Crohn's Disease: A pictorial review

Transcription

1 Crohn's Disease: A pictorial review Poster No.: C-0390 Congress: ECR 2012 Type: Educational Exhibit Authors: N. Rojo Sanchis, A. M. Sanchez Laforga, B. Y. Barragan Requena, A. Marin Canete, I. Santos Gomez, M. Teixidor, M. R. CAMBRA MARTI, J. Saavedra López, J. M. Lopez Balaguer; Sant Boi de Llobregat/ES Keywords: Inflammation, Diagnostic procedure, Contrast agent-oral, CT, Gastrointestinal tract, Abdomen DOI: /ecr2012/C-0390 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 39

2 Learning objectives The aim of this poster is to illustrate the radiological findings of Crohn's disease, based on our experience, by comparing different diagnostic imaging tests, and emphasizing the enteroct as a diagnostic test. We also review the technical protocol of the enteroct and appreciate the advantages and disadvantages front other diagnostic techniques. Background Crohn's disease is a bowel inflammatory disease of unknown origin, chronic, that runs with periods of activity (sprouts) and downtime (referrals). Its debut usually occurs in young patients, being the predominant symptoms abdominal pain and diarrhea. These symptoms vary depending on the location of the tissue damage that can occur in any section of the digestive tract (inccluding rectum) ( Fig. 1 on page 2 ), being most common location distal ileum ( Fig. 2 on page 3 )and proximal colon ( Fig. 3 on page 4 ). Crohn's disease presumption diagnosis is mainly based on the image, requiring histopathological confirmation. We have a battery of diagnostic tests including classically baritated intestinal transit, and most recently the entero-ct and the entero-mri, not forgetting the endoscopy allowing biological sample to histopathological study. In our work we retrospectively check image tests conducted in our center from November 2010 to July 2011 in patients diagnosed of Crohn's disease, including initial diagnosis or evolutionary monitoring. A total of 11 patients were studied, doing all entero-ct and colonoscopy. Some of these patients also were in baritated intestinal transit, abdominal ultrasound or standard abdominal CT scan. All the studied patients were diagnosed with endoscopic biopsies and histopathological confirmation. Images for this section: Page 2 of 39

3 Fig. 1: Crohn's disease afectting the rectum Page 3 of 39

4 Fig. 2: US: ileum's wall thickening Page 4 of 39

5 Fig. 3: US: cecum's wall thickening Page 5 of 39

6 Imaging findings OR Procedure details The TECHNICAL PROTOCOL of the ENTERO-CT that we use in our work was as follows: Preparation: Acquisition of images: The CT is performed after the injection of 150 ml of iodine contrast (370mg/ml) + 30 ml of saline solution (via intravenous, a flow of 3-5ml/s). We use MDCT GE BrightSpeed Elite of 16 crowns with helical acquisition of images. A single series after a delay time of seconds, from diaphragmatic domes to pubic symphysis, with a slice thickness of 5 mm and Noise Index of 25 [2,7] The patient should be at least 6 hours in fasting, administering ml of neutral oral contrast (Polyetilglicol, PEG) one hour before the test, which should drink in 5 shots from 250 ml to 15minutes intervals, the last being taken immediately prior to the completion of the TC [6]. Manage antiperistaltic medication (glucagon IV 1 mg) before starting the test. In diabetic patients is obviated this medication either replaced by buscapina. Image reconstruction: Retro-axial reconstruction to 1.25 mm Multiplanar reconstructions. RADIOLOGICAL FINDINGS in the ENTERO-CT of Crohn's disease can be classified in several ways, for example depending on the location of the tissue damage (enteric / extraenteric) or depending on the phase of the disease in which there are (acute, chronic stage or complications)[2,5] Page 6 of 39

7 Table 1: Imaging findings in Crohn's disease References: N. Rojo Sanchis; Radiodiagnosis service, Sant Boi de Llobregat, SPAIN ACUTE phase: activity indicators Wall thickening: > 3 mm (normal 2 mm) [1] Fig. 4 on page 19. Page 7 of 39

