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IMAGING IN INFLAMMATORY BOWEL DISEASE Dr. Ishfaq A. Shad
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PROTOCOL INTRODUCTION CLASSIFICATION DEFINATIONS ETIOPATHOLOGY CLINICAL FEATURES IMAGING MODALITIES COMPLICATIONS DIFFERENCES BETWEEN UC & CD DIFFERENTIAL DIAGNOSIS CONCLUSION
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INTRODUCTION
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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.
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CLASSIFICATION
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Typical IBD (2 Major Types): Ulcerative Colitis (Colitis Ulcerosa) Crohn’s Disease (Regional Enteritis) Atypical IBD: Lymphocytic Colitis Collagenous Colitis Ischaemic Colitis Diversion Colitis Indeterminate Colitis Bachet’s Disease
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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.
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CROHN’S DISEASE (CD) Crohn’s disease (CD): although it most commonly affects the bowel, Crohn’s disease can involve any part of the gastrointestinal tract from the mouth to the anus. Diseased segments, called “skip areas” 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.
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ANATOMY
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AFFECTED AREAS
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SUB TYPES OF CD & UC
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ETIOPATHOGENESIS
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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 E.coli. Defective immune responses fail to clear invading bacteria, which seems to activate other immune cells fuelling further inflammation.
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ETIOPATHOGENESIS… 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.
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CLINICAL FEATURES
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CLINICAL FEATURES (IBD) Abdominal Pain/Cramping Diarrhea, often with Blood in the Stool Weight Loss Fever & Fatigue Reduced Appetite Weight Loss
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CLINICAL FEATURES (UC) Bloody Diarrhea Urgency Abdominal Pain (Left Sided) Fever Nocturnal Diarrhea Frequent small volume bowel movements
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CLINICAL FEATURES (CD) Persistent Diarrhea Loss of Appetite & Weight Loss May have Rectal Bleeding Abdominal Pain/Cramping Steatorrhea Fatigue Fever
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EXTRA INTESTINAL FEATURES:
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INVESTIGATIONS
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ABDOMINAL X RAY Helpful in cases of Obstruction secondary to Crohn’s Disease Extra Intestinal Manifestations To Assess Intestinal Obstruction Pneumoperitoneum
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ABDOMINAL X RAY.. Small Bowel Obstruction Multiple Air fluid levels >2 Wide Air fluid levels >2.5 cm Differential Air fluid levels Small bowel / Colon ratio > 0.5 Pneumoperitoneum Air under Diaphragm Rigler sign/Double Wall sign (Air on both sides of the bowel)
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ABDOMINAL X RAY… Step Ladder configuration of Small Bowel loops String of Pearl sign Thumb printing appearance Toxic Megacolon
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SBO..
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SBO...
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STEP LADDER CONFIGURATION (SMALL BOWEL LOOPS ARRANGING THEMSELVES IN A STEP LADDER CONFIGURATION FROM LUQ TO RLQ)
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CONSISTS OF AN OBLIQUELY OR HORIZONTALLY ORIENTED ROW OF SMALL GAS BUBBLES IN THE ABDOMEN.
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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.
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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 LEAKAGE.1 IT CAN RESULT FROM ANY PROCESS THAT LEADS TO OEDEMA OF THE BOWEL WALL.
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FLUOROSCOPY Features on barium small bowel follow-through include: mucosal ulcers aphthous ulcers initially deep ulcers (more than 3mm depth) longitudinal fissures transverse stripes when severe leads to cobblestone appearance 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
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APHTHOUS ULCERS ARE SMALL, DISCRETE LESIONS & ARE SURROUNDED BY SLIGHTLY ELEVATED EDEMATOUS MUCOSA. BARIUM COLLECTS IN THE CENTRAL DEPRESSION, WITH THE SURROUNDING ELEVATION APPEARING AS A RADIOLUCENT HALO.
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APHTHOUS ULCER
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APHTHOUS ULCER
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APHTHOUS ULCER
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COBBLESTONE- DEEP LONGITUDNAL ULCERS COMBINED WITH ADJACENT MUCOSAL EDEMA, RESULTS IN CHARACTERISTIC COBBLESTONE APPEARANCE
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COBBLESTONE- LONGITUDNAL & CIRCUMFERENTIAL FISSURES AND ULCERS SEPARATE ISLANDS OF MUCOSA, GIVING IT AN APPEARANCE REMINISCENT OF COBBLESTONES.
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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
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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 – SO-CALLED ‘COBBLESTONING’. THIS IS CAUSED BY EXTENSIVE FISSURES AND ULCERATION IN BETWEEN AREAS OF INTACT BUT OEDEMATOUS MUCOSA, RESEMBLING COBBLESTONES (ARROWS).
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ROSE THORN THE DEEP, LINEAR ULCERS (ARROWS) THAT HAVE FILLED WITH BARIUM IN THIS STENOSED TERMINAL ILEUM ARE KNOWN AS ‘ROSE-THORN ULCERS’ AND ARE TYPICAL OF CROHN DISEASE.
