Radiology Website
http://myweb1.lsbu.ac.uk/~dirt/museum/
http://myweb1.lsbu.ac.uk/~dirt/museum/unk-gastro.html for case histories with radiology
Clinical presentation:
A 26 year old woman gives a history of increasing abdominal pain with blood and mucus in
the stool.
The plain film shows visible gas-filled colon with variable mucosal thickening, giving typical
thumb-printing appearance. The colon appears shorter than normal and has lost its usual haustral
pattern.
The 'instant' barium enema, without preparation, demonstrates an extensive continuous
involvement of the bowel with areas of mucosal thickening and areas of mucosal loss. There are
visible ulcers, particularly in the descending colon where they have a typical undercut edge. The
process gives a granular appearance to the sigmoid colonic mucosa. In the tranverse and
ascending colon, the mucosa is irregularly thickened. There is a general loss of the normal
haustral pattern.
Plain X Ray Abdomen
Barium Enema
D/D
Crhon’s colitis
Plain X-Ray Toxic Dilatation Colon
Diverticulosis
Carcinoma Colon in pre existing U. Colitis
19 year old with a 9 year history of bowel disorder.
The view is a late follow-through examination. The terminal ileum is wide and featureless. The
colon is shortened and featureless, except in the transverse colon where is appearance is probably
redundancy of the taeniae. The contrast shows mucosal coating with unformed faecal material.
There is a block to the transit of barium suspension at the splenic flexure. This takes place at a
point where acute angles are formed as the walls of the colon end in an irregular convexity of
soft-tissue density. The appearance does not exclude the possibility of more proximal mucosal
thickening, but at the time this
picture was taken, additional
imaging was not available
A barium enema has demonstrated irregular
narrowing of the sigmoid colon at its junction with
the descending colon. The affected area shows
variable nodular mucosal thickening and occasional
Crohn’s Disease
deep ulcers "rose thorn" appearance. Asymmetrical
involvement of the mid-sigmoid colon gives an area
of wall thickening and ulceration on its right side. A
further section of irregularly strictured sigmoid
colon lies in the mid-line. A collection of barium
over this loop has an ambiguous appearance and
resembles an extra-luminal process. A biconcave
area outlined by barium on the left side of the pelvis,
adjacent to the rectosigmoid junction might also
represent extraluminal contrast. The terminal ileum
is opacified and shows irregular mucosal thickening
and deep ulceration.
Crhon’s Disease Skip Lesions
30 year old female with abdominal pain and fever.
Ileo-coecal Crhon’s
This oblique view in a barium followthrough examination shows two adjacent
abnormal loops, including terminal
ileum. There is narrowing with irregular
mucosal thickening. Occasional
penetrating ulcers can be seen in the
terminal ileum. There are two calcific
ring densities in the right para-midline
epigastrium. A single view of underfilled
small-bowel peristalsis is, by definition,
inconclusive.
Clinical presentation:
Female, 40 year old, with right iliac
fossa abdominal pain.
The follow-through barium examination shows
contrast in the ascending colon, which has not
reached the splenic flexure. The examination
shows contrast in widely separated loops of
narrowed ileum. These show generally
thickened mucosal folds. There is
pseudodiverticula formation on the
antimesenteric side of the terminal ileum about
15 cm.from the ileocaecal valve. Nearer the
valve, a fistula from the ileum has filled
sigmoid colon. The distribution of affected
bowel suggests an inflammatory mass with its
centre of radius over the medial side of the
lower pole of the caecum.
Ileo-Coecal Crohn’s with Fistula in Sogmoid Colon
Clinical presentation:
Follow-up of a 30 year old female for known chronic condition treated conservatively for
the last 10 years.
Crohn's disease
http://myweb1.lsbu.ac.uk/~dirt/museum/p7-262.html
Crohn's disease is an inflammatory condition of bowel that may affect any part of the bowel,
including stomach. Its other name indicates its commonest location, regional ileitis. The
causative agent (agents?) has still not been identified. Recent culprits include a mycobacterium
from sheep, which causes Johnes disease in them and is thought to be transmitted by
inadequately pasteurised milk to vulnerable humans. The theory is a worthy successor to those
of Tooth-paste particles, or measles and impaired mucosal vascularity. Other theories include
the combination of an immature immune system that is exposed to an antigen, or infective
agent, with the possibility of an inherited vulnerability. Despite research, conclusive proof of a
causative agent is not available yet...
