Download Atlas of Signs and Findings in Crohn’s Disease

Shivani Priyadarshni
Gillian Lieberman, MD
05/26/2015
Atlas of Signs and Findings in
Crohn’s Disease
Shivani Priyadarshni, Kasturba Medical College, India
4th Year Medical Student
Gillian Lieberman, MD.
Shivani Priyadarshni
Gillian Lieberman, MD
Outline
1. Our Patient’s Clinical Features: History and
Physical Exam
2. Differential Diagnosis
3. Investigations of our patient
4. Crohn’s Disease
i. Clinical Manifestations
ii. Extraintestinal Manifestations
iii. Diagnostic Tests
iv. Radiological Findings
v. Crohn’s vs Ulcerative colitis
5. Conclusion
6. Summary
2
Shivani Priyadarshni
Gillian Lieberman, MD
History
A 55 yo F with
• 2-3 loose-formed nonbloody bowel
movements a day
• Fleeting cramps prior to bowel movements
• Came for follow up
• No fever, chills, nausea, vomiting
• No loss of appetite or weight change
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Shivani Priyadarshni
Gillian Lieberman, MD
Past History
• PMH:
– Crohn’s Disease
– GERD
• PSH and Family History - Not significant for
GI problems
• Social History: Smoked 2 PPD for 30 years,
stopped 10 years ago
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Shivani Priyadarshni
Gillian Lieberman, MD
Physical Exam
• General: Well-developed, well-nourished
female in no apparent distress
• Vital Signs WNL
• HEENT: Unremarkable
• Neck: Supple, no lymphadenopathy
• Abdomen: Soft, mild tender below umbilicus
without guarding or rebound
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Shivani Priyadarshni
Gillian Lieberman, MD
Differential Diagnosis
•
•
•
•
•
•
Crohn’s Disease
Ulcerative Colitis
Irritable Bowel Syndrome
Yersinia Ileitis
Ileocaecal Tuberculosis
Mesenteric Adenitis
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Shivani Priyadarshni
Gillian Lieberman, MD
Investigations of Our Patient
• CT scan done outside, 5 years ago, showed
inflammation in the proximal transverse
colon, with focal microperforations and some
abnormal thickening of the terminal ileum
• A repeat CT scan showed an ileocecal fistula
• Colonoscopy, 5 years back, showed a single
aphthous erosion in the terminal ileum and
an area in the transverse colon that looked
like a probable fistula site
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Shivani Priyadarshni
Gillian Lieberman, MD
Our Patient Past Coronal C+ T2
Weighted MR Enterography Image
Terminal ileum showing mural thickening and BIDMC: PACS
8
mucosal enhancement
Shivani Priyadarshni
Gillian Lieberman, MD
Let us view another image of the same
study.
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Shivani Priyadarshni
Gillian Lieberman, MD
Our Patient Past Coronal C+ T2
Weighted MR Enterography Image
Abnormal inflammatory process between the terminal ileum and
BIDMC: PACS
proximal transverse colon
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Shivani Priyadarshni
Gillian Lieberman, MD
Let us move on to the report of the same
study.
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Shivani Priyadarshni
Gillian Lieberman, MD
Our Patient Past C+ MR Enterography
• Abnormal wall thickening, mucosal enhancement
and surrounding mesenteric inflammatory changes
of the terminal ileum, consistent with terminal ileitis
• Abnormal inflammatory process between the
terminal ileum and proximal transverse colon
without fluid collection or discrete tract, suggest
early changes of fistulization or may represent
changes related to recent perforation
• No lymphadenopathy, no evidence of abscess or
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ascites
Shivani Priyadarshni
Gillian Lieberman, MD
Labs on Present Admission
• Hb - 13.8
• ESR -14
• CRP - 1.2
Hb, ESR and CRP are normal suggesting that
there is no active disease.
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Shivani Priyadarshni
Gillian Lieberman, MD
Coronal C+ CT Enterography
in Our Patient
Focal tethering of terminal ileum against proximal transverse colon
Mild active inflammation and ulcerations in terminal ileum
BIDMC: PACS
14
Shivani Priyadarshni
Gillian Lieberman, MD
Let us view another image of the same
study.
