Ulcerative Colitis: Radiological Manifestations

Saif ul Islam, Poznan University of Medical Sciences

4th year medical studentGillian Lieberman, MD

April 15th 2011

Our Patient • 57 year old female with a history of ulcerative colitis

presented with four weeks of right lower quadrant pain and bloody diarrhea.

• Past Medical History:- Ulcerative Colitis- HTN- DM2- Asthma

• Family History: Negative for any GI problems• Social History: Does not drink alcohol or use tobacco

products

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Our Patient: Physical Exam.• Physical Exam;

- T;98.5, BP;124/76, P;93, RR; 16, O2 100%.- HEENT: Normal- ABD: Soft with normal active bowel sounds, tenderness in RLQ, no rebound tenderness or guarding- Labs: mild normocytic anemia HG;10.7 and HCT,32.4

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Differential Diagnosis

- UC flare- Infectious Colitis- Crohn’s Colitis- Pseudomembranous Colitis- Ischemic colitis- Appendicitis

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What radiological tests should be ordered?Barium EnemaCT

• Radiological tests are not diagnostic but they help in narrow the differential diagnosis.

• CT is the most common test usually ordered and it accurately demonstrate inflammatory changes and extent of disease.

• BE is good for looking at mucosal detail of bowel wall• Ulcerative colitis on CT and BE can be distinguished from

crohn in terms of location, extent and appearance of colonic wall thickening.

• UC and Crohn rarely associated with ascites, which is often seen in infectious, ischemic and pseudomembraous colitis.

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Ulcerative Colitis and Crohn disease are Inflammatory Bowel disease. Exact cause is unknown but it is believed that for some reason immune systems especially subset T- cells accumulate in the epithelial cells of GI tracts. This result in an increase B cells and plasma cells which in turn increase IgG and IgE. This leads to acute and chronic inflammatory process.

Pathophysiology of the Ulcerative colitis

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Crohn vs Ulcerative Colitis(UC)

Crohn UCTransmural MucosalSkip lesion ContinousRectum not Rectum involved

involvedFistula NoMesenteric Perirectal fatfat increase increase

Saif ul IslamGillian Lieberman, MD

www.hopkins-gi.org

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Classification of UC

www.hopkins-gi.org

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Normal Colon Under BE.Hepatic Flexure

Splenic Flexure

Transverse Colon

Cecum

Sigmoid Colon

Rectum

BIDMC: Normal Colon under Double Contrast Barium Enema

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=Transverse CT image of normal colon

BIDMC: PACS

Transverse Colon

DescendingColon with normal wallthickness

cecum

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Radiological Manifestations of Ulcerative Colitis

• Acute Stage:

Fine mucosal granularity = edema, hyperemia, and abnormal mucin production.

Saif ul IslamGillian Lieberman, MD

Granular Mucosaof sigmoid colon

Imaging.consult.com

Double contrast BEof sigmoid colon

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Radiological manifestations of UC Acute Stage

Ulcerations= Two typesa) Button type = Flask like ulcers with flat baseb) Double tracking = these are longitudinal ulcers in

submucosa.

Single-contrast BE of colon showing UlcersDouble contrast BE shows collar button ulcers:

Ulcers descendingColonic wall

Imaging.consult.comCourtesy of Dr Marc D Basson emedicine.medscape.com/article/183084-overview

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Radiological manifestations of UC Acute Stage

Pseudopolyps = raised area of inflamed tissue resembles

polyps and sever ulcerations caused denuded area)

Double contrast BEof descending colon

Imaging.consult.com

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Radiological Manifestions of Ulcerative Colitis Acute /subacute stage.

Target sign: Disproportionate edema in various layers of the bowel wall result in series of concentrated rings of varied attenuation.

Target sign

- The inner and outer rings of high attenuationRepresent hyperemia of the mucosa and muscularisPropia.

- The middle low attenuation represent submucosa edema.

Saif ul IslamGillian Lieberman, MD

Transverse CT with IV contrast

Imaging.consulting.com

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Radiological Manifestions of Ulcerative Colitis Chronic stage

Loss of haustration on left side of colon = Demage to muscularis propria results in colonic dilation and loss of haustra.

Loss of haustra on left colonIn crohn it is usually to right

side

Double contrast BE imageof colon

Imaging.consult.com

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Radiological Manifestions of Ulcerative Colitis Chronic Stage

- Filiform polyps (long worm like lesions)

Double contrast BE imageof colon.