The pathology affects the whole thickness of the bowel and produces a rigid and narrowed
bowel. The wall-thickening separates adjacent loops. In contra-distinction to Ulcerative Colitis,
the involvement of the bowel is typically irregular and discontinuous. The mesenteric and antimesenteric margins may be affected to differing degrees. There is serosal involvement and more
reaction in the regional lymph nodes. The mucosal involvement is of nodular thickening and
fissures that may be deep, "rose thorn ulcers". Microscopy reveals non-caseating granulomas,
rather like Sarcoidosis. Fibrosis develops in the diseased segments.
Where there is colonic involvement, the pathology is often typically asymmetric. A pan-colitis
may also be seen. Generally, extensive or continuous colitis is often seen on the plain film as an
unusually large length of undilated gas-filled bowel, implying a local lack of peristalsis. If there
is colonic dilatation, the same reasoning as in Ulcerative colitis applies to the relationship
between diameter and wall-tension.
Because of the involvement of the whole wall, fistula formation is common. The fistula may
link the affected bowel with other loops, or may join to other hollow organs or even may
fistulate to the skin. Perineal fistulae may be a clinical indication of Crohn's disease. The
process may interfere directly with nutrient absorption or indirectly through non-absorption in
the terminal ileum of the constituents of the entero-hepatic circulation and secondary effects
from the lack of bile salts. Anaemia and fat-soluble vitamin deficiencies are clinical sequelae.
Long term, there is some increased chance of adenocarcinoma. This risk is less than in
Ulcerative Colitis, but assessment is much more difficult in Crohn's disease with so many
strictures that are present anyway.
There is an increased risk of arthropathies in bowel disorders. The association varies, depending
on the underlying pathological process. A vasculitis is easy to associate, but bowel disorders
with their effects on absorption of nutrition and toxins may have a more complex aetiology. A
large proportion of those patients with a Sacroiliitis in Crohn's or other Colitis test positive for
the HLA B27 antigen, which is often found in Anklyosing Spondylitis.
On follow-through examination, the abnormal loops are revealed by the bowel-wall thickening
and the inflammatory mass that separates the loops with lots of space around them. This same
inflammatory mass can be seen on ultrasound examination, often tender to palpation.
Various anatomic expressions of pathology.
Cobblestone
mucosa
terminal
ileum (cases
reports)
inflammat
ory mass,
abcess
terminal
ileum
(cases
report)
Asymmetric
involvement
string sign.
(case report)
Ileal
incidental
gallstones
(case
report)
Involvement
of adjacent
loops,
fistula? (case
report)
Colitis
with ileum
involved.
(case
report)
Colitis with
skip-lesions.
(case report)
Postresection
Recurren
ce (case
report)
Fistula, ileocolic. (case
report)
Fistula
vesico
ureteric
junction
(case
report)
Hypertrophic
Osteoarthrpa
thy, HPOA.
(case report)
associate
d Sacroiliitis
(case
report)
Ileal
Obstruction,
sacroiliitis
(case report)
Ulcerative Colitis
http://myweb1.lsbu.ac.uk/~dirt/museum/p75-261.html
Ulcerative colitis is an inflammatory process in the bowel that can be found at any age, but has
its peak incidence in young adults (about 80% between 20 and 40 years in UK.). The bowel is
typically involved by a fairly superficial mucosal inflammation in a continuous area of bowel.
The presence of a continuous pattern of colitis with rectal bleeding helps to distinguish the
condition from Crohn's disease. The distal part of the bowel is involved in Ulcerative Colitis
with more extensive cases having greater involvement of the proximal bowel. The mucosa may
become oedematous, particularly if there is haemorrhage or secondary infection by opportunist
or commensal organisms. The absorption of toxins from the bowel contributes to the clinical
picture.
The Radiology contributes to the management, but the management of a toxic colitis will often
depend on general clinical assessment, including colonoscopy. The plain film will often give a
clue to the degree of involvement. Since normal peristalsis has to affect short segments of
bowel, by definition, the presence of visible gas-filled long segments of bowel implies an ileus.
The plain film abdomen may demonstrate visible gas-filled anhaustral colon, without its usual
faecal contents. The extent of the emptying of the faecal material from the colon can give an
indication of the extent of colitis. At barium enema, the view will show superficial ulceration
and a shortened bowel, often without the usual haustral pattern. The ulcers are typically shallow
and can be wide mouthed with undercutting of the mucosa, sailor hat ulcers. The mucosa may
slough off (incompletely) and leave oedematous tags of mucosa, the pseudo-polyps.
