1. NEW IMAGING TECHNIQUES IN THE EVALUATION OF CROHNS DISEASE
Barry Daly, M.D.
Department of Radiology
University of Maryland School of Medicine

2. University Logo…

3. Unofficial Abdominal Imaging Logo

4. Imaging for Crohn Disease
Traditional Techniques
Newer Techniques

5. Imaging for Crohn Disease Traditional Techniques
Abdominal Radiographs
Barium UGI
Barium small bowel follow through
Barium Enteroclysis
Barium Enema

6. Imaging for Crohn Disease Newer TechniquesCT
CT Enteroclysis
CT Enterography
Magnetic Resonance
Ultrasound
Nuclear Medicine

7. Imaging for Crohn Disease Traditional Techniques
Abdominal Radiographs
Use for initial evaluation of acute pain
Bowel obstruction
Perforation
Limited value

8. Imaging for Crohn Disease Traditional Techniques
Barium UGI
limited in the evaluation of milder cases of mucosal and transluminal inflammation in EGD region

9. Imaging for Crohn Disease Traditional Techniques
Barium small bowel follow through
Distention of small bowel with contrast material is essential for proper evaluation - poor distension of the lumen causes subtle lesions to be overlooked
Must use intermittent compression to find lesions
Role in 2005: pre capsule endoscopy evaluation for strictures ?

10. SIFT Crohn Disease

11. Ileo-vesical Fistula

12. SIFT still useful on occasion…

13. “Hunt the Capsule”

14. Imaging for Crohn Disease Traditional Techniques
Enteroclysis
Enteroclysis can improve small bowel distension by infusing barium contrast rapidly via a duodenal tube
Unfortunately, the passing of the enteroclysis catheter into the distal duodenum is often difficult and unpleasant for the patient
Time consuming procedure, difficult technique

15. Imaging for Crohn Disease Enteroclysis

16. Imaging for Crohn Disease Traditional Techniques
Barium Enema
Used less frequently in recent years
helpful in patients who have strictures that preclude endoscopy
Asymmetric colonic wall involvement
Punched-out ulcers (aphthous, rose thorn, collar stud)
Discontinuous bowel inflammation
Terminal ileum often involved

17. Crohn’s Disease

18. Imaging for Crohn Disease Newer TechniquesCT
CT Enteroclysis
CT Enterography
Magnetic Resonance
Ultrasound
Nuclear Medicine

19. Imaging for Crohn Disease Newer TechniquesCT
CT Enteroclysis
CT Enterography
Magnetic Resonance
Ultrasound
Nuclear Medicine

20. Imaging for Crohn Disease Newer TechniquesCT
Widely used to evaluate for abscess
Mesenteric fatty proliferation
May show strictures but wall thickening difficult to assess due to variable distension
not as sensitive in delineating fissure or fistula as barium studies
superior to barium in showing the extraluminal sequelae of Crohns

21. SBO – Crohn Disease

22. Enteropathic Arthropathy
SacroIliitis – see in 10-20% of Crohns

23. Imaging for Crohn Disease Newer Techniques
CT Enteroclysis
High volume positive contrast infused rapidly via tube
improves small bowel distension – sensitive for small lesions
Time consuming procedure to pass Enteroclysis tube
Need to use Fluoro room & CT scanner
Unpopular with patients (and radiologists !)

24. CT Enteroclysis

25. CT Enteroclysis
Active Crohns disease, not seen on SIFT done previously

26. Imaging for Crohn Disease Newer Techniques
CT Enterography
High volume (1200ml) negative oral contrast (VoLumen) over 1 hour
improves small bowel distension c/w regular CT or SIFT
Give IV contrast to evaluate bowel wall
Use thin section multislice CT cuts to generate 3D coronal and sagital views also
Well tolerated by patients, no need for jejunal tube

27. View as stack of thin 4 mm images through entire abdomen
NORMAL SMALL BOWEL
WITH VOLUMEN
View as stack of thin 4 mm images through entire abdomen

28. Coronal cuts simulate traditional SIFT view
NORMAL SMALL BOWEL
WITH VOLUMEN
Coronal cuts simulate traditional SIFT view

29. Normal
Terminal
Ileum

30. Imaging for Crohn Disease Newer Techniques
CT Enterography
Enhanced wall seen better with negative lumen contrast
Early studies show superiority to barium studies and conventional CT for detection of mucosal disease activity and strictures (Lee et al, AJR 03)
May be problematic in cases of suspected infection or perforation
Fluid collections/abscesses may appear similar to bowel
May avoid post operatively or when abscess suspected

31. Crohn’s
Disease

32. Crohn’s Disease
Inflammatory
Hyperemia and
Reactive adenopathy

33. Evaluate all abdomen organs as well as bowel

35. Crohn’s With Neo-TI & Colonic Disease
Better evaluation of colon than with SIFT

36. ILEO-SIGMOID FISTULA

37. ILEOVESICULAR FISTULA ?

38. Coronals Show Definite Ileo-vesicular
Fistula

39. Chronic Crohns in TI
Fat in bowel wall

40. CT Enterography Post Op. patient with fever
Need to look carefully for extraluminal fluid collections

41. CT Enterography Post Op. Post Op. patient with fever

42. CT Enterography Post Op.

43. CT Enterography Post Op.
Abscess seen better after positive oral contrast

44. CT Enterography Post Op.
Abscess has enhancing wall and is stable on delayed imaging

45. Imaging for Crohn Disease Newer Techniques
Magnetic Resonance
MRI has become especially helpful in the detection and localization of ano-rectal Crohns disease
Thin section coronal, axial and sagital sequences
can readily detect the presence of active distal colonic disease and perianal fistulae
T2 weighted fat saturated sequence
T1 weighted Gadolinium enhanced fat saturated sequence

46. Anorectal Crohns
CT shows abnormal ischeo-rectal fossa but can’t see exact pathology

47. MR of Ano-rectal disease
Axial
Coronal

48. MR of Ano-rectal disease
Axial
Axial

49. MR of Ano-rectal disease
Coronal
Coronal

50. MR of Ano-rectal disease
Bilateral severe complex trans-sphincteric fistulae

51. Liver Disease associated with Crohns/UC

52. Primary Sclerosing Cholangitis

53. PSC & Cholangiocarcinoma

54. Imaging for Crohn Disease Newer Techniques
Ultrasound
difficult to do, inconsistent results
May be used to monitor therapy in kids
Nuclear Medicine
Indium scan
Not often used
May be incidental finding of increased activity in bowel

55. Imaging for Crohn Disease Newer Techniques
CT Colography (Virtual Colonoscopy)

56. Imaging for Crohn Disease Virtual Colonoscopy

57. Imaging for Crohn Disease Virtual Colonoscopy
Longstanding IBD, can’t pass scope

58. Imaging for Crohn Disease Virtual Colonoscopy
Long sigmoid stricture: Adenocarcinoma

59. Imaging for Crohn Disease Conclusions
Traditional Techniques
Newer Techniques

60. Imaging for Crohn Disease Traditional Techniques
Abdominal Radiographs
Barium UGI
Barium small bowel follow through
Barium Enteroclysis
Barium Enema

61. Imaging for Crohn Disease Newer TechniquesCT
CT Enteroclysis
CT Enterography
Magnetic Resonance
Ultrasound
Nuclear Medicine

62. Imaging for Crohns Disease Conclusion
Useful Newer Techniques evolving
CT Enterography
Comprehensive evaluation of all bowel & solid organs
Magnetic Resonance
Useful for ano-rectal disease
Real-time MR has potential for detection of strictures
Traditional imaging techniques still of value in selected cases

63. THANK YOU