FOCAL ULCERATIONS OF THE COLON IN SAN FRANCISCO, CALIFORNIA

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1 O(iOB}-R, 1y67 FOCAL ULCERATIONS OF THE COLON IN GRANULOMATOUS COLITIS* By HENRY I. GOLDBERG, M.l).t T HE segmental distribution, eccentric location, and deep ulcerating nature of granulomatous colitis has been thoroughl descri bed.#{176} 16 Ulcerations localized to a few centimeters in granulomatous colitis have been described,#{176} but have not been illustrated in the reproduced roen tgenogram 1_16 This report stresses the occurrence of localized eccentric ulcerations of the colon in granulomatous or transm u ral colitis. Roentgenograms and SAN FRANCISCO, CALIFORNIA illustrations of histologic specimens of 2 cases are presented. REPORT OF CASES CASE I. A 3 year old white man complained of weight loss, bloody diarrhea, and cramping abdominal pain of 3 months duration. His local physician treated him with antibiotics and oral prednisone, which resulted in decrease of diarrhea. When medications were withdrawn, however, the symptoms recurred. The patient had had a perirectal abscess 8 years previously. On admission, barium enema examination disclosed 2 lesions in the left colon (Fig. i). A left hemicolectomy was performed. The gross and histologic specimens are illustrated in Figures 2,Aand B; and3,aand B. CASE II. A 14 year old white girl was admitted because of arthralgia, fever, skin lesions, rectal bleeding, abdominal pain, and weight loss of months duration. A rectovulvar fistula was present and several perirectal fistulae. On sigmoidoscopy, the rectum appeared normal. The stools contained no gross blood. An upper gastrointestinal roentgen series showed ulceration and a pseudopolypoid pattern of the terminal ileum. The cecum was also deformed and its mucosal pattern was irregular. The roentgenographic results on barium enema examination and the abnormalities noted on histologic examination of the sections of the colon are illustrated in Figures ; and, A and B. ROENTGEN AND HISTOLOGIC CHANGES Short segments of the colon were involved in both patients. The abnormal segments were 3 to 6 cm. long. In Case i (Fig. 1-3), both roentgenographic and histologic studies showed 2 areas of disease in the left colon, with normal intervening bowel. Three ulcerating areas in the left colon with normal bowel between were noted in Case ii (Fig. 4). The cecum in this patient was also abnormal. The rectum was free of disease in both instances. The short segmental lesions involved only one wall of the colon in both patients. The bowel lumen in these segments was not significantly narrow in caliber. Gross examination disclosed the ulcer margins to be sharp with clearly demarcated overhanging 11G. 1. Case 1. In the medial wall of the left colon are 2 lesions, each to 6 cm. long. Sharply defined intraluminal projections with loss of mucosal contour are seen in the upper lesion (upper arrow). * From the Department of Radiology, University of California School of Medicine, San Francisco, California. Supported in part by the United States Public Health Service, Grant GM t Research Fellow, Diagnostic Radiology, National Institutes of Health. 296

2 : A 0 :: B * / 11G. 2. Case I. (A) Magnified view of the 6 cm. lesion in the proximal descending colon. (B) Sharply demarcated ulcerations (arrows) in a segment of the proximal descending colon are in close proximity to one another. The gross mucosal pattern between ulcers is preserved. 0 FIG. 3. Case I. (A) Section through the fixed specimen of Figure 2 B. The mucosa at the margin of the ulcer is thickened, forming an overhanging edge (solid white arrow). A thickened and discolored submucosa (solid black arrow) and greatly widened muscularis (open arrow) are present. Clefts or fissures penetrate the ulcer base. (B) Microscopic section (XI0) of specimen from the margin of ulcer shows: (I) hyperplastic mucosa forming an overhanging lip or margin; (2) edematous submucosa with vascular engorgement and cellular infiltrate forming the base of ulcer; () hypertrophied, thickened muscularis; and () thickened serosa, also infiltrated by inflammatory cells.

3 298 Henry 1. Goldberg Ut I (till S, 1( 1 1(i. 4. Case II. i iie left colon contains 2 distinct areas of involvement, characterized by short, eccentrically located ulcers with sharpl v defined, overhanging margins (open arrows). A third area of involvement is in the transverse colon (solid arrow). edges. The ulcers appeared either as single large plaque-like lesions, or as multiple contiguous lesions (Fig. 2B). The depth of the ulcers was accentuated by the overhanging margins, composed of intact hyperplastic mucosa infiltrated by inflammatory cells. Normal mucosa exten(led to within i or 2 cn. of the ulcer nargin (Fig. 3/1). The mucosa between ulcerating lesions was normal. On roentgenograms, the ulcers did not appear to project beyond the luminal contour, even though they were deep (Fig. i alid 4). Because of inflammation and edema of the entire bowel wall, an indurated tissue mass (mound) had formed, projecting into the lumen (Fig. 3, 4 and B; and s, A and B). Ulcers in such involved areas may not project beyond the contour of the colon. The area of greatest thickening and induration was in the muscle layers. Fhe transnlural nature of the disease was (lemons tra ted on h i stologi c exani i nation. Acute and chronic inllammatorv cells were scattered through all layers of bowel, as well as in periserosal tissue. Edema was present throughout. Clefts or fissures penetrated to the level of longitudinal muscle (Fig. 3, A and B; and #{231}, A and B). No granulomata were seen histologically in either case. DISCUSSION I n volvem en t of the cob II i n gra u 10- matous colitis ranges from universal colon disease to small multiple segniental lesions. Examples of the latter have been presented to stimulate awareness of the truly local, eccentric form of granulomatous colitis. anowitz ci a/.,c Lin(Iner et al., I ockhart-n Iunirner and Morson, Marshak and Lindner, and \Volf and Marshak t have aptly characterized tile roentgenographic featu res of granu atous colitis. Skip lesions, lack of rectal involvement, deep longitudinal ulcers with transverse fissures, and eccentric involvement are the distinguishing roen tgenographi c characteristics. Strictures of multiple short segments have also been reported.8 Pseudodiverticula may appear along the wall opposite the site of segfllelltal disease,1#{176} although none was noted in the 2 patients of this report. I)espite limitation of the disease process to a 3 to 6 cm. area along

4 \oi.. 101, No. 2 Ulcerations in Granulom atoiis Colitis ;. c. Case II. (A) Magnified view of lower ulcer on lateral wall of descending colon. (B) I he microscopic Section ( X io) of specimen of ulcer margin shows: (i) mucosa forming a