Inflammation, by its effect on peristalsis, may give an appearance of proximal bowel dilatation.
Given the abundance of intraluminal material (and gas) that goes through the ileo-caecal valve
and accumulates from colonic inflammatory exudate, it is worth noting that colonic bacterial
fermentation will not be completely suppressed by problems with colonic wall movement. The
colon may show atonic gaseous dilatation and this can be a Radiological indication of a Toxic
Colitis. The assessment of possible developing colitis must include clinical features.
Recognisably dilated colon on the plain film may arrive a little too late to benefit the patient, if
surgery proves necessary. The plain film may hint at the degree of wall involvement, but is not
accurate at predicting the point of failure.
Bowel dilatation can increase to a point where the tension and stretching of the wall may
impair its blood supply. Even if relative pressures inside the bowel and abdomen remain the
same, the geometry means that an increase in radius 'r' will mean an increase in the tension 't'
in the wall. The point at which normal bowel may perforate is about 10 cm. diameter. The
crucial point is that abnormal bowel may perforate earlier. At some stage, surgical
intervention may be necessary. This is where co-operative clinical assessment becomes so
important. The last thing anyone wants is for the surgeon to have to operate on necrotic
bowel. The presence of a severe colitis may be indicated by mucosal thickening, widely
dilated bowel, extensive involvement and gas in the bowel wall. If you wait for these without
paying attention to the clinical features, then Surgery might be too delayed. A colleague once
described the situation "like trying to sew up wet blotting paper" (loose weave soft paper), not
to mention the greater risk of faecal soiling of the peritoneum. The text book definition of
Toxic Dilatation of the Colon is of systemic toxicity in a patient whose colonic diameter
exceeds 6cm, but no author would recommend delaying surgery on a particular measurement.
In addition to the general symptoms of ill-health, there may be an arthropathy, often
with a Sacro-iliitis, sometimes with a uveitis as well. Erythema nodosum, pyoderma
gangrenosum may also occur in combination with inflammatory bowel disease. Longer
term complications of Ulcerative colitis include ascending cholangitis. It's not a bad
idea to ask for a history of bowel disorder in unknown chronic liver disease, especially
if the bile ducts appear a little irregular on Liver ultrasound. Strictures with fibrosis
rarely occur in Ulcerative colitis. If there is a long history you should consider the
possibility of Carcinoma being the cause of an smooth stricture of the colon. In a
patient with a long history, not only is carcinoma a higher risk, up to 30% in some
families, but the presentation may be atypical. Multiple tumours are also commoner
than the usual 5%. Each case of Ulcerative Colitis is managed individually and
supervised by regular colonoscopy. It is not appropriate to make a general statement
about the time to proceed to pre-emptive colectomy, but indications include epithelial
dysplasia and polyp formation.
Various anatomic expressions of pathology.
Smallbowel
fluid-levels
(case
report)
Ulcers and
mucosal
thickening
(case
report)
Sailor-hat
ulcers
(case
report)
Typical
acute
appearanc
e on plain
film. (case
report)
Toxic
dilatation.
(case
report)
Pseudopoly
ps (case
report)
Preexisting
diverticulos
is. (case
report)
Carcinoma
9 year
history of
colitis (case
report).
Carcinoma
s can be
atypical
and may
resemble
fibrous
strictures.
TB Intestine
Journal of Medical Case Reports 2008, 2:90
A 14-year-old girl presented with complaints of
paraplegia, ataxia, fever and fatigue that had
started a few months earlier, which had
progressively worsened in the last three weeks.
Her laboratory results were indicative of
macrocytic anemia with a serum B12 level <100
(normal, 160-970) pg/ml and hypersegmented
neutrophils and MRI revealed brain atrophy. Her
fever workup eventually led to the diagnosis of
tuberculosis, documented by bone marrow
aspiration smear & culture. A small bowel series
showed that tuberculosis had typically involved
the terminal ileum which had resulted in vitamin
B12 deficiency. She was treated for vitamin B12
deficiency and tuberculosis. Her fever ceased
and her hemoglobin level returned to normal.
This is the first report of macrocytic anemia with
unusual manifestations such as brain atrophy
and seizures due to intestinal tuberculos
.
Brain MRI shows senile dilatation in the CSF space
and sulci of brain hemispheres that is compatible
with mild atrophic changes.
Plain X-Ray abdomen