Gore Et Al 2013 CT Features of Ulcerative Colitis and Crohn S Disease

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Review Article
CT Features of Ulcerative Colitis and Crohn’s Disease

Richard M. Gore1, Emil J. Balthazar2, Gary G. Ghahremani1, Frank H. Miller3
U Icerative
ease,
colitis
collectively
and
known
Crohn’s dis-
as idio-
the
patients
value and
with
current
IBD.
applications of CT for a power injector
known or suspected
at 2 mI/sec.
urinary
In patients
tract complications
with
pathic inflammatory bowel of IBD, scans also should be obtained before

disease (IBD), remain a diagnostic and thera- IV contrast material injection. These non-con-
Technical Considerations trast-enhanced scans assist in the visualization
peutic challenge. Whereas other inflammatory
diseases ofthe gut are distinguished either by a Complete opacification of a well-distended of renal stones and intracystic orally adminis-
specific etiologic agent or by the nature of the gut is mandatory for accurate CT evaluation of tered contrast material resulting from an
inflammatory activity, ulcerative colitis and the bowel wall thickening and distortion of enterovesical fistula. This pathology might oth-
Crohn’s disease are disorders with unknown mural components that are the hallmarks of erwise be obscured by dense iodinated contrast
etiologies, uncertain and unpredictable IBD [8-10]. Nonopacified bowel loops are material in the kidneys and bladder.
courses, and variable responses to medical and potential sources of diagnostic error because In patients in whom it is important to differ-
surgical management. Colonoscopy and bar- they can simulate an abscess, mass, or enlarged entiate inflammatory from neoplastic colonic
ium studies are the principle methods of evalu- lymph nodes. The patient should drink 1000 ml disease. rectal air insufflation immediately
ating patients with known or suspected IBD of a 2% barium suspension (Readi-CAT 2; E- before scanning is useful in maximizing
[11. Both techniques provide superb visualiza- Z-EM, Westbuiy, NY) the evening before the colonic distension. It allows better assessment
tion of the bowel mucosa, abnormal surface CT examination to opacify the colon by the of bowel wall homogeneity by minimizing
patterns, and changes in intestinal caliber [21. next day. An additional 1000 ml of dilute bar- artifacts that may be caused by dense, positive
However, these techniques cannot show the ium suspension is administered orally over a I - intraluminal contrast material. This technique
transmural extent of inflammation or the intra- hr period before the scan to opacify the stom- should be used in conjunction with the IV
peritoneal or extraintestinal complications of ach and small bowel. Dilute (2%) water-solu- administration of glucagon to induce intestinal
IBD. In recent years, CT has become indis- ble contrast material should be used in hypomotility, which reduces peristaltic arti-
pensable in the assessment of patients with preoperative and trauma patients as well as facts and assists in the retention of the insuf-
IBD by virtue of its ability to show pathologic those with suspected bowel perforation. flated air. In the clinical setting of fulminant
changes involving the bowel wall, mesenteric lodinated contrast material should be admin- colitis, however, air insufflation is contraindi-
attachments, and adjacent structures [3-51. For istered IV to all patients unless contraindicated cated because of the risk of perforation.
acutely ill patients, CT is often the only study because bowel wall contrast enhancement is an Our standard imaging protocol is to obtain
re-quired. providing crucial information for important indicator of the degree of mural scans from the diaphragm through the
both accurate diagnosis and management of inflammation and mesenteric engorgement. perineum using 10-mm collimation at 10-mm
the many complications associated with IBD We give 150 ml of 60% iodinated contrast intervals (pitch, I : I). In patients with known
[6, 7]. The purpose of this article is to review material, delivered as a monophasic bolus with or suspected IBD, this protocol is modified so
Received January 3, 1996; accepted after revision February 20, 1996.

1 Department of Diagnostic Radiology, Evanston Hospital-McGaw Medical Center of Northwestern University, 2650 Ridge Ave., Evanston, IL 60201. Address correspondence to R. M. Gore.
2Department of Diagnostic Radiology, New York University-Bellevue Medical Center, First Ave. and 27th St., New York, NY 10016.
3Department of Diagnostic Radiology, Northwestern Memorial Hospital, Northwestern University Medical School, 710 N. Fairbanks Ct., Chicago, IL 60611.
AJR 1996;167:3-15 0361-803X/96/1671-3 © American Roentgen Ray Society
AJR:167, July 1996

