse CT images of normal appearance of

the appendix

Figure(15)

Bristol Stool Form Scale. Figure(16)

A diagram showing the regulation of Absorptive

and Secretory Processes in the Intestine.

Figure(17)

LIST OF FIGURES

V

Page Figure

Plain x ray showing toxic megacolon Figure 18(A,B)

Barium enema for case of UC showing Granular

mucosa, stippling, collar button ulcers, polyps,

loss of haustrations, shortening, and narrowing

Figure(19)

image of small bowel follow-through in a patient

with history of Crohn's disease demonstrates

evidence of terminal ileal wall thickening,

causing narrowing of the lumen

Figure(20)

appearance of Crohn’s disease with cobblestone

appearance

Figure(21)

Endoscopic appearance of ulcerative colitis;

diffuse erythema, friability and ulceration there is

a loss of the normal vascular pattern associated

with inflammation

Figure(22)

Coronal reconstructions of different contrast

agents for CT enterography

Figure 23(A-C)

Transverse CT scan of active Crohn's shows

vascular dilatation, tortuosity, and enlargement of

the vasa recta

Figure(24)

Transverse CT scan in the same patient shows a

long and tortuous segment of ileum with

moderate mural thickening (7 mm) along bowel

walls and luminal narrowing

Figure(25)

CT enterogram with coronal reconstruction

demonstrates markedly dilated small bowel loops

and multiple inflammatory strictures with mural

heterogeneous hyperenhancement and wall

thickening

Figure(26)

Coronal reformation of CT enterography image

obtained with water as enteral contrast agent

shows 3-cm hyper-vascular mass in ileum

Figure(27)

LIST OF FIGURES

VI

Page Figure

Thick slab volume rendered image obtained after

ingestion of dilute water-soluble oral contrast

medium

Figure(28 A&B)

Axial MSCT (A) and coronal reconstruction (B)

show dilated proximal small bowel loops and

collapsed distal bowel in the pelvis indicating a

proximal obstruction

Figure(29 A&B)

MSCTE Axial cut shows collapsed terminal

ileum has the same attenuation as adjacent

bowel loops

Figure(30)

MSCTE axial cut shows normal jejunum (circle)

enhances more than distal small bowel during

the arterial phase.

Figure(31)

A diagram showing the affected areas in Crohn's

disease

Figure(32)

CT enterogram shows active Crohn's disease in

the terminal ileum with bilaminar mural

stratification and intramural soft tissue

attenuation

Figure(33)

Variable patterns of mural hyperenhancement

indicating active CD.

Figure(34 A-C)

. Axial CT enterographic section showing skip

lesions in Crohn disease

Figure(35)

Axial CT enterographic section shows mucosal

hyperenhancement and mural stratification of the

terminal ileum.

Figure (36 A&B)

CT enterogram depicts mural hyperenhancement

with mural stratification within the thickened

bowel wall denoting active ileal Crohn's disease

Figure(37)

Duodenal Crohn's disease in a 42-yearold

woman. CT enterogram demonstrates mucosal

hyperenhancement and stratification.

Figure (38)

LIST OF FIGURES

VII

Page Figure

Bilaminar and trilaminar stratification. Increased

mucosal enhancement and intramural edema

(arrows) hypervascularity consistent with active

CD

Figure(39)

Trilaminar stratification in chronic CD showing

fatty intramural deposition .

Figure(40)

Axial CT enterographic section shows

abnormally low attenuation of the bowel

wall denoting Submucosal fat deposition

in longstanding Crohn disease.

Figure(41)


reversible strictures. Narrowing of the

bowel lumen caused by intramural edema

indicates these strictures are not yet

fibrotic.

Figure(42 A&B)


Chronic, non reversible strictures .

Figure(43 A&B)

Inflammatory bowel stricture in a patient

with active Crohn disease.

Figure(44 A&B)

Transverse MSCTE shows thickened

small bowel with mucosal and mural

hyper-enhancement adherent to thickened

lateral peritoneal lining.

Figure(45)


active CD with small bowel wall

thickening and enhancement in the ileum

with engorged vasa recta (comb sign)

extending to the bowel wall

Figure(46)

LIST OF FIGURES

VIII

Page Figure

Coronal volume-rendered CT

enterographic sections from two patients

demonstrate prominence of the vasa recta,

or “comb sign”

Figure(47 A&B)

Axial CT enterographic sections showing

large bowel involvement in Crohn's

disease.

Figure(48 A-C)

Axial CT enterographic sections recurrent

Crohn disease after bowel resection.

Figure(49)

Recurrent Crohn's disease in a 33-year-old

woman. Sequential CT enterograms

demonstrate mural wall thickening and

mucosal hyperenhancement in the small

bowel adjacent to an ileocolic anastomosis

Figure(50 A,B)

Capsule impaction in bowel stricture due

to Crohn's disease.

Figure(51 A,B)

CT enterographic sections showing fistula

types with CD.

