Ezekiel T.

Arteta

Imaging
PLAIN FILM • Detects colonic obstruction, colonic ileus, and the toxic megacolon syndrome in IBD SINGLE CONTRAST
• Demonstrates anatomy and tonus (contraction) of colon, along with most abnormalities

DOUBLE CONTRAST
• Allows visualization of lumen with any polyps or lesions

CT • Determines the presence and extent of extracolonic disease UTZ • Rarely used because of intraluminal gas

Anatomy

Physiology
Function
• Formation, transport, and evacuation of feces

• Water absorption by the right colon

air bubbles. feces. mucus. tumors. • May be caused by polyps. • Polyp • Protrusions from the mucosa • Does not imply a histologic diagnosis .Colon Filling Defects/ Mass Lesions Filling Defect • radiolucency in a barium pool caused by a protruding mass lesion. or foreign objects.

Colorectal Adenocarcinoma Most common malignancy of the GI tract Location: • Rectum and Rectosigmoid area (50%) • Sigmoid Colon (25%) Most developed from preexisting adenomas Most are annular constricting lesions. Spreads through . with raised everted edges and ulcerated mucosa.

Colorectal Adenocarcinoma .

Colorectal Adenocarcinoma Spreads through: • Direct Invasion into pericolonic fat and adjacent organs • Lymphatic Invasion to regional nodes • Hematogenous Invasion through the portal veins to the liver and the systemic circulation Most common complication is obstruction .

Colorectal Adenocarcinoma Risk factors: • Ulcerative colitis • Crohn’s disease • Familial Adenomatous Polyposis • Peutz-Jeghers syndrome Clinical Features • Peak age 50-70 years • Weight loss • Blood in stool • Loss of appetite • Change in bowel habits .

Colorectal Adenocarcinoma Imaging Methods • Transrectal or Colononoscopic US: Local disease staging • CT and MR: For more advanced disease and to detect recurrence • CT is the method of choice for tumor recurrence because it can survey the whole abdominal cavity .

and hemorrhagic areas within the tumor mass • Linear soft tissue stranding into the pericolonic fat • Enlarged regional lymph nodes • Distant metastases. especially in the liver • Thickening of the wall of the uninvolved colon proximal to the tumor .Colorectal Adenocarcinoma Cross-Sectional Findings • Polypoid Primary Tumor (usually >1 cm) • “Apple-core” lesions • Cystic. necrotic.

Annular Adenocarcinoma (Single Contrast Study) .

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Polyps Localized mass that projects from the mucosa into the lumen. Presence is a major indication for barium studies of the colon Rules of Thumb: • <5 mm: almost all hyperplastic.5% • 5-10 mm: 90% adenomas. 1% risk of malignancy • 10-20 mm: adenomas. risk of malignancy <0. 10% risk of malignancy • >20 mm: 50% malignant .

major risk for developing adenocarcinoma • Neoplasms with a core of connective tissue Hamartomatous polyps (juvenile polyps) • common cause of rectal bleeding in children Inflammatory polyps • usually multiple.Polyps Hyperplastic polyps • Nonneoplastic. associated with inflammatory bowel disease . round and sessile. nearly all are smaller than 5 mm Adenomatous polyps • Distinctly premalignant.

Polyp .

Polyp “Bowler Hat Sign” .

Polyp .

1/3 spontaneous Autosomal dominant Tubulovillous adenomas that becomes prominent at age 20 Colorectal cancer will eventually develop in nearly all patients Tx: total colectomy with rectal mucosectomy and ileoanal pouch construction .Familial Adenomatous Polyposis Syndrome 2/3 inherited.

Familial Adenomatous Polyposis Syndrome .

Lymphoma Less commonly involved than the stomach or small bowel • Anal and rectal lymphoma= frequent in AIDS patients Morphology • Multinodular (lymphomatous polyposis) • Solitary (resemble a polypoid carcinoma) .

Rectal Lymphoma .

usually 1 to 3 cm in diameter • CT: fat-density tumor (definitive) . elliptic filling defect.Lipoma Most common submucosal tumor of the colon Most frequent in the cecum and ascending colon Nearly 40% present with intussusception Appearance: • Barium: smooth. well-defined.

Colon Inflammatory Diseases Ulcerative Colitis Crohn’s Disease Infectious Colitis Toxic Megacolon Pseudomembranous Colitis Amoebiasis .

symmetry of disease around the lumen. and continuous confluent diffuse involvement. confluent shallow ulcerations.Ulcerative Colitis Idiopathic inflammatory disease involving primarily the mucosa and submucosa of the colon Peak age: 20 to 40 years. and hyperemia Granular mucosa. edema. onset after age 50 is common. Superficial ulcerations. .

Ulcerative Colitis Radiographic Hallmarks: • Granular mucosa • Confluent shallow ulcerations • Symmetry of disease around the lumen • Continuous confluent diffuse involvement Morphology: • Collar button ulcers: deeper ulcerations of thickened edematous mucosa with crypt abscesses extending in the submucosa • Coarse granular pattern by replacement of diffusely ulcerated mucosa with granulation tissue .

Collar Button Ulcers .

Ulcerative Colitis Late Changes: • Pseudopolyps= mucosal remnants in areas of extensive ulceration • Inflammatory polyps= small islands of inflamed mucosa • Postinflammatory polyps= mucosal tags that are seen in quiescent phases of the disease • Filiform polyps= postinflammatory polyps with a wormlike appearance • Hyperplastic polyps= may during healing after mucosal injury .