15
Shivani Priyadarshni
Gillian Lieberman, MD
Coronal C+ CT Enterography
in Our Patient
Skip lesion proximal to the previous segment
BIDMC: PACS
16
Shivani Priyadarshni
Gillian Lieberman, MD
Let us move on to the report of the same
study.
17
Shivani Priyadarshni
Gillian Lieberman, MD
C+ CT Enterography in Our Patient
• Terminal ileum demonstrating mild active
inflammation and ulcerations, with focal tethering
against the adjacent proximal transverse colon
without patent fistula, similar in configuration to
the past MR enterography. Tiny skip lesion just
proximal to this segment appears new
• No new fistula or fluid collection
• No obstruction
• No lymphadenopathy or ascites
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Shivani Priyadarshni
Gillian Lieberman, MD
Crohn’s Disease
• Type of inflammatory bowel disease (IBD)
• Etiology: Unknown, Possible environmental,
genetic and autoimmune factors
• Involvement: any segment from mouth to
perianal region
• Distal ileum - most common
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Shivani Priyadarshni
Gillian Lieberman, MD
Clinical Manifestations
LOCATION
SYMPTOMS
COMMON DIAGNOSTIC TESTING
Ileum and colon
Diarrhea, cramping, abdominal
Colonoscopy with ileoscopy, CT enterography,
pain, weight loss
biopsy
Diarrhea, rectal bleeding,
Colonoscopy with ileoscopy, CT enterography,
perirectal abscess, fistula,
biopsy
Colon only
perirectal ulcer
Small bowel only
Diarrhea, cramping, abdominal
Colonoscopy with ileoscopy, CT enterography,
pain, weight loss
capsule endoscopy, small bowel follow-through,
enteroscopy, biopsy, MR enterography
Gastroduodenal
Anorexia, weight loss, nausea,
Esophagogastroduodenoscopy, small bowel
region
vomiting
follow-through, enteroscopy
Wilkins T, Jarvis K, Patel J.(2011). American Family Physician.84(12).
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Shivani Priyadarshni
Gillian Lieberman, MD
Extraintestinal Manifestations
• Dermatological
• Rheumatological - Migratory polyarthritis,
Ankylosing spondylitis
• Ocular - Conjunctivitis, Anterior uveitis, Episcleritis
• Urological - Nephrolithiasis
• Hepatobiliary - Cholelithiasis, Hepatic steatosis,
Primary sclerosing cholangitis
• Metabolic bone disorder - Osteoporosis,
osteonecrosis, pathological fracture
• Venous and arterial thrombosis
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Shivani Priyadarshni
Gillian Lieberman, MD
Let us view some images of the same.
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Shivani Priyadarshni
Gillian Lieberman, MD
Extraintestinal Manifestations
Erythema nodosum
Schwartz and Nervi. Am Fam Physician. 2007.
Superficial erosion of tongue
Sanderson, et al. Inflamm Bowel Dis. 2005.
Pyoderma gangrenosum
Brooklyn, et al. BMJ. 2006.
Anterior uveitis
Mintz, et al. Inflammatory bowel diseases. 2004.
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Shivani Priyadarshni
Gillian Lieberman, MD
Various Diagnostic Tests for Crohn's Disease
TEST
COMMENT
Small bowel follow-
Visualization of lumen using contrast medium (barium)
through/ enteroclysis/
enema
Computed tomography
enterography
Magnetic resonance
enterography
radiation exposure, no wall and extraluminal visualization
Permits visualization of the bowel wall and lumen;extraluminal sequelae
exposes patient to ionizing radiation.
Similar to CT, no ionizing radiation
expensive
Endoscopy
Direct visualization of mucosa - inflammation, fistula, or stricture of terminal ileum and colon; ability to
obtain biopsies.
extraluminal not seen.