Gore et al.
that 5-mm-thick scans at 5-mm intervals teric or perivisceral masses; (6) size of the pre- able to edema, hyperemia, and abnormal
(pitch, I : 1 ) are obtained from the iliac crest sacral space; (7) gallbladder and liver ab- mucin production [7]. These changes are
through the perineum. If specific bowel loops normalities, such as gallstones, choledocholith- beneath the spatial resolution of CT [I, 2].
are of concern, as indicated by other studies, iasis, sclerosing cholangitis, and steatosis; (8) With progressive disease, severe mucosal
it is important to obtain high-resolution, thin- pancreatitis; (9) hydronephrosis and urinary ulceration can denude certain portions of the
section images with optimum levels of intra- tract stones; ( 10) sacroiliitis and spinal liga- colonic wall, leading to inflammatory
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vascular contrast enhancement when the mentous ossification; (11) osteomyelitis; and pseudopolyps. When sufficiently large, these
affected gut is scanned. (12) avascular necrosis of the femoral heads. pseudopolyps can be visualized on CT scans
On CT scans, the thickness of the wall of [1 1, 12] (Fig. I). Mural thinning, unsuspected
the normal small bowel and colon does not perforations, and pneumatosis can be detected
Ulcerative Colitis
exceed 2-3 mm. This measurement should on CT scans in patients with toxic megacolon
be made when the gut is fully distended and Ulcerative colitis is characterized pathologi- [13] (Fig. 2). In this regard, CT can be quite
imaged transaxially because oblique scan- cally by extensive ulceration and diffuse helpful in determining the urgency of surgery
ning planes may artificially increase this inflammation of the mucosa. The disease char- in patients with stable plain abdominal films
measurement. A wall thickness of greater acteristically begins in the rectum and extends but with a deteriorating clinical course.
than 4 mm in any segment of well-distended proximally to involve part or all of the colon. Postinflammatory pseudopolyps also can be
small bowel and colon is abnormal. Early in the disease course, CT scans often are seen on CT scans [11, 12].
The mesentery and omentum normally normal; however, with more advanced dis-
contain blood vessels and small lymph nodes ease, significant mural pathology usually is Subacute and Chronic Phases: Mural Involvement
smaller than 3-5 mm and fat having an atten- present and can be detected on CT scans [7]. Mural thickening (Fig. 3) and luminal nar-
uation value of -75 to -125 H [8, 9]. A CT is not recommended as a primary means of rowing (Figs. 4 and 5) are common CF fea-
higher attenuation value indicates the pres- diagnosing ulcerative colitis because of its low tures of subacute and chronic ulcerative colitis
ence of fluid, cellular infiltrate, edema, hem- diagnostic sensitivity for early disease. Never- [14-18]. Although it is easy to understand why
orrhage, or fibrosis. theless, CT is a useful complementary imaging the bowel wall becomes thick in a transmural,
When patients with IBD are evaluated, it is technique because it can detect certain compli- fibrosing inflammatory disorder such as
important to specifically search for the follow- cations and can explain many of the morpho- Crohn’s disease, its pathogenesis is not intu-
ing CT features and associated complications: logic changes of advanced ulcerative colitis itively obvious in ulcerative colitis, which is
(I) bowel wall thickness, homogeneity, and seen on barium enema studies. predominantly a mucosal disease.
contrast enhancement; (2) mesenteric, perirec- In chronic ulcerative colitis, the muscularis
tal, retroperitoneal, and omental fat attenuation Acute Phase: Mucosal Inflammation and Ulceration mucosae, for unknown reasons, becomes
and homogeneity; (3) lymph node number and The early stages of ulcerative colitis are markedly hypertrophied, often by a factor of
size; (4) extraluminal contrast collections, manifested radiologically and colonoscopi- 40-fold (Fig. 4). Forceful contraction of this
abscesses, fistulas, and sinus tracts; (5) mesen- cally by a granular mucosal pattern attribut- hypertrophied longitudinal muscle may pull
Fig. 1.-Mucosal disease in acute ulcerative colitis. Fig. 2.-CT scan shows unsuspected perforation and abscess
A, Pelvic CT scan shows diffuse mucosal thickening of fluid-filled rectum and sigmoid. Deep ulcer- (straight in patient who had fulminant ulcerative colitis
arrows)
ations (arrows) are visualized. Note normal luminal caliber and ascites (A). and toxic megacolon and who was not improving clinically de-
B, Magnified CT image of distal descending colon shows residual islands of inflamed mucosa protrud- spite intensive medical management. Patient had sustained
ing above denuded colonic surface (so-called inflammatory pseudopolyps) (arrows). clinically silent perforation. This CT scan prompted colectomy
and surgical abscess drainage. Curved arrow shows fluid in
right paracolic gutter. TC = transverse colon.
4 AJR:167, July 1996

tis, ischemic and radiation enterocolitides,

mesenteric venous thrombosis, bowel edema,
and graft-versus-host disease [21-25].
Certain CT findings can help differentiate
granulomatous from ulcerative colitis. Mural
stratification (i.e., the ability to visualize
individual layers of bowel wall) is seen in

61% ofpatients with chronic ulcerative coli-
tis but in only 8% of patients with chronic
granulomatous colitis [5, 16]. Also, the
mean colonic wall thickness in chronic
ulcerative colitis is 7.8 mm, significantly
smaller than that observed in granulomatous
colitis (I 1 mm) [161. Finally, the outer con-
tour of the thickened colonic wall is smooth
Fig. 3.-Target sign in subacute ulcerative colitis. and regular in 95% of ulcerative colitis
A, CT section through rectum and sigmoid shows diffusely inflamed and thickened mucosa. Note that edematous patients, whereas serosal and outer mural
layer of submucosa (arrowl of lower attenuation is paralleled by external layer of muscularis propria and internal
layer of mucosa, both of which show higher attenuation. Also note prominent blood vessels and lymph nodes in irregularities are present in 80% of granulo-
sigmoid mesocolon. matous colitis patients [5].
B, Axial CT scan shows rectum with target appearance produced by two higher-attenuation rings (mucosa and
muscularis propria) that are separated by edematous submucosa of lower attenuation (arrovvj. This mural strat- Rectal and Perirectal Diseases
ification is typical of ulcerative colitis.
Rectal narrowing and widening of the pre-
sacral space are hallmarks of chronic ulcerative
Normal Chronic Ulcerative Colitis colitis (Fig. SA). High-resolution CT depicts
the anatomic alterations that underlie these
rather dramatic morphologic changes. The rec-
tal lumen is narrowed because of the previ-
ously described mural thickening that attends
chronic ulcerative colitis. As a result, the rec-
tam has a target appearance on axial scans,
which should not be mistaken for the external
anal sphincter, mucosal prolapse, or the levator
ani muscle. The widening of the presacral
a. space is caused by the proliferation of perirectal
fat. On CT scans, this fat is characterized by an
increased number of nodular and streaky soft-
tissue densities and an abnormal attenuation
value, 10-20 H higher than that of normal
extraperitoneal or mesenteric fat (Fig. SB).
These fatty changes relate to a number of fac-
tors, including ex vacuo replacement by fat of
Fig. 4.-Pathologic features of chronic ulcerative colitis indicating morphologic basis of target sign. Diagram the void produced by rectal luminal narrowing
shows marked hypertrophy of muscularis mucosae found in chronic ulcerative colitis. This longitudinally orient- and lipodystrophy resulting from an influx of
ed muscle becomes chronically contracted, shortening and narrowing involved colon. Submucosa widens be-
inflammatory cells and edema. Edematous adi-
cause of fatty infiltration, causing further narrowing of lumen. When viewed axially, fatty infiltration of
submucosa produces central ring of low attenuation that is surrounded by rings of soft-tissue density represent- pose tissue and enlarged lymph nodes often are
ing mucosa internally and muscularis propria externally, which do not undergo fatty infiltration. These rings pro- observed in the perirectal region at the time of
duce target or halo sign on CT scans. (Reprinted from 1201) abdominoperineal resections in patients with
chronic ulcerative colitis [7, 14, 19].
the mucosa away from the submucosa, pro- On axial CT scans (Fig. 5), these mural
ducing diffuse or segmental narrowing of the changes produce a target or halo appearance: Carcinoma Complicating Ulcerative Colitis
lumen. This contraction also causes shorten- the lumen is surrounded by a ring of soft-tissue Patients with ulcerative colitis have a mark-
ing of the colon [7, 19]. density (mucosa, lamina propria, and hypertro- edly increased risk of developing cancer of
The submucosa becomes thickened because phied muscularis mucosae), which is sur- the colon and rectum [26]. IBD-related col-
of the deposition of fat or, in acute and sub- rounded by a low-density ring (fatty infiltration orectal cancers are notoriously difficult to
acute cases, edema [20]. Submucosal thicken- of the submucosa), which in turn is surrounded diagnose early by barium enema and colonos-
ing further contributes to luminal narrowing. by a ring of soft-tissue density (muscularis pro- copy because these neoplasms are frequently
Additionally, the lamina propria is thickened pria) [7, 17, 19]. This mural stratification is not scirrhous and flat and are superimposed on a
because of round-cell infiltration in both acute specific and also can be seen in Crohn’s disease, colon that is shortened and narrowed and con-
and chronic ulcerative colitides [7, 12]. infectious enterocolitis, pseudomembranous coli- tains chronically inflamed mucosa. Therefore,
AJR:167, July 1996

