IMAGING IN INFLAMMATORY

BOWEL DISEASE
 INTRODUCTION

 Group of chronic disorders that cause inflammation

and ulceration in small and large bowel.

 Mainly two most common diseases are –chron’s

disease and ulcerative colitis
ANATOM
Y
AFFECTED AREAS
SUB TYPES OF CD & UC
 CHRON’S DISEASE

 Idiopathic, chronic, transmural inflammatory process

of bowel - affect whole GI system starting from
mouth to anus.
 Most commonly involved- terminal ileum, ileocaecal
valve and caecum with regional enteritis.
 SKIP LESIONS ARE PATHOGNOMIC
 Diagnosed typically between 15-25 years of age
group.
 No gender predilection, runs in families.
 Smokers - more affected.
• Chron’s disease can be Stricturing, Penetrating, Inflammatory

• Etiology – idiopathic, genetic(DR5 DQ1 alleles), immunologic, microbial,

psychosocial

• Clinical presentation- diarrhoea, abdominal pain, weight loss

• Intermittent attacks of active disease followed by periods of remission.

• Disease re-activation by triggers like stress, dietary factors, smoking.

• Risk of colonic adenocarcinoma is increased in long standing cases.

• on X-ray- plain radiograph of abdomen is usually helpful in cases of
obstruction secondary to chron’s or extraintestinal manifestations
 Barium small bowel follow-through
 MUCOSAL ULCERS
 APHTHOUS ULCERS initially
 deeper transmural ulcers typically either longitudinal or circumferential in
orientation

 when severe leads to COBBLESTONE APPEARANCE

 may lead to sinus tracts and fistulae

 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
 APTHOUS ULCERS
First sign of chron’s disease
on barium
Cobblestone appearance:
due to deep fissuring
ulcers around inflammed
mucosa
Fissuring ulceration in Crohn's disease
- graphically called `raspberry thorn'
ulcers.
String sign: spasm/fibrosis of bowel wall
ILEOILEAL FISTULA: long
standing chron’s
 ULTRASOUND

 limited role, it has been evaluated as an initial screening tool

 Typically examination is limited to the small bowel and wall

thickness assessed:
Bowel wall thickness should be <3 mm, normally

 thickness < 3 mm helps exclude the disease in a low risk patient.

 thickness > 4 mm helps establish the diagnosis in a high risk patient.

 Ultrasound in the assessment of extraintestinal manifestations.

US image - stricture in a patient with active
Crohn's disease
 CT FINDINGS

 FAT HALO SIGN

 COMB SIGN
 Bowel wall enhancement
 Bowel wall thickening (1-2 cm) -terminal ileum
 strictures and fistulae
 mesenteric/intra-abdominal abscess or phlegmon
formation
Fat halo sign in chron’s disease
Transverse CT scan shows the central fatty submucosal layer of low attenuation (*)
surrounded by higher-attenuation inner (long arrow) and outer(short arrow) layers
grossly corresponding to the mucosa and muscularis propria and serosa of the
descending colon, respectively.
COMB SIGN:Hypervascular appearance of the mesentery in active Crohn's disease.
Fibrofatty proliferation and perivascular inflammatory infiltration outline the
distended intestinal arcades. This forms linear densities on the mesenteric side of
the affected segments of small bowel, which give the appearance of the teeth of a
comb.
 ULCERATIVE COLITIS

 Causes superficial ulceration of colon and rectum.

 It starts from rectum and retrogradely involves whole colon

continuously.
 In total colitis- back wash ileitis.

 More common in DR2 related genes.

 More female predilection, age group 30-40 yrs.

 Clinical symtoms- diarrhoea, tenesmus, bleeding per rectum, passage of mucus, crampy
abdominal pain.
 PATHOGENESIS

 MILD DISEASE: fine granularity

 MODERATE: marked erythema, coarse granularity, contact bleeding

and no ulceration.

 SEVERE: spontaneous bleeding,edematous and ulcerated

 Long standing cases epithelial regeneration- pseudopolyps, pre
cancerous condition
 Eventually shortening and narrowing of colon

 FULMINANT DISEASE: toxic colitis/megacolon

Acute UC – descending colon
has irregular outline.
 BARIUM ENEMA

 Mucosal inflammation-granular appearance to the surface of

the bowel.
 Mucosal ulcers are undermined -button-shaped ulcers

 Islands of mucosa remain giving it a pseudo-polyp

appearance

 In chronic cases the bowel becomes featureless with loss of

normal haustral markings, luminal narrowing and bowel
shortening- lead pipe sign
FINE MUCOSAL
GRANULARITY- FIRST SIGN
NARROWING OF LUMEN
COLLAR
BUTTON
ULCERS
LEAD PIPE COLON
 CT FINDINGS

 Inflammatory pseudopolyps

 Inflamed and thickened bowel - target appearance, due concentric

rings of varying attenuation- mural stratification

 In chronic cases, submucosal fat deposition is seen particularly in the

rectum fat halo sign

 Extramural deposition of fat, leads to thickening of the perirectal

fat, widening of the presacral space

 Marked muscularis mucosa hypertrophy-lead pipe sign.

INFLAMMATORY PSEUDOPOLYPS
 MRI

 Wall Thickening- median wall thickeness of colon

ranges from 4.7 to 9.8 mm, more severe the disease
more thicken the wall

 Increased Enhancement- enhancement of the mucosa

with no or less enhancement of the submucosa

 Loss of haustral markings

Mri image reveals thickening
of colon with loss of
haustral markings
 DIFFERENCE
CHRON’S DISEASE
 70-80%Small bowel involvement
 Skip lesions
 Fat halo sign seen in 8%
 Apthous ulcers are seen
 Bowel wall more thicker
 Irregular serosal surface
 Perianal fistula/sinus/abscess
more common
 Creeping fat and abscess are
very common in chronic cases
ULCERATIVE COLITIS
 95% cases rectal involvement
 Continuous spread from rectum
upwards
 Fat halo sign is commonly seen
 Collar button ulcers are seen.
 Smooth serosal surface
 Mesenteric creeping fat and
abscess are uncommon.
 Carcinoma is more common in
long standing cases.
 DIFFERENTIAL DIAGNOSIS

 Ileocaecal tuberculosis
 Acute appendicitis
 Mesenteric adenitis
 Malignancy
 Acute diverticulitis
 Acute epiploic appendagitis
 Ischaemic colitis
 Pseudomembranous colitis
THANK YOU