Ultrasonography
Detects increase in vascular flow, abscess, sinus tracts, and lymphadenopathy
operator dependant, obesity
Wilkins T, Jarvis K, Patel J.(2011). American Family Physician.84(12).
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Shivani Priyadarshni
Gillian Lieberman, MD
Barium Follow Through Image
of Companion Patient #1
Long narrow ileum with mucosal irregularity
Koh, D. M., et al. (2001). American Journal of Roentgenology. 177(6) .
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Shivani Priyadarshni
Gillian Lieberman, MD
Barium Enema Image of
Companion Patient #2
String sign - severe narrowing of terminal ileum with
dilated proximal bowel
Wells, C.(1952). Annals of the Royal College of Surgeons of England .11(2).
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Shivani Priyadarshni
Gillian Lieberman, MD
Axial C+ CT Abdomen of
Companion Patient #3
Target sign
Periintestinal fat showing marked inflammatory change
Gore, R.M., et al.(1996). American journal of roentgenology. 167(1).
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Shivani Priyadarshni
Gillian Lieberman, MD
Target Sign
Seen on contrast enhanced CT and MRI.
It consists of 3 concentric circles of bowel wall:
• Outer Layer: Inflamed muscularis propria (high
attenuation)
• Middle Layer: Intermediate edema/fat (low attenuation)
• Inner Layer: Inflamed mucosa (high attenuation)
Best seen during late arterial, early venous phase.
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Shivani Priyadarshni
Gillian Lieberman, MD
Axial C+ CT Abdomen of
Companion Patient #4
A
D
Luminal narrowing and mural thickening of distal ileum
Dilatation of fluid-filled small bowel proximally due to obstruction.
Collapsed ascending colon (A) and descending colon (D)
Gore, R.M., et al.(1996). American journal of roentgenology. 167(1).
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Shivani Priyadarshni
Gillian Lieberman, MD
Axial C+ CT Abdomen of
Companion Patient #5
*
*
Creeping fat of mesentery
Homogeneously thickened walls of ileum and ascending colon
Separation of normal small-bowel loop from these diseased segments
caused by abnormal mesenteric fat
Gore, R.M., et al.(1996). American journal of roentgenology. 167(1).
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Shivani Priyadarshni
Gillian Lieberman, MD
Creeping Fat of Mesentery
Fibrofatty proliferation with hypertrophied
mesenteric fat between inflamed intestinal
segments.
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Shivani Priyadarshni
Gillian Lieberman, MD
Axial C- CT Pelvis of Companion
Patient #6 and Patient #7
R
*
Perirectal abscesses with sinus tract
extending into right buttock.
*
*
Presacral abscess attributable to
fistula from rectum (R).
Gore, R.M., et al.(1996). American journal of roentgenology. 167(1).
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Shivani Priyadarshni
Gillian Lieberman, MD
Coronal C+ MRI of Companion
Patient #8
Mucosal enhancement with narrowing of lumen of terminal ileum
Dilation of proximal bowel
Albert, J.G., et al.(2005). Gut. 54(12).
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Shivani Priyadarshni
Gillian Lieberman, MD
Coronal C+MRE(a) and Conventional
Enteroclysis(b) in Companion Patient #9
Terminal ileum shows Two aphthous ulcers with
Wall thickening and cobblestoning.
Gourtsoyiannis, et al. (2006). European radiology.16(9).
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Shivani Priyadarshni
Gillian Lieberman, MD
Coronal T1 Fat Suppressed C+ MRI
of Companion Patient #10
Comb sign
J. Panés, et al. (2011). Aliment Pharmacol Ther. 34(2).
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Shivani Priyadarshni
Gillian Lieberman, MD
Comb Sign
Shaft of comb - Mural hyper enhancement
and thickening in the distal ileum
Bristles of comb - Prominent engorged
vasa recta in the mesentery
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Shivani Priyadarshni
Gillian Lieberman, MD
Axial 3D FLASH C+ MRI of
Companion Patient #11
Mesenteric lymphadenopathy
Gourtsoyiannis, et al. (2006). European radiology. 16(9).