Gore et al.
show mural stratification and often have a target

or double-halo appearance 128, 29] (Fig. 7). As
in ulcerative colitis, a ring of soft-tissue density
(corresponding to mucosa) is surrounded by a
low-density ring with an attenuation near that of
water or fat (corresponding to submucosal
edema or fat infiltration, respectively), which in

turn is surrounded by a higher-density ring
(muscularis propria) 1211. Inflamed mucosa and
serosa may show significant contrast enhance-
ment after bolus IV administration of contrast
material, and the intensity of enhancement cor-
relates with the clinical activity ofthe disease.
Two recent papers in the sonography litera-
ture have shown that the sonographic demon-
stration of mural stratification (i.e., the ability
to visualize distinct mucosal, submucosal, and
Fig. 5.-CT scan-barium enema correlation for rectal changes in chronic ulcerative colitis.
muscularis propria layers) indicates that trans-
A, Lateral view of rectum on double-contrast barium enema film shows narrowing of lumen, granular appear-
ance of mucosa, loss of valves of Houston, and significant widening of presacral space (arrows). mural fibrosis has not occurred and that medi-
B, Corresponding pelvic CT scan shows target sign of rectum. Middle, low-density ring (curved arrow), which is cal therapy may be successful in ameliorating
seen in chronic disease, is attributable to fatty infiltration. Widened presacral space (straight double-headed ar- luminal compromise 130, 311. These studies
row) is filled with abnormal fat with higher-than-normal attenuation and increased number of lymph nodes.
(Adapted from 1201) also have shown that before the onset of fibro-
sis, the edema and inflammation of the bowel
wall that cause mural thickening and luminal
CT scans in patients with long-standing ulcer- more accurate than plain abdominal films for obstruction are reversible to some extent 130,
ative colitis should be scrutinized for asym- the detection of the intramural gas (Fig. 6) and 311. A modest decrease in bowel wall thick-
metric mural thickening, focal loss of mural mural thinning found in toxic megacolon asso- ness often produces a dramatic increase in
stratification, and mural thickening of greater ciated with Crohn’s disease 113). luminal cross-sectional area and resolution of
than I .5 cm, all features suggesting malig- Crohn’s disease is manifested on CT scans by the patient’s symptoms of obstruction. These
nancy. In patients with established carcinoma, bowel wall thickening ranging from I to 2 cm studies also have shown that the loss of mural
CT is useful for tumor staging. 15’ 14, 15, 29]. This thickening, which occurs in stratification is indicative of transmural fibro-
up to 83% of patients. is observed most fre- sis [30, 311. This has been our experience with
quently in the terminal ileum, but other portions CT (Figs. 7 and 8) as well.
Crohn’s Disease
of the small bowel, colon, duodenum, stomach,
Crohn’s disease can affect any portion of and esophagus may be similarly affected 151. Chronic Phase: Transmural Fibrosis and Cicatrization
the gastrointestinal tract, most commonly the During the acute. noncicatrizing phase of In patients with long-standing Crohn’s dis-
terminal ileum and proximal colon. The acute, Crohn’s disease, the small bowel and colon ease and transmural fibrosis, mural stratification
active phase of Crohn’s disease is character-
ized by focal inflammation, aphthoid ulcer-
ation with adjacent cobblestoning, a chronic
inflammatory reaction with lymphoid aggre-
gates and granulomas that may be transmural,
fissures, and tistulas. The chronic, resolving
phase of this disorder is associated with fibro-
sis and stricture formation [27, 28].
Acute Phase: Inflammation