Figure(52) A-C

Coronal volume-rendered CT

enterographic sections showing fistula

formation in Crohn disease.

Figure(53 A,B)

Axial CT enterogram demonstrates an

enterocutaneous fistula arising from

matted loops .

Figure(54)

CT enterogram reveals an ileoileal fistula

arising from an ileal loop, with

asymmetric bowel inflammation .

Figure(55)

LIST OF FIGURES

IX

Page Figure

CT enterogram shows Enterovesical

fistula

Figure(56 A-C)

CT enterographic sections showing

abscess formation in Crohn disease.

Figure(57 A&B)

Axial Ulcerative colitis with backwash

ileitis.

Figure(58 A-C)

CT enterographic sections showing active

ulcerative colitis with"backwash"ileitis

Figure(59 A-C)

Transverse CT enterograghic image in

patient with ulcerative colitis

demonstrates the double halo, or target,

sign

Figure(60)

Transverse CT enterographic image in

patient with chronic ulcerative

colitis.showing the fat halo sign.

Figure(61)

CT enterographic images showing long-

term complications of ulcerative colitis

Figure(62 A&B)

Transverse CT image in patient with

tuberculous ileocolitis.

Figure(63)

BMFT demonstrates ascaris as a

longitudinal filling defect in the distal

small bowel.

Figure(64)

A diagram showing Marsh grading

system.

Figure(65)

Coronal reformatted CT enterographic

image demonstrates celiac disease with

fold reversal.

Figure(66)

LIST OF FIGURES

X

Page Figure

Coronal reformatted CT enterographic

shows thickened bowel wall with mucosal

hyperenhancement in the jejunum

Figure(67)

Axial reconstruction shows dilatation of

multiple loops of jejunum with absence of

valvulae conniventes, findings that

indicate villous atrophy.

Figure(68)

CT enterographic sections show

jejunization of the ileal mucosa in celiac

disease.

Figure(69 A-C)

CT images show lymph nodes before and

after treatment with a gluten-free diet

showing resolution of both the prominent

lymph nodes and the mesenteric vein

enlargement.

Figure(70 A&B)

Axial CECT shows hepatomegaly, biliary

ductal dilation, thickened bowel wall and

fluid distention of lumen and sclerotic

lesions in pelvic bones due to

mastocytosis

Figure(71 A&B)

Axial CECT shows thickened bowel wall

and intussusceptions due to mastocytosis.

Figure(72 A&B)

SBFT & MSCTE show mural thickening

and micronodular pattern of jejunum in a

patient with Whipple disease.

Figure(73 A&B)

SBFT & MSCTE in a patient with

Whipple disease.

Figure(74 A&B)

LIST OF FIGURES

XI

Page Figure

Axial CECT shows small bowel fold

thickening, excess fluid in lumen &

esenteric engorgement due to primary

lymphangiectasia

Figure(75)

Burkitt lymphoma. Contrast-enhanced CT

scan shows an ileocolic intussusception

with thickening of the terminal ileum.

Figure(76)

Contrast-enhanced CT scan shows the

ileocolic intussusception (arrowheads) in

the midabdomen. In a case of large B-cell

lymphoma .

Figure(77)

MSCTE shows enteropathy type T-cell

lymphoma with an abnormal jejunal small

bowel loops.

Figure(78)

Percentile prevalence of patients in each

decade of the study group.

Figure(79)

Gender distribution among studied

patients.

Figure(80)

Distribution of the clinical presentation in

the patients.

Figure(81)

Distribution of Pathological findings of

the studied group.

Figure(82)

Prevalence of lesions at different intestinal

segments.

Figure(83)

percentile prevalence of mucosal

thickening in different pathological

lesions.

Figure(84)

LIST OF FIGURES

XII

Page Figure

prevalence of mucosal thickening in

different pathological lesions.

Figure(85)

Prevalence of mucosal hyper

enhancement among different

pathological findings

Figure(86)

percentile prevalence of lymph node

among different pathological findings

Figure(87)

prevalence of lymph node among


Figure(88)

The prevalence of different pathological

categories in relation to the patient’s age

Figure(89)

case 1. Non Hodgkin lymphoma Figure(90)

case 2 . Terminal ilieum Crhon’s disease Figure(91)

case 3. Terminal ilieum Crhon’s disease Figure(92)

case 4. Tuberculous enteritis. Figure(93)

case 5. Terminal ilieum Crhon’s disease

with fistulous communication to adjacent

bowel loop.

Figure(94)

case 6. Crhon’s disease with fistulous

communication to the skin

Figure(95)

case 7 . Ulcerative colitis. Figure(96)

case 8. Malabsorption syndrome (Celiac

disease)

Figure(97)

case 9 . recurrent post operative crohn's

disease

Figure(98)

case 10. Crhon’s disease. Figure(99)

role of ct enterography in chronic diarrhea...

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