1. Imaging of IBD and Other Colitides
Cynthia Walsh, MD FRCPC
Department of Radiology

2. Outline Three quiz questions Imaging modalities available
Ulcerative Colitis
Crohn’s Disease
Three quiz questions- answers

3. Question 1
The typical distribution of ulcerative colitis is described as:
Affects any segment of the gastrointestinal tract, but preferentially localizes in the terminal ileum.
Begins in the rectum and extends proximally with segmental discontinuous involvement.
Begins in the rectum and extends proximally with contiguous spread.
Transmural disease of the bowel wall, causing fistulas and abscesses.

4. Question 2 What critical finding is in this upright Chest X-ray?

5. Question 3
What extra colonic finding is demonstrated in this patient with Crohn’s Disease?

6. What imaging modalities are used to image the bowel?
Plain Films
Enema
Barium - Single or double contrast
Water-soluble
CT Techniques
CT (with or without IV or oral contrast)
CT Enterography (small bowel imaging)
Virtual Colonography (colon imaging)
MRI (*** NO IONIZINH RADIATION)
MR Enterography (small bowel)
Perianal disease (for fistulas or abscesses)

7. Plain Film of the Abdomen
Projections: supine and upright (or lateral decubitus if cannot stand)
To Exclude:
intestinal obstruction
toxic megacolon
pneumoperitoneum

8. Barium or Water Soluble Enema
DCBE
Dynamic evaluation of the colon performed under fluoroscopy after rectal infusion of contrast
Colon wall is coated with:
Barium only (single contrast Barium Enema)
Barium and air (double contrast Barium Enema)
Water soluble contrast (Water Soluble Enema)
Can demonstrate polyps, colon cancer, diverticula, strictures, fistulas, ulcers, leak, stenosis (etc.)
Lesion detection depends largely on the operator and lesion size
SCBE

9. Single contrast barium enema (SCBE)
Indications for Different Types of Enema: Single vs. Double contrast Barium vs. Water Soluble
Water Soluble Enema:
Suspected perforation
pre or post-operative study (don’t want barium in the peritoneal cavity)
Single contrast barium enema (SCBE)
Differentiate mechanical obstruction from pseudo-obstruction (Ogilvie syndrome
Exclude anastomotic leak (use water soluble) or stenosis
Limited information (can miss mucosal abnormalities, polyps and cancer)
Double contrast barium enema (DCBE):
Now nearly OBSOLETE
For polyps and Colon Cancer: Replaced by CT Colonography
For IBD:
Small bowel: CT Enterography or MR Enterography
Colon: Primarily Colonoscopy

10. Double Contrast Barium Enema
Single Contrast Barium Enema
Double Contrast Barium Enema
Polyp not visible
polyp

11. Double Contrast Barium Enema: Two Polyps

12. CT
Can us IV contrast, Oral contrast, neither or both (depends on the indication).
Main indications for CT of the Colon:
Stage Colon Cancer
Abdominal pain
Complications from colitis
Determine the site or cause of bowel obstruction
Diagnose ischemia

13. CT or MR Enterography Ingest 1.5 L of oral contrast (PEG)
Distends the small bowel
Main indications:
Diagnosis of small bowel IBD (where colonoscopy cannot get)
Complications of IBD (stenosis, obstruction, fistula, abcess etc.)
Preoperative evaluation
Evaluation of anemia or GI bleeding in the context of negative colonoscopy and endoscopy

14. CT Colonography Main indications:
Find polyps and colon cancer if colonoscopy is incomplete or contraindicated
Contraindicated in the setting of acute colitis.

15. Imaging of IBD: What is the best imaging test?
It depends on the Clinical Question:
Establish diagnosis of IBD, or determine the extent of disease
Colon: Colonoscopy
Small Bowel: CT enterography, or MR enterography (MR especially useful in young patients, to avoid radiation)
Complications of inflammatory disease
Plain film CT
Perianal disease: MRI

16. Ulcerative Colitis Proximal extension from rectum
CONTIGUOUS disease (no skip lesions)
Mucosal disease
Increased risk of colon cancer
On Double Contrast Barium Enema
Mucosal granularity
Collar button ulcers
Single contrast enema not much use

17. Ulcerative Colitis on DCBE
Contiguous mucosal irregularity
in the rectum and sigmoid
Normal mucosa

18. Ulcerative Colitis on DCBE:
Collar button ulcers

19. Ulcerative Colitis:
Featureless colon
(“lead pipe”)
Normal DCBE

20. Ulcerative Colitis on CT
Colonic wall thickening with contiguous spread (without skipped segments)

21. Imaging of Crohn’s Disease:
Frequently involves the terminal ileum, however can involve any portion of GI tract
Discontinuous (skip lesions)
Transmural
Apthoid ulcers
Branching/linear ulcers (cobblestoning)
Fistulas, sinus tracts, abscesses
Perianal disease

22. Crohn’s Disease on DCBE: apthoid ulcers

23. Crohn’s Disease on DCBE: strictures and fistulas
Mucosal irregularity
fistula

24. Crohn’s Disease: Terminal ileum involvement on MR Enterography
- Layered appearance of the bowel wall (“target sign”) - Submucosal edema - Mural hypervascularity: evidence of inflammatory activity

25. Crohn’s Disease: Terminal ileum involvement on CT

26. Crohn’s Disease on CT Entero-enteric fistula Pre-stenotic dilatation
Mesenteric hyperemia: engorgement of mesenteric vessels

27. Crohn’s Disease – Extra colonic Disease: Sacroiliitis
Erosions and sclerosis in the SI joints
Normal

28. Perianal fistula on MRI
Crohn’s Disease:
Perianal fistula on MRI

29. Enema and CTC are contraindicated (as in any acute colitis)
Toxic Megacolon
Acute complication of colitis
Risk of perforation
Most common in UC, but can occur with any colitis.
Imaging recommended
CT or Plain film
Enema and CTC are contraindicated (as in any acute colitis)

30. Toxic Megacolon: Imaging Findings
Colon Dilatation
Best seen in the transverse colon, but can affect the whole colon
Thumb printing (mural edema)
Colonic Dilatation on imaging can raise the possibility of Toxic Megacolon.
However, this is ultimately a clinical diagnosis.

31. Toxic Megacolon - Upright Chest x-ray (in the same patient)
- Dilated colon with thumb printing

32. Toxic Megacolon: Perforation
Free air under the diaphragm (Pneumoperitoneum)

33. Ischemic Colitis

34. Ischemic Colitis
Air in the wall of the ascending colon = PNEUMATOSIS

35. Thumbprinting in transverse colon
DDx: colitis (ischemic, inflammatory, infectious)

36. Question 1
The typical distribution of ulcerative colitis is described as:
Affects any segment of the gastrointestinal tract, but preferentially localizes in the terminal ileum.
Begins in the rectum and extends proximally with segmental discontinuous involvement.
Begins in the rectum and extends proximally with contiguous spread.
Transmural disease of the bowel wall, causing fistulas and abscesses.

37. Question 2 What critical finding is in this upright Chest X-ray?
Pneumoperitoneum
-free air under the diaphragm
-bowel perforation

38. Question 3
What extra colonic finding is demonstrated in this patient with Crohn’s Disease?
SACROILIITIS
Normal

39. Questions or comments? cwalsh@ottawahospital.on.ca
Thank you
Questions or comments?