8 Fig. 4: Wall thickening and increased enhancement of a segment of the ileum References: N. Rojo Sanchis; Radiodiagnosis service, Sant Boi de Llobregat, SPAIN Wall enhancement: largest segmental enhancement of a distended bowel loop comparing to the rest [1]Fig. 5 on page 20. Wall stratification (target sign): largest mucous and serous layer enhancement comparing to the muscular layer variable enhancement. [1]Fig. 5 on page 20 Page 8 of 39

9 Fig. 5: Bowel wall thickened and stratificated (target sign). Vascular and fat hipertrophy (star) and fat infiltration. References: N. Rojo Sanchis; Radiodiagnosis service, Sant Boi de Llobregat, SPAIN Hypertrophy of the vasa recta (comb sign): tortuous and prominent perienteric vessels.fig. 6 on page 21[3] Page 9 of 39

10 Fig. 6: Fibrofatty and vascular hipertrophy References: N. Rojo Sanchis; Radiodiagnosis service, Sant Boi de Llobregat, SPAIN Perienteric fat infiltration: hyperdense and trabeculated fat.fig. 7 on page 22 Page 10 of 39

11 Fig. 7: Mesenteric fat trabeculation (circle) References: N. Rojo Sanchis; Radiodiagnosis service, Sant Boi de Llobregat, SPAIN Local enlarged nodes.fig. 8 on page 23 CHRONIC pahse: Thickened and stratificated wall: presence of fat density in the submucous layer.fig. 9 on page 24 Page 11 of 39

12 Fig. 9: Chronic stenosis: mural fat density References: N. Rojo Sanchis; Radiodiagnosis service, Sant Boi de Llobregat, SPAIN Fibroadipose tissue hypertrophy (sign of the rope).fig. 10 on page 25 Page 12 of 39

13 Fig. 10: Fibrofatty hipertrophy (circle): rope sign References: N. Rojo Sanchis; Radiodiagnosis service, Sant Boi de Llobregat, SPAIN Pseudodiverticula: sacculated antimesentric edge of the affected bowel loop.fig. 11 on page 26 Page 13 of 39

14 Fig. 11: Pseudodiverticula: sacculation of the antimesenteric edge of a bowel (arrow) References: N. Rojo Sanchis; Radiodiagnosis service, Sant Boi de Llobregat, SPAIN COMPLICATIONS: Acute Inflammatory stenosis.fig. 12 on page 27 Page 14 of 39

15 Fig. 12: Inflammatory estenosis (circle) in the acute stage. References: N. Rojo Sanchis; Radiodiagnosis service, Sant Boi de Llobregat, SPAIN Fistulas [4].Fig. 13 on page 28 Fig. 14 on page 29 Fig. 15 on page 30 Fig. 16 on page 31 Page 15 of 39

16 Fig. 13: Complication: fistula (coronal view) References: N. Rojo Sanchis; Radiodiagnosis service, Sant Boi de Llobregat, SPAIN Abscesses.Fig. 17 on page 32 Fig. 18 on page 33 Page 16 of 39

17 Fig. 17: Complication : abcess (arrow) References: N. Rojo Sanchis; Radiodiagnosis service, Sant Boi de Llobregat, SPAIN Chronic Fibrotic stenosis.fig. 9 on page 24 ADVANTAGES AND DISADVANTAGES In which case the other above-mentioned diagnostic tests and the advantages and disadvantages of the enteroct: Baritated intestinal transit X-ray is a widely available test, which radiates little, and allows assessing only some aspects of the disease such as murals strictures, peristalsis of the affected bowel loop, the extent of the damage tissue and indirectly signs of chronicity as fibroadipose tissue hypertrophy.fig. 19 on page 34 Page 17 of 39

18 Fig. 19: Baritated study: filling defect of terminal ileum. References: N. Rojo Sanchis; Radiodiagnosis service, Sant Boi de Llobregat, SPAIN It provides little information to assess the degree of disease activity and to assess acute complications. Entero-CT allows assessing both the local intestinal damage providing data on the activity of the disease, such as other extraenteric findings, valuable above all to assess complications. The main drawback of this test is ionizing radiation, although there are study protocols to minimize the exposure of the patient to the same. In our work, we use Noise Index to reduce radiation to 60%. Despite this, sufferers of Crohn's tend to be young patients who will be controlled for long periods, so if you have it, checks should be made by MRI while complications should be studied by CT [4] Fig. 20 on page 35. Entero-MRI also allows you to evaluate optimally the local intestinal damage as well as the degree of activity, but provides less information concerning extraenteric complications. The main drawback is the availability of the test and its duration.fig. 21 on page 36 Page 18 of 39