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RASPBERRY THORN
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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 ‘STRING SIGN OF KANTOR’. THIS IMAGE ALSO DEMONSTRATES ANOTHER TYPICAL FEATURE OF LONGSTANDING CROHN DISEASE – THE AFFECTED BOWEL LOOP SEEMS TO BE SEPARATED FROM THE NORMAL SMALL BOWEL.
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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).
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STRING SIGN
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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.
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LEAD PIPE COLON DOUBLE CONTRAST BARIUM ENEMA IN LONG STANDING ULCERATIVE COLITIS CASE SHOWS CLASSIC ‘LEAD PIPE’ SIGN. THE IMAGE DEMONSTRATES DESCENDING COLON AND SIGMOID COLON TO BE FEATURELESS WITH LACK OF HAUSTRA AND NARROWING.
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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.
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ILEO ILEAL FISTULA
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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 mesenteric/intra-abdominal abscess or phlegmon formation 8 abscesses are eventually seen in 15-20% of patients
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FAT HALO SIGN- INFILTRATION OF THE SUBMUCOSA WITH FAT B/W THE MUSCULARIS PROPRIA AND THE MUCOSA. CHARACTERISED BY AN INNER (MUCOSA) & OUTER (MUSCULARIS PROPRIA AND SEROSA) RING OF ENHANCING BOWEL WALL ALONGWITH A NON ENHANCING MIDDLE LAYER (SUBMUCOSA).
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FAT HALO SIGN
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COMB SIGN- HYPERVASCULAR APPEARANCE OF THE MESENTRY. FIBROFATTY PROLIFERATION & 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.
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COMB SIGN
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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 & SEROSA)
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TARGET SIGN
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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.
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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: thickening of extramural fat, which separates bowel loops equivalent to the fat halo sign on CT vascular engorgement: comb sign stenoses and strictures
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ACTIVE CROHN'S DISEASE. LONG SEGMENT OF ILEAL WALL THICKENING WITH COMB SIGN AND TRANSMURAL ENHANCEMENT.
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WALL THICKENING IN IBD SHOULD BE DIFFERENTIATED FROM MALIGNANT WALL THICKENING. DISTINGUISHING FEATURES OF INFLAMMATION (CROHN'S DISEASE) ARE ULCERATIONS, INCREASED MESENTERIC VESSELS (COMB SIGN), SKIP LESIONS AND INCREASED SURROUNDING FAT (CREEPING FAT).
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TERMINAL ILEITIS: INFLAMED MUCOSA.
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MURAL THICKENING WITH MUCOSAL IRREGULARITY, ULCERS AND ENHANCEMENT. CORONAL VIEW T1-W POST-GADOLINIUM INJECTION DEMONSTRATING IRREGULAR ENHANCEMENT OF THE MUCOSA MIMICKING “COBBLE STONE APPEARANCE” WITH DEEP ULCERATION AND ENTEROENTERIC FISTULA (ARROW). FIESTA: MURAL THICKENING DUE TO INFLAMMATION CAUSING LUMINAL NARROWING (ARROWHEAD).
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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).
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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.
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MESENTERIC HYPERTROPHY (CREEPING FAT) (ARROW). (A) FIESTA CORONAL VIEW. (B) FIESTA AXIAL VIEW. NOTICE CHOLELITHIASIS (ARROWHEAD).
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MRI ENTEROCLYSIS MRI enteroclysis requires the placement of a nasojejunal catheter through which 1.5-2 L of contrast solution (e.g. 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.
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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.
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CD WITH FISTULAE
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ROUTINE MRI Routine MRI can also give valuable information: perianal disease liver disease sacroiliac joints and spine
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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 4,20. Typically examination is limited to the small bowel and wall thickness assessed: bowel wall thickness should be <3 mm
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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
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ULTRASOUND… Ultrasound does of course have a significant role to play in the assessment of: perianal disease: rectal ultrasound hepatobiliary disease
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STRICTURE
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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
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THICKENED BOWEL WALL- ADDITIONAL COLOUR DOPPLER IMAGES SHOW HYPERERMIA OF THE BOWEL
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Complications Of IBD
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Malnutrition Colon Cancer Fistulas Intestinal Rupture / Perforation Bowel Obstruction
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DIFFERENCES BETWEEN UC & CD
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CROHN DISEASE VS ULCERATIVE COLITIS Due to the overlap in clinical presentation of Crohn disease (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)
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CD VS UC.. distribution CD: skip lesions typical UC: continuous disease from rectum up gender CD: no gender preference UC: male predilection
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CD VS UC… 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
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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 fossa/perirectal fat (73%) fistulas/sinus tracts (22%)
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CD VS UC… 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
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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
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Differential Diagnosis
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The differential diagnosis depends on the presenting symptom. When terminal ileitis is the main presentation, then differentials (adjusted for patient's age) include 1: acute appendicitis Yersinia ileitis mesenteric adenitis ileocaecal tuberculosis 9 malignancy
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When colonic involvement is the predominant feature then other considerations include: ulcerative colitis acute diverticulitis acute epiploic appendagitis ischaemic colitis pseudomembranous colitis infectious colitis
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CONCLUSION
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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.
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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
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THANKS…