The earliest macroscopic manifestations of
Crohn’s disease are enlarged lymphoid follicles
and aphthoid
demonstrable
ulcerations.
on double-contrast
These changes
barium radi-
are
i.j,I:.
ography but are beneath the spatial resolution of
CT. Consequently, when the disease is limited
to the mucosa, CT scans usually are normal.
Although inflammatory and postinflammatory
pseudopolyps may be identified on CT scans,
Fig. 6.-CT scan-plain film correlation for toxic megacolon complicating Crohns disease.
the assessment of the mucosa is best done with
A, Plain abdominal radiograph shows diffuse dilatation of colon with blunted haustral folds (arrows).
barium studies and colonoscopy, which are B, CT scan obtained on same day as A shows unsuspected intramural gas collections in colon (arrows). Patient
more direct and sensitive III, 12]. CT scans are subsequently underwent colectomy on basis of this finding.
6 AJR:167, July 1996

is lost, so that the affected bowel wall typically implications. This diagnostic dilemma is fur- Contrast-enhanced CT scans often show
shows homogeneous attenuation on CT scans ther complicated by the fact that many hypervascularity of the involved mesentery,
(Fig. 9). Homogeneous attenuation of the thick- patients are receiving immunosuppressive manifesting as vascular dilatation, tortuosity,
ened bowel wall in the presence of good intra- therapy that can mask signs and symptoms. prominence, and wide spacing of the vasa
vascular contrast material levels on thin-section CT can readily differentiate the extraluminal recta (Fig. II). These distinctive vascular
scans suggests irreversible fibrosis; therefore, manifestations of Crohn’s disease [28, 36]. changes have been called vascular jejuniza-
antiinflammatory agents may not provide a sig- Fibrofatty pro! jferation of the mesentery’.- lion of the ileum or the comb sign [33]. Iden-
nificant reduction in bowel wall thickness. If the Fibrofatty proliferation, also known as creep- tification of such hypervascularity should
affected segments become sufficiently narrow, ing fat of the mesentery, is the most common suggest active disease and may be useful in
surgery or stricturoplasty will be necessary to cause of separation of bowel loops on small- differentiating Crohn’s disease from lym-
relieve the patient’s obstruction. bowel series in patients with Crohn’s disease phoma or metastases, which tend to be
[3, 7]. On CT scans (Fig. 10), the sharp inter- hypovascular lesions [33].
Mesenteric Involvement face between bowel and mesenteiy is lost and Abscess-About 15-20% of patients with
Palpation of an abdominal mass or separa- the attenuation value of fat is elevated by 20- Crohn’s disease eventually develop an intraab-
tion of bowel loops on small-bowel series in 60 H because of the influx of inflammatory dominal abscess [38, 39). Abscesses are most
patients with Crohn’s disease evokes an cells and fluid. Mesenteric adenopathy, with frequently associated with small-bowel disease
extensive differential diagnosis: abscess, lymph node size ranging from 3 to 8 mm, also or ileocolitis. Once developed, an abscess can
phiegmon, fibrofatty proliferation or creep- may be present (Figs. 9B and 11). When the burrow through the adjacent tissue or break open
ing fat of the mesentery, bowel wall thicken- lymph nodes are larger than 1 cm, the presence and drain spontaneously into another part of the
ing, and enlarged mesenteric lymph nodes of lymphoma or carcinoma, both of which bowel and/or adjacent organs. Abscesses usually
132-351. Each of these disorders has signifi- occur with greater frequency in Crohn’s dis- result from sinus tracts, fistulas, perforations, or
cantly different prognostic and therapeutic ease, must be excluded [26, 37]. surgical operations for Crohn’s disease [40].
Fig. 7.-Target sign in acute, noncicatrizing phase of Crohn’s disease.

A, Contrast-enhanced CT scan of terminal ileum shows intense enhancement of
mucosa and muscularis propria-serosa. Mural stratification is present as edem-
atous, thickened submucosa of low attenuation (straight arrow) in relation to oth-
er bowel wall layers, producing target sign. Periintestinal fat also shows marked
inflammatory change (curved arrows). Patient had low-grade small-bowel ob-
struction and fever.
B, CT scan obtained for same patient as in A after 9-week course of antibiotic and
steroid therapy shows diminished mural thickening and contrast enhancement of
involved ileum (arrow) as well as marked reduction of inflammatory change in ad-
iacent mesentery. Patient’s symptoms of obstruction improved as well.
Fig. 8.-Small-bowel obstruction attributable to Crohns disease of distal ileum.

Contrast-enhanced CT scan shows luminal narrowing and mural thickening of dis-
tal ileum (straight arrow) causing dilatation of fluid-filled small bowel proximally
(curved arrow) and collapsed ascending colon (A) and descending colon (0) distal
to diseased ileum. Mural stratification of involved segment is maintained. This
ability to visualize various layers of bowel wall suggests that stenosis may be re-
versible with medical therapy.
AJR:167, July 1996

Gore et al.
Fig. 9.-Chronic, cicatrizing phase of Crohn’s disease in which loss of mural stratification often indicates irreversible transmural fibrosis.
A, Pelvic CT scan shows homogeneous mural thickening (straight arrows) of distal ileum associated with luminal narrowing (curved arrow) attributable to chronic, cica-
trizing fibrosis.
B, CT scan in another patient shows deep ulcers penetrating otherwise homogeneously thickened walls of ascending colon (small curved arrow). Terminal ileum (straight
open arrow) and descending colon (straight solid arrow) also are involved. Note increased linear and nodular densities in mesenteric fat around inflamed intestinal seg-
ments (large curved arrow). Also note prominent lymph nodes seen in small-bowel mesentery.
Fig. 10.-Creeping fat of mesentery in Crohn’s disease. CT scan shows homoge- Fig.11.-Vascular engorgement of ilealmesentery associated with active Crohn’s
neously thickened walls of ileum (straight open arrow) and ascending colon disease. CT scan shows vascular dilatation, tortuosity, and prominence of vasa recta
(straight solid arrow). On their medial aspects, note large amount of mesenteric (solid arrow) on mesenteric border of ileum, known as comb sign. Diseased ileal loop
fat with increased number of strandlike densities (large curved arrows). Also shows mural thickening and target appearance (open arrow). Also note prominent
note separation of normal small-bowel loop (small curved arrow) from these dis- mesenteric lymph nodes.
eased segments; this separation has been caused by abnormal mesenteric fat.
An intraabdominal abscess may be difficult and show the full extent and location of the important diagnostic features seen in 30-
to diagnose on clinical grounds in patients with abscess cavity (Fig. 12). 50% of cases [41]. These bubbles may be
Crohn’s disease because symptoms may be CT is the procedure of choice for both the formed by gas-forming bacteria but most
inconspicuous, masked by corticosteroids, or diagnosis and the percutaneous management often are secondary to a sinus tract commu-
mistaken for an exacerbation of disease. Bar- of intraabdominal abscesses (Fig. 13). On nicating with the skin surface or the gas-
ium studies and endoscopy typically can only CT scans, abscesses usually appear as cir- trointestinal tract. The gas may be distributed
suggest the presence of an abscess indirectly by cumscribed round or oval water-density as finely dispersed air bubbles throughout a
a mass effect, spiculation of the mucosa, or masses with an attenuation of 10-30 H. If the collection or as an air-fluid level.
identification of a fistula. Also, these studies do abscess has a well-formed capsule, it may The treatment of abscesses in patients with
not evaluate the ischiorectal fossa, psoas mus- show peripheral contrast enhancement, Crohn’s disease is difficult. When surgically
cle, and solid abdominal organs, common loca- whereas the liquefied central area of the drained, these abscesses reform in 40-90% of
tions of abscess formation 1321. Cross-sectional abscess, which may contain necrotic mate- cases, with a death rate of 2-4% 142). In the
imaging is required to confirm the diagnosis rial, does not. Extraluminal bubbles of air are past, there was a reluctance to percutaneously
8 AJR:167, July 1996