Ulcerative Colitis CT Findings • Halo sign: low-density submucosal edema with wall thickening • Narrowing of the lumen of the colon • Pseudopolyps • Pneumatosis coli with megacolon Complications: • Strictures • colorectal adenocarcinoma .

Ulcerative Colitis Complications: • Strictures • Colorectal adenocarcinoma • Toxic megacolon • Massive hemorrhage .

Strictures .

Lead Pipe Sign .

Crohn’s Disease Involves the colon in two thirds of cases Isolated to the colon in approximately one third of all cases Hallmarks: • Early aphthous ulcers • Later confluent deep ulcerations • Predominant right colon disease • Discontinuous. fistulas. asymmetric involvement • Strictures. and sinus formation .

Crohn’s Disease Ulcerative Colitis Circumferential disease Regional (continuous disease) Predominantly left-sided Crohn Colitis Eccentric disease Skip lesions (discontinuous disease) Predominantly right-sided Rectum usually involved Confluent shallow ulcers No aphthous ulcers Collar button ulcers Terminal ileum usually normal Terminal ileum patulous No pseudodiverticula No fistulas High risk of cancer Risk of toxic megacolon Rectum normal in 50% of cases Confluent deep ulcers Aphthous ulcers early Transverse and longitudinal ulcers Terminal ileum usually diseased Terminal ileum narrowed Pseudodiverticula Fistulas common Low risk of cancer No toxic megacolon .Ulcerative Colitis vs.

E. Shigella. coli) • Parasites • Viruses (CMV.Infectious Colitis Etiologic Agents: • Bacteria (Salmonella. Herpes) • Fungi (Histoplasmosis. . Mucormycosis) Most cause a pancolitis with edema and inflammatory wall thickening with infiltration of pericolonic fat Pericolonic fluid and intraperitoneal fluid may be present.

CMV Colitis .

Toxic Megacolon Potentially fatal Marked colonic distension and risk of perforation Complication of fulminant colitis Radiographic Findings: • Marked dilatation of the colon (transverse colon >6 cm) with absence of haustral markings • Edema and thickening of the colon wall • Pneumatosis coli • Evidence of perforation Barium studies must be avoided .

Pseudomembranous Colitis Inflammatory disease characterized by the presence of a pseudomembrane of necrotic debris and overgrowth of Clostridium difficile Radiographic Findings: • Dilated colon • Nodular thickening of the haustra • Ascites .

Pseudomembranous Colitis CT findings: • marked wall thickening up to 30 mm (average 15 mm) with halo or target appearance • characteristic stripes of intraluminal contrast media trapped between nodular areas of wall thickening (accordion sign) • Mild pericolonic fat inflammation disproportionate with the marked colonic wall inflammation • ascites .

Pseudomembranous Colitis .

Amoebiasis Infection by the protozoan parasite Entamoeba histolytica Barium studies demonstrate a disease that closely mimics Crohn colitis Primary areas: cecum and rectum (terminal ileum is characteristically not involved) .

Diverticular Diseases Diverticulosis Diverticulitis .

Diverticulosis Acquired condition Mucosa and muscularis mucosae herniate through the muscularis propria of the colon wall. producing a saccular outpouching False diverticula Common with age over 75 years old Major risk factor: low-residue diet Most common site: sigmoid colon .

Diverticulosis Severely affected portions of bowel are usually shortened in length. resulting in crowding of the thickened circular muscle bundles. Diverticulosis without diverticulitis is a cause of painless colonic bleeding Radiographical Findings: • gas-filled sacs parallel to the lumen of the colon • Barium studies show diverticula as barium or gas-filled sacs outside the colon lumen .

Diverticulosis CT Findings • Thickened colon wall and distorted luminal contour • diverticula are shown as well-defined gas-. or contrastfilled sacs outside the lumen . fluid-.

Diverticulosis .

usually with perforation and intramural or localized pericolic abscess Complications: • Bowel obstruction • Bleeding • Peritonitis • Sinus tract and fistula formation .Diverticulitis inflammation of diverticula.

Diverticulitis inflammation of diverticula. usually with perforation and intramural or localized pericolic abscess Complications: • Bowel obstruction • Bleeding • Peritonitis • Sinus tract and fistula formation .

Diverticulitis Barium Studies • deformed diverticular sacs • demonstration of abscess • extravasation of barium outside the colon lumen CT Findings • localized wall thickening • inflammation of pericolonic fat • pericolonic abscess • diverticula at or near the site of inflammation .

Diverticulitis .

especially acute appendicitis . Both CT and US have proven extremely useful in the diagnosis of appendiceal disease.Appendix Filling of the appendix is attained most reliably by single-contrast barium enema examination Failure to fill the appendix with barium on barium enema examination is not definitive evidence of appendiceal disease.

the normal appendix appears as a thin-walled tube less than 6 mm in diameter . mucosa is heavily infiltrated with lymphoid tissue On CT and US.Anatomy arises from the posteromedial aspect of the cecum at the junction of the taenia coli. although it may be up to 30 cm long. blind-ended tube that is 5 to 10 mm in diameter (on barium studies) and approximately 8 cm in length. approximately 1 to 2 cm below the ileocecal valve.

Anatomy (CT Scan) .

but free perforation and pneumoperitoneum occasionally occur .Acute Appendicitis most common cause of acute abdomen results from obstruction of the appendiceal lumen Bacterial infection causes gangrene and perforation with abscess Most periappendiceal abscesses are walled off.

Plain films will demonstrate an appendiceal calculus (appendicolith or fecalith) in approximately 14% of patients .