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Shivani Priyadarshni
Gillian Lieberman, MD
Mesenteric Lymphadenopathy
Mesenteric lymphadenopathy <1 cm may be
seen in Crohn’s disease.
If >1 cm, then rule out other causes,
especially lymphoma.
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Shivani Priyadarshni
Gillian Lieberman, MD
Crohn’s vs Ulcerative
Features
CD
UC
Mucosal Granularity
+
++
Aphthoid ulcers
++
-
Deep ulceration
++
-
Discontinuous ulceration/
Skip lesion
++
-
Rectal sparing
+
-
Colonic shortening
+
++
Halligan and Robinson.(2003). In Sutton, D. (Ed.), A Textbook of Radiology and Imaging, Volume 1.
39
7th edition.
Shivani Priyadarshni
Gillian Lieberman, MD
Let us see some more features that
differentiate the two diseases.
40
Shivani Priyadarshni
Gillian Lieberman, MD
Crohn’s vs Ulcerative
CD
UC
Haustral obliteration
+
++
Pseudodiverticula
++
-
Enteric fistulae
++
-
Abscess
++
-
Small bowel disease/ Anal
disease
++
-
Toxic megacolon
+
++
Halligan and Robinson.(2003). In Sutton, D. (Ed.), A Textbook of Radiology and Imaging, Volume 1.
7th edition.
41
Shivani Priyadarshni
Gillian Lieberman, MD
Conclusion
Based on the clinical features and radiological
findings of our patient, a diagnosis of Crohn’s
disease was arrived upon.
Patient counselled and does not want to take
medications, but is willing for follow up.
Plan of follow up:
- ESR, CRP
- Repeat CT Enterography
42
Shivani Priyadarshni
Gillian Lieberman, MD
Summary
• Crohn’s disease is a type of IBD which can affect any
part of GIT, most commonly ileum
• Clinical features include abdominal pain, diarrhea,
weight loss, abscess, fistula, etc
• Extraintestinal manifestations may also be present as
already mentioned
• Various investigations for evaluation include small
bowel follow through, enteroclysis, enema with
barium contrast, CT enterography, MR enterography,
endoscopy and ultrasonography
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Shivani Priyadarshni
Gillian Lieberman, MD
Summary
Radiological findings include:
● Aphthous ulcers, eccentric bowel wall thickening
● Skip lesions
● String sign, creeping fat of mesentery
● Target sign
● Comb sign
● Abscesses and Fistulae
44
Shivani Priyadarshni
Gillian Lieberman, MD
Summary
Treatment:
● Symptomatic OR to induce remission
● Medical
○ Steroids
○ 5-ASA derivatives
○ Immunomodulators
● Surgical
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Shivani Priyadarshni
Gillian Lieberman, MD
References
1. Lichtenstein, G.R., Hanauer, S.B., Sandborn, W.J.(2009). Management of Crohn's disease in adults. Am
J Gastroenterol.104(2): 465-83. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19174807.
[Accessed: 22 May 2015].
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al(eds.). Harrison’s Principles Of Internal Medicine, Volume 2. 18th edition. New York: McGraw-Hill
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Magnetic Resonance Imaging for the Diagnosis, Assessment of Activity and Abdominal Complications of
Crohn's Disease. Alimentary Pharmacology & Therapeutics. 34(2):125-145. Available from:
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Physician. 75(5): 695-700. Available from: http://europepmc.org/abstract/med/17375516. [Accessed: 22
May 2015].
8. Halligan, S., Robinson, P.A.J.(2003). Chapter 20: The small bowel and peritoneal cavity and Chapter 21:
The large bowel. In D Sutton (Ed.), A Textbook of Radiology and Imaging, Volume 1. 7th edition. New
46
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Shivani Priyadarshni
Gillian Lieberman, MD
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Shivani Priyadarshni
Gillian Lieberman, MD
Acknowledgements
Dr. G. Lieberman, MD
Dr. Jonathan Kim
48
Shivani Priyadarshni
Gillian Lieberman, MD
Thank You
49