Fig. 12.-Small-bowel series-CT correlation for abscess formation complicating Crohn’s ileocolitis.
A, Spot film from small-bowel series shows deformed and narrowed ileocecal region, with extraluminal barium in fistulas (arrows). This study provides no hint of large
flank abscess.
B, CT scan shows full extent of abscess (A), which involves right retroperitoneal space and adjacent musculature (P = psoas, Q = quadratus lumborum) and extends ex-
traperitoneally into soft tissues of right flank (arrow).
drain abscesses in patients with Crohn’s dis- anorectal, duodenopancreatic, gastrocolic, cob- When surgical or percutaneous interven-
ease because these abscesses often have bronchial, and enterospinal [48-54 1. tion is planned for symptomatic fistulas,
accompanying fistulas and may be multilocu- The origin, anatomic course, and sites of cross-sectional imaging should be done to
lar. Recent studies, however, have shown great communication of sinus tracts and fistulas define precisely their anatomic relationships.
success in the percutaneous managenlent of should first be evaluated by conventional Such definition is particularly important for
these abscesses, either as a temporizing mea- barium studies, excretory urography. cystog- anorectal lesions.
sure or, more often, as definitive therapy [43- raphy, and sinography. These studies, how-
47). Two-stage surgical resections that initially ever, may be limited by the fact that the Rectal and Perianal Pathology
bypass the diseased gut often can be simplified origin of the fistula may be edematous and Perianal disease is common in patients
into single-stage surgery. To date, no entero- prevent contrast opacification. Additionally, with Crohn’s disease. Unfortunately, the pen-
cutaneous fistulas resulting from catheter tiny fistulas may not be seen on barium stud- anal area often is poorly evaluated by barium
drainage have been reported. ies, and evaluation of anorectal fistulas and studies because the enema tip may be
CT-guided percutaneous abscess drain- sinus tracts on such studies often is painful inserted too cephalad or because exquisite
age may obviate the need for surgery in and difficult. CT often is required to show anal tenderness may preclude adequate retro-
many cases. Because 70-90% of patients the full extent of these tracts (Fig. 15). grade distension and evaluation. In a recent
with regional enteritis eventually will require
surgery, avoiding an operation for abscess
drainage is a tangible benefit of CT [42].
Ph!egrnon.-A phlegmon is an ill-defined
inflammatory mass in the mesentery or omen-
tum that may resolve completely with antibiot-
ics or progress to form an abscess. A phlegmon
is another common cause of a mesenteric mass
effect in patients with Crohn’s disease [7]. On
CT scans, a phlegmon produces a loss of defi-
nition of surrounding organs and a smudgy or
streaky appearance of the adjacent mesenteric
or omental fat (Fig. 14).
Fistuki.s and sinus iracts.-Fistulas and sinus
tracts are hallmarks of Crohn’s disease, affect-
ing approximately 20-40% of patients [7]. The
morphology and anatomic sites of fistulas are
Fig. 13.-CT-directed percutaneous abscess drainage in Crohn’s disease.
protean: enteroenteric, enterocolic, colocolic, A, CT scan shows extraperitoneal abscess (A) along posteromedial aspect of right iliopsoas muscle.
enterovesical, enterovaginal, enterocutaneous, B, CT scan obtained after percutaneous insertion of catheter shows complete drainage of abscess.
AJR:167, July 1996 9

Gore et al.
their series [55]. MR imaging does offer cer-

tain advantages in evaluating anorectal dis-
ease by virtue of its ability to directly image
fistulas and sinus tracts in the sagittal and
coronal planes [56-58]. Transrectal sonogra-
phy has proven superior to CT in determining
the depth of mural involvement in the anorec-

turn and the integrity of the anal sphincter in
patients with Crohn’s disease [59, 60].
Neoplasms Complicating Crohn’s Disease

Patients with chronic Crohn’s disease
show an increased incidence of adenocarci-
noma and lymphoma of the small bowel and
colon, particularly in the bypassed or
excluded segments of the gut [37]. Because
Fig. 14.-Phlegmon associated with Crohn’s disease. Unenhanced CT scan shows homogeneous mural thicken- these bowel loops cannot be studied by con-
ing of descending colon (c), pericolic phlegmon (straight arrows), and fascial thickening (curved arrow). ventional barium or endoscopic techniques,
CT is helpful in detecting a tumor mass and
providing accurate tumor staging.
study, CT showed penirectal-perianal abnor- emphasized that in patients with Crohn’s dis-
malities in 82% of patients: inflammation of ease, the plane of scanning must continue
caudal to the symphysis to include the entire Differential Diagnosis of IBD
fat planes in the perirectal region and
ischiorectal fossa (73%), rectal wall thicken- perineum because significant disease was The differentiation of granulomatous coli-
ing (30%), fistulas or sinus tracts (22%), and found beneath the level of the symphysis tis and ulcerative colitis is important in terms
abscesses (14%) 1551 (Fig. 16). The authors pubis in more than one-third of patients in of medical management, surgical options, and
Fig. 15.-Fistulas and sinus tracts in three patients.