Imaging.consult.com

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Radiological Manifestions of Ulcerative Colitis Chronic stage

Backwash ileitis = wide ileocecal valve and dilated terminal ileum. In UC no ulcers or fistula presents in terminal ileum

Double contrast BE Image. Loss of haustra

Imaging.consult.com

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Radiological Manifestions of Ulcerative Colitis Chronic stage

Thickening of colonic and rectal wall = deposition of fat in submucosa and edema andInfiltration of inflammatory cells in lamina propria

Transverse CT with contrast image shows diffuse mucosalthickening of fluid filled rectum and sigmoid.

Deep ulcerations(white arrows)

Imaging.consult.com

Colonic wall thickness in UC is usuall less prominent 7.8+1.7mmIn crohn 11.0+5.1mm.

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Coronal CT image of the abdomen and pelvis shows thickening of colonic wall (white arrows)

Roggeveen M J et al. Radiographics 2006;26:947-951

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Crohn

Arrow points distorted mucosa and narrowed Cecum. Arrowhead points to ulcers. Black arrow Is normal small bowel.

Transverse CT with contrast showsthick walled terminal ileum (white arrows)Left side colonic wall is normal.

Normal colon wall

Atlas of Radiological Images.

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Crohn

Transverse CT with IV contrast image shows (white arrow) thick walled terminal ileum (Target sign)

Atlas of Radiological Images

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OUR PATIENT

Transversecolon

Ascending colon

BIDMCPACS: Transverse CT with IV contrast image shows thickened colonic wall

Saif ul IslamGillian Lieberman, MD

Thickening colonicwall. More then 3mm

Cecum

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Our Patient

BIDMCPACS: Coronal CT with IV contrast image of abdomen and pelvic showsColonic wall thickening.

Colonic wall thickening

No mesenteric fat infiltration

Cecum

Ascending colon

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Our Patient

Target sign

BIDMCPACS: Coronal CT with IV contrast image of Abdomen and pelvis showsTarget sign.

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Loss of haustra andthickened colonic wall

BIDMCPACS: Coronal CT with IV contrast image shows loss of haustra

Our PatientSaif ul IslamGillian Lieberman, MD

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Our Patient

Thickened colonic wall

BIDMCPACS: Sagital CT wth IV contrast image shows thickened colonic wall

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Radiological findings in our Patient

57 year old female with a history of UC presented with aacute symptoms of bloody diarrhea and right lower quadrant pain. CT exam was performed and findings were:

• Colonic wall thickening mostly on the left side• Edema involving rectum, sigmoid and descending colon.• Ahaustral appearance involving left colon• No fistula and fissure• No Skip lessions• No ascites• No mass• No blockage of the vessels• No evidence of perforation

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Conclusion.

These radiological finding strongly suggest acute proctocolitis secondary to chronic Ulcerative Colitis.

Because of acute nature of UC, colonoscopy was not performed. Rectosigmoidscopy revealed edema and inflammations. She was treated with IV methyleprednisolone which subsided her symptoms and she was discharged on mesalamine and oral prednisone.

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References

• --, John Hopkins Medicine Gastroenterology & Hepatology. www.hopkins- gi.org/GDL. Accessed 04/10/2011

• --, Learning.Radiology.com www.learningradiology.com/notes/ginotes/ulcerativecolitispage.htm. Accessed 4/05/2011.

• Rued F. Thoeni, MD and John P. Cello. MD. CT Imaging of Colitis. Radiology, September 2006. 240,623-638. Website; radiology.rsna.org/content/240/3/623.full. Accessed 04/07/2011.

• Marc D. Basson, MD Julian Katz, MD. Medscape Reference. March 29,2011. Website; emedicine.medscape.com/article/183084-overview. Accessed 04/07/2011.

• --, Ulcerative Colitis, Imaging.consult.com. Accessed 04/10/2011• Arcot J. Chandrasekhar, MD. Terrence C. Demos, MD. Atlas of Radiological

Images. Harrison e Supplement. Department of Radiology Stritch School of Medicine Website;www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Harrisons. Accessed 04/10/2011

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Acknowledgements

• Samir Shah, MD• Gunjan Senapati, MD

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Thank You