19 Images for this section: Table 1: Imaging findings in Crohn's disease Page 19 of 39

20 Fig. 4: Wall thickening and increased enhancement of a segment of the ileum Page 20 of 39

21 Fig. 5: Bowel wall thickened and stratificated (target sign). Vascular and fat hipertrophy (star) and fat infiltration. Page 21 of 39

22 Fig. 6: Fibrofatty and vascular hipertrophy Page 22 of 39

23 Fig. 7: Mesenteric fat trabeculation (circle) Page 23 of 39

24 Fig. 8: Little multiple mesenteric nodes (circle) Page 24 of 39

25 Fig. 9: Chronic stenosis: mural fat density Page 25 of 39

26 Fig. 10: Fibrofatty hipertrophy (circle): rope sign Page 26 of 39

27 Fig. 11: Pseudodiverticula: sacculation of the antimesenteric edge of a bowel (arrow) Page 27 of 39

28 Fig. 12: Inflammatory estenosis (circle) in the acute stage. Page 28 of 39

29 Fig. 13: Complication: fistula (coronal view) Page 29 of 39

30 Fig. 14: Complication: fistula (sagital view) Page 30 of 39

31 Fig. 15: Complication: fistula Ccircle) Page 31 of 39

32 Fig. 16: Complication: fistula Page 32 of 39

33 Fig. 17: Complication : abcess (arrow) Page 33 of 39

34 Fig. 18: Complication: abcess (arrow). Axial view Page 34 of 39

35 Fig. 19: Baritated study: filling defect of terminal ileum. Page 35 of 39

36 Fig. 20: Complications: fluid collections (star). It's difficult to differenciate between fullfilled bowel and fluid collecton. Page 36 of 39

37 Fig. 21: Entero-MR: right colon wall thickening Page 37 of 39

38 Conclusion Entero-CT is a good technique used as a tool to evaluate Crohn's disease, providing valuable information about disease's activity or chronicity, and also making possible to evaluate complications. Personal Information Dr. Nuria Rojo Sanchis Radiologist Hospital General, Parc Sanitari Sant Joan de Deu Sant Boi de Llobregat, Barcelona (SPAIN) nuria.rojo@pssjd.org References Chron's disease: mural attenuation and thickness at contrast-enhanced CT enterography-correlation with endoscopic and histologic findings of inflamation. Kale D. Bodily,Joel G. Fletcher, Craig A. Solem et al. Radiology 2006; 238: CT findings and interobservor agreement of enteric phase CT enterography. Fargol Booya, Joel G. Fletcher, James E. Huprich et al. Radiology 2006;241: CT of prominent pericolic or perienteric vasculature in patients with crohn's disease: correlation with clinical disease activity and findings on barium studies. Seung Soo Lee, Hyun Kwon Ha, Suk-Kyun Yang, Ah Young Kim. AJR 2002;179: CT enteroclysis. Dean D. T. Maglinte, Kumaresan Sandrasegaran, John C. Lappas, Michael Chiorean et al. Abdominal Imaging 2007;245: CT enterography of fistulizing Crohn's disease: clinical benefit and radiographic findings. Booya, Fargol; Akram, Salma; Fletcher, Joel G.Abdominal imaging 2009;34[3]: CT enterography of crohn's disease. Amy K. Hara, Paul G. Swartz. Abdominal imaging 2009;34[3]: Page 38 of 39

39 7. 8. Comparision of neutral oral contrast versus positive oral contrast in abdominal multidetector CT. Berther R, Patak MA, Eckhardt B, Erturk SM, Zollikofer CL. Eur Radiol Sep;18(9): Multidetector row CT od the small bowel: peak enhancement temporal window - initial experience. Sebastian T. Schindera, Rendon C. Nelson, David M. DeLong. Radiology 2007; 243: Page 39 of 39