A, CT scan shows abscess (A) that is associated with fistula to colon (straight solid
arrow) and sinus tract (straight open arrow) and that extends into thickened trans-
versus abdominis muscle (curved arrow).
B, Pelvic CT scan shows rectovaginal fistula (arrow). B = bladder; V = contrast ma-
terial-filled vagina; C = cervix; R = rectum.
C, CT sinogram obtained before surgery shows relationship of patient’s rectocuta-
neous fistula to levator ani muscles (arrow) and rectum (R).
10 AJR:167, July 1996

Fig. 16.-Anorectal pathology secondary to Crohn’s disease in three patients.

A, CT scan of pelvis shows circumferential, homogeneous mural thickening of rectum (R). Note phlegmon (arrow) extending into left perirectal fat. U = uterus.
B, CT scan shows perirectal abscesses (solid arrows) associated with sinus tract extending into right buttock (open arrow).
C, CT scan of pelvis shows presacral abscess (curved arrows) attributable to fistula (straight arrow) from rectum (R).
prognosis. This distinction usually can be Extraintestinal Complications of IBD by fat malahsorption, hyperalimentation, sepsis,
made on the basis of colonoscopy with Extraintestinal complications develop in protein-losing enteropathy, malnutrition, and
biopsy, histologic studies, double-contrast one-quarter to one-third of patients with IBD corticosteroids. CT is an excellent means of
barium enema, determination of disease dis- 161 1. These complications can be divided into showing hepatic steatosis noninva.sively [62].
tribution, and clinical course. CT occasionally three categories: ( I ) those that are intimately About 30-50/e of patients with Crohn’s
can help distinguish these disorders by show- related to the activity or extent of disease and disease develop gallstones, especially in the
ing differences in wall thickness, wall density, that are responsive to therapy directed at the presence of extensive terminal ileal disease or
distribution of cobonic involvement, and the bowel disease (e.g.. arthritis or iritis); (2) after ileal resection. These patients form litho-
presence or absence of small-bowel disease, those whose course is independent of the genic bile as a consequence of bile salt malab-
abscesses. fistulas, and rnesentenic fibrofatty severity of the underlying bowel disease sorption or loss through the enterohepatic
proliferation (Table I). (e.g., sclerosing cholangitis or ankylosing circulation 1621. Although sonography is the
Idiopathic IBD also must be differentiated spondylitis); and (3) those that result from primary means of detecting gallstones, CT is
from infectious, ischemic, and radiation entero- inadequate or disordered intestinal function superior for detecting choledocholithiasis.
colitides. A recent study showed considerable (e.g., cholelithiasis or nephrolithiasis) 161 1. Primary sclerosing cholangitis occurs in
overlap in the CT findings for these disorders; 1-4% of patients with ulcerative colitis and
however, certain defining features were found Hepatobiliary Complications less commonly in those with Crohn’s disease
1161. The presence of ascites was more sugges- The most frequent. serious complications [64). Although the sensitivity of CT for the
tive of an acute rather than a chronic cause of of extraintestinal IBD occur in the liver and diagnosis of sclerosing cholangitis has not
colonic inflammation. Penitoneal fluid was the biliary tract 162-651. As a rule, these been established. CT can directly visualize
commonly found in acute colitides, particularly complications do not correlate with disease the fibrous mural thickening of the larger bile
pseudomembranous. infectious, and ischemic activity, duration, or severity, with the ducts that characterizes this disease. Other
colitides, and not in chronic IBD. Ascites was exception of fatty infiltration, which tends to CT signs suggesting sclerosing cholangitis
only infrequently seen in patients with acute occur in patients who are more seriously ill. include focal duct dilatation, discrepancy
IBD. Submucosal fat deposition on CT scans debilitated, and malnourished or who are on between the sizes of the intrahepatic and
was primarily found in subacute and chronic hyperalimentation therapy. extrahepatic bile ducts, focal clustering of
colitides, usually ulcerative colitis, and not in Fatty liver is found on liver biopsy in 20- intrahepatic ducts, and discontinuous areas of
acute colitis (16). 50% of patients with IBD and may be caused minimal intrahepatic bile duct dilatation (Fig.
17). These findings are best appreciated on
contrast-enhanced scans. CT offers three
-w’.]-’.. Features of Ulcerative Colitis and Crohn’s Disease
major advantages in evaluating patients with
CT Feature Ulcerative Colitis Crohn’s Disease p known or suspected sclerosing cholangitis
Wall thickness (mm) (mean ± SD) 7.8 ± 1.9 11.0 ± 5.1 <.0002 166]. First, it is a noninvasive technique, an
Submucosal fat (% of patients) 61 8 .0001 important consideration for patients who
Isolated right colon involvement 0 38 <.0004 need multiple serial examinations. Second.
(% of patients) CT can visualize the entire hiliary tract in
Mesenteric fibrofatty proliferation 0 49 <.0004 cases in which strictures obstruct the flow of
(% of patients) contrast medium during cholangiography,
Abscess (% of patients) 0 35 <.0007 occasionally leaving large portions of the
Note-Adapted from (161. intrahepatic bile ducts unexamined. Finally.
AJR:167, July 1996

Gore et al.
-- contents into the duct; and (6) autoantibodies

w --
against pancreatic acinar cells [69, 70].
Regardless ofthe cause, CT is needed to help
k -‘
confirm the diagnosis of pancreatitis and,

more importantly, its complications.
Urinary Tract Complications

...
Between 2% and 10% of patients with
Crohn’s disease develop nephrolithiasis
attributable to water and electrolyte losses
from diarrhea, malabsorption, and high ileo-
stomy output [71, 72]. Oxalate stones are the
most common stones to develop but may not
be sufficiently dense to be visible with con-
ventional radiology techniques.
Hydronephrosis may develop in patients
with Crohn’s disease for a variety of reasons:
calculous disease, obstruction attributable to
Fig. 17.-Sclerosing cholangitis associated with inflammatory bowel disease. CT scan shows focal clustering of
dilated intrahepatic ducts associated with discontinuous areas of minimal intrahepatic bile duct dilatation. Note the inflammatory effect of an abscess (Fig. 19)
beaded appearance of left ductal system (arrow). or phlegrnon, or the mass effect of creeping
fat of the mesentery encroaching on the ure-
ter. CT is useful in detecting both hydro-
CT can depict complications of sclerosing for the development of hepalic abscesses in nephrosis and the obstructing mass or stone.
cholangitis, such as secondary biliary cirrhosis patients with Crohn’s disease [68]. CT is the Fistulas may develop between the diseased
and portal hypertension, as well as soft-tissue premier means of diagnosing hepatic abscesses gut and the kidney(s) in patients with Crohn’s
masses associated with cholangiocarcinoma. and guiding the percutaneous drainage of suit- disease, leading to a renal or perinephric
About 1.5% of patients with ulcerative colitis able collections (Fig. 18). abscess. More commonly, enterovesical fistulas
develop cirrhosis attributable to chronic active develop [48, 72]. Conventional studies detect
hepatitis, sclerosing cholangitis, pericholangi- Pancreatic Complications fewer than 50% of enterovesical fistulas,
tis, or any combination of these 165]. Approximately 1-2% of patients with whereas CT has a nearly 90% success rate [72].
Hepatic abscesses are well-described com- Crohn’s disease develop pancreatitis attribut- The presence of air in the bladder in the absence
plications of Crohn’s disease [67, 68]. Hepatic able to a variety of causes: (I) drugs, such as of a Foley catheter or previous instrumentation
abscesses most commonly develop in patients steroids, azathiopnine, and metronidazole; is diagnostic of an enterovesical fistula.
with long-standing disease but may occur as (2) choledocholithiasis; (3) fistula from the
the initial manifestation of Crohn’s disease. adjacent gut; (4) sclerosing cholangitis; (5) Musculoskeletal Complications
Steroids and other immunosuppressive agents, sphincter of Oddi dysfunction or stenosis of Arthritis, one of the most common extrain-
perforations, intraabdominal abscesses, and the descending duodenum leading to ob- testinal manifestations of IBD, is manifested
anastornotic leaks are all predisposing factors struction of the duct or reflux of duodenal as peripheral arthritis, sacroiliitis-spondylitis,
Fig. 18.-Liver abscess complicating Crohn’s disease.

A, CT scan shows multiple areas of low attenuation in left hepatic lobe.
B, CT scan taken after injection of contrast material through percutaneous drainage catheter shows multilocular liver abscess.
12 AJR:167, July 1996

Fig. 19.-Crohn’s disease abscess causing hydronephrosis.

A, CT scan of midabdomen shows right-sided hydronephrosis.
B, CT scan of iliac fossae shows right lower-quadrant abscess (arrows) secondary to Crohn’s ileitis and causing
right ureteral obstruction.
C, Retrograde pyelogram confirms level of right ureteral obstruction (arrow).
or both. The radiologic findings of entero-

pathic peripheral arthritis usually are minimal
and are best seen, if at all, on conventional
radiographs. IBD-related changes in the axial
skeleton are similar to changes seen with
ankylosing spondylitis [73-75] (Fig. 20). CT
can detect the subtle changes of early sacroilii-
tis before they become apparent on plain films:
bilateral, usually symmetric joint narrowing
with osseous erosions and then sclerosis, more
pronounced on the iliac side of the articulation.
Between 10% and 30% of patients with IBD
have symptomatic sacroiliitis; some of them
experience significant disability [76]. In a
recent study, CT showed the presence of
asymptomatic sacroiliitis in 32% of patients
with IBD, although it was identified by plain
film radiography in only 10% of patients [77].
The CT identification of asymptomatic sacro-
iliitis may enable the earlier introduction of
Fig. 20.-Crohn’s disease-associated ankylosing spondylitis. Pelvic CT scan photographed at bone window
therapy to inhibit disease progression or per- shows partial bony ankylosis of right sacroiliac joint (straight arrow). Note mural thickening (curved arrows) of
mit the earlier diagnosis of IBD in a previously distal ileal loop.
AJR:167, July 1996

Gore et al.
disease and ulcerative colitis. borlschr R#{246}ntgeisir

1995: I63:9-IS
6. Balthazar El. CT of the gastrointestinal tract: prin-
ciples and interpretation. AiR 1991 : I 56:23-32
7. Gore RM. Laufer I. Ulcerative and granuloma-
tous colitis: idiopathic inflammatory bowel dis-
ease. In: Gore RM, Levine MS. Laufer I, eds.
Te.sibook 0/ ,‘(I.Vtfl)i?1te5ti1Ull radiology. Philadel-

