ULCERATIVE COLITIS - CT Author Nina Le

Editor Ilse Castro-Aragon

CASE HISTORY

10 year old male otherwise healthy presents to GI clinic for follow up of vomiting, diarrhea, hematochezia, and weight loss. He endorses abdominal pain, bloody diarrhea, and tenesmus.

Labs show fecal occult blood test (+), C. diff. (-), CRP (9.4), ESR elevated (46), GGT wnl, calprotectin elevated (1470.5).

MRE of ULCERATIVE COLITIS

MR enterography of the abdomen with contrast of a 10 year old male shows bowel wall thickening (yellow arrow) and mild enhancement of the cecum and ascending colon without signs of skip lesions or abscess consistent with ulcerative colitis.

MRE of ULCERATIVE COLITIS

MR enterography of the abdomen with oral contrast of a 10 year old male shows diffuse mild enhancement of the colonic wall in the cecum (yellow arrow), without signs of skip lesions or abscess consistent with ulcerative colitis.

MRE of ULCERATIVE COLITIS

MR enterography of the abdomen with contrast of a 10 year old male shows bowel wall thickening (yellow arrow) of the cecum and ascending colon without signs of skip lesions or abscess consistent with ulcerative colitis.

CLINICAL FOLLOW UP

Follow up with EGD and colonoscopy showed congested, erythematous, friable (with contact bleeding) and vascular-pattern-decreased mucosa in the entire examined colon consistent with Mayo 1 pancolitis.

Pathology revealed colonic mucosa showing epithelitis, cryptitis, rare crypt abscesses, crypt architectural distortion, basal plasmacytosis and gland branching from the cecum to the rectum.

IN A NUTSHELLMost important findings include;

Wall thickening (>4 mm)Mucosal or submucosal enhancement

Other relevant findings include;Loss of haustral markingsIncreased signal of surrounding colonic fat

Potential complications include;Toxic megacolonPerianal diseaseLower GI bleed

RememberInflammation of the entire colon may lead to edema of the terminal ileum and cause backwash ileitis

VOICE RAD MRE AND ULCERATIVE COLITIS

by Dr. Castro-Aragon (2020)

OLA

A 14 year old girl with a history of ulcerative colitis undergoes MR enterography for correlation with a prior colonoscopy. What would you expect to see on MRE?

a. Transmural colonic wall thickening

b. Continuous diffuse colonic wall enhancement

c. Skip lesions

d. Segmental wall enhancement of the small bowel

OLAA 9 year old boy with a history of chronic diarrhea presents to the ED with abdominal pain and bloody stool. He has had no sick contacts and no fevers. Abdominal ultrasound shows no signs of appendicitis but reveals bowel wall thickening of the descending and sigmoid colon. Follow up MRE shows this (see image) at the level of the sigmoid colon. What is the most likely diagnosis?

a. Colitis

b. Gastroenteritis

c. Large bowel obstruction

d. Intussusception

IMAGING SPECTRUM of UC

MRE of the abdomen of an 11 year old male shows circumferential wall thickening (yellow arrow) of the sigmoid colon and rectum, with loss of haustrations and enhancement after contrast, consistent with a diagnosis of ulcerative colitis. Differential diagnosis includes Crohn’s disease and gastroenteritis.

IMAGING SPECTRUM of UC

MRE of the abdomen of an 11 year old male shows circumferential wall thickening (yellow arrow) of the sigmoid colon and rectum, with loss of haustrations, consistent with a diagnosis of ulcerative colitis. Differential diagnosis includes Crohn’s disease and gastroenteritis.

IMAGING SPECTRUM of UC

MRE of the abdomen of an 11 year old male shows circumferential wall thickening of the sigmoid colon and rectum, with loss of haustrations and enhancement after contrast (yellow arrow), consistent with a diagnosis of ulcerative colitis. Differential diagnosis includes Crohn’s disease and gastroenteritis.

IMAGING SPECTRUM of UC

Axial CT scan of the abdomen shows wall thickening of the sigmoid colon (yellow arrow), consistent with a diagnosis of ulcerative colitis. Differential diagnosis includes Crohn’s disease.

IMAGING SPECTRUM of CROHN’S Disease

MRE of the abdomen with contrast of a 10 year old male shows transmural thickening and enhancement of a long segment of distal ileum (yellow arrows) and cecum with inflammatory changes of the adjacent fat, consistent with a diagnosis of Crohn’s disease. Differential diagnosis includes ulcerative colitis and gastroenteritis.

IMAGING SPECTRUM of CROHN’S Disease

MRE of the abdomen with contrast of a 10 year old male shows transmural thickening of a long segment of distal ileum (yellow arrow) with inflammatory changes of the adjacent fat, consistent with a diagnosis of Crohn’s disease. Differential diagnosis includes ulcerative colitis and gastroenteritis.

IMAGING SPECTRUM of CROHN’S Disease

MRE of the abdomen with contrast of a 10 year old male shows transmural thickening and enhancement (yellow arrow) of a long segment of distal ileum with inflammatory changes of the adjacent fat, consistent with a diagnosis of Crohn’s disease. Differential diagnosis includes ulcerative colitis and gastroenteritis.

IMAGING SPECTRUM of CROHN’S Disease

Ultrasound of the abdomen of a 14 year old male shows wall thickening of the terminal ileum (yellow arrows), consistent with a diagnosis of Crohn’s disease. Differential diagnosis includes ulcerative colitis and gastroenteritis.

IMAGING SPECTRUM of CROHN’S Disease

Ultrasound of the abdomen of a 14 year old male shows wall thickening of the ascending colon (yellow arrow), consistent with a diagnosis of Crohn’s disease. Differential diagnosis includes ulcerative colitis and gastroenteritis.

IMAGING SPECTRUM of CROHN’S Disease

MRE of the abdomen of a 14 year old male shows bowel wall thickening extending from the cecum to the terminal ileum (yellow arrows), consistent with a diagnosis of Crohn’s disease. Differential diagnosis includes ulcerative colitis and gastroenteritis.

DISCUSSION

Ulcerative colitis is a chronic disease that most commonly presents in children and adolescents <20 years old. The etiology is unknown but the symptoms generally include abdominal pain and bloody diarrhea. MR enterography is used to image patients with suspected UC and diagnosis is confirmed by EGD and colonoscopy with biopsies showing cryptitis.

The disease is associated with increased risk of colon cancer, thus patients should receive surveillance colonoscopies every 2-3 years starting 8 years after initial onset of UC.

LINKS AND REFERENCES

National GuidelinesACR Guidelines – CRC ScreeningACR Guidelines – Crohn Disease

Consistent References: RadiopediaRadioGraphics

VideosRadiology Capsules

Other Journals and TextsRadiographical evaluation of ulcerative colitis

OLAS