phia: Saunders, 1994:1098-I 141
8. Gore RM. Cross-sectional imaging of the colon.
In: Gore RM. Levine MS. Laukr I, eds. Textbook
ofgastroil:t(’stillal rathologv. Philadelphia: Saun-
ders. 1994:1051-1063
9. Vecchioli A, Dc Franco A, Maresca G, Gore RM.
Cross-sectional imaging of the small bowel. In:
Gore RM, Levine MS. Laufer I. eds. Tvthook of
Fig. 21.-Osteomyelitis of right iliac crest complicating Crohn’s ileocolitis. CT scan shows mural thickening of gastrointesiiuzl radiology. Philadelphia: Saun-
ascending colon (A), with retrocolic extension of inflammatory change (curved arrow) into pelvic wall and de- ders, 1994:789-801
struction of right iliac bone (straight arrow). 10. Scholten ET. des Plantes BGZ, Falke THM.
Computed tomography of the large bowel wall.
Choice of slice thickness and intraluminal con-
unidentified host. There appears to be no cor- right psoas muscle abscess may develop second- trast medium. I,ii’est RwIiol 1995;30:27S-284
relation between the presence of sacroiliitis WY to terminal ileal disease, and a left psoas I I. Archibald GR, Scholz FJ. Larsen CR. Computed
and the type, duration, or severity of IBD [77]. muscle abscess can result from sigmoid or jeju- tomographic findings of giant intestinal pseudopoly-
Osteonecrosis has been reported as a rare nal involvement. Most patients with psoas mus- posis. (kzstroi,uest Radiol 1988: I 3: 1-1S9
12. Foderaro AE, Barlow Ti, Murray JA. Giant
complication of IBD in the following clinical dc abscesses have well-established Crohn’s
pseudopolyposis in Crohn’s disease with com-
settings: during or after corticosteroid therapy; disease, but the clinical manifestations may be
puted tomography correlation. J Conipiit T()lnogr
during total parenteral nutrition. especially with nonspecific. Occasionally, psoas muscle ab- 1987:11:288-290
lipid emulsions; and, most recently, as a direct scesses are seen at the initial presentation of 3. Siskind BN. Burrell MI, Klein ML, Princenthal
complication of the disease without other pre- Crohn’s disease. CT has emerged as the best RA. Toxic dilatation in Crohn disease with CT cor-
cipitating factors 178, 79). CT studies often can technique for the diagnosis and percutaneous relation. J Coitiput Assist Thiiiogr 1985:9: I 93-195
4. Gore RM. Maim CS. Kirby DF. et al. CT findings
show early signs of avascular necrosis before management ofpsoas muscle abscesses [84’ 851.
in ulcerative, granuloniatous. and indeterminate
plain film studies. CT abnormalities include Primary rectal sheath abscesses also have
colitis. AiR 1984:143:279-284
subtle alterations in the trabecular pattern. joint been reported as a complication of Crohn’s dis-
15. Gore RM. Goldberg HI. Computed tomographic
space integrity, femoral head contour, and ace- ease and may be diagnosed and treated with evaluation of the gastrointestinal tract in diseases
tahulum, which may be undetectable or poorly percutaneous drainage under CT guidance 1861. other than primary adenocarcinoma. Radiol Cli,,
defined on plain films. However. MR imaging North, Atti 1982:20:78 1-798
is the best technique (or establishing the diagno- 6. Philpotts LE, Heiken JP, Westcott MA, Gore RM.
Conclusion
Colitis: use of CT findings in dillerential diagno-
sis ofavascular necrosis.
CT is the premier imaging procedure fbr sis. Radiology 1994; I 90:445-449
Septic arthritis of the hip can complicate a
evaluating the mural and extraintestinal mani- 17. Gore RM. CT of inflammatory bowel disease.
psoas muscle abscess or a retroperitoneal Radiol Cli,, North Au, 1989:27:7 17-730
festations of IBD. Although barium studies
abscess progressing through the greater sciatic 8. Gon RM. Crvws-sectiond imaging of inflammatory
have been and remain the primary radiographic
notch. MR imaging and CT show these changes bowel disease. Rathol Cli,, North,A,n 1987;25: I 1-133
means of diagnosing IBD, CT plays a critical
before they can be recognized on plain films. 19. Gore RM. Characteristic morphologic changes in
role in detecting abscesses, in differentiating
The iliac bone (Fig. 21) and the sacrum are chronic ulcerative colitis. Abdoni Imaging 1995;
various causes of mesenteric abnormalities, and 20:275-278
the most frequent sites of osteomyelitis in
in discovering the extraintestinal complications 20. Gore RM. Colonic contour changes in chronic
patients with Crohn’s disease [80. 81]. Iliac and
that so often afflict IBD patients. ulcerattve colitis: reappraisal of some old con-
sacral bone infections are almost invariably the cepts. AiR 1992:158:59-61
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Gore Et Al 2013 CT Features of Ulcerative Colitis and Crohn S Disease

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CT Features of Ulcerative Colitis and Crohn’s Disease

pathic inflammatory bowel of IBD, scans also should be obtained before

Received January 3, 1996; accepted after revision February 20, 1996.

AJR 1996;167:3-15 0361-803X/96/1671-3 © American Roentgen Ray Society

AJR:167, July 1996

4 AJR:167, July 1996

tis, ischemic and radiation enterocolitides,

individual layers of bowel wall) is seen in

AJR:167, July 1996

show mural stratification and often have a target

edema or fat infiltration, respectively), which in

Acute Phase: Inflammation

6 AJR:167, July 1996

Fig. 7.-Target sign in acute, noncicatrizing phase of Crohn’s disease.

Fig. 8.-Small-bowel obstruction attributable to Crohns disease of distal ileum.

AJR:167, July 1996

8 AJR:167, July 1996

AJR:167, July 1996 9

their series [55]. MR imaging does offer cer-

the depth of mural involvement in the anorec-

Neoplasms Complicating Crohn’s Disease

Fig. 15.-Fistulas and sinus tracts in three patients.

10 AJR:167, July 1996

Fig. 16.-Anorectal pathology secondary to Crohn’s disease in three patients.

AJR:167, July 1996

-- contents into the duct; and (6) autoantibodies

confirm the diagnosis of pancreatitis and,

Urinary Tract Complications

Fig. 18.-Liver abscess complicating Crohn’s disease.

12 AJR:167, July 1996

Fig. 19.-Crohn’s disease abscess causing hydronephrosis.

or both. The radiologic findings of entero-

AJR:167, July 1996

disease and ulcerative colitis. borlschr R#{246}ntgeisir

Te.sibook 0/ ,‘(I.Vtfl)i?1te5ti1Ull radiology. Philadel-

14 AJR:167, July 1996

AJR:167, July 1996

120. Jaime L. Bohl, Alan E. Timmcke. Radiology 77-106. [Crossref]

Radiology 16:4, 277-282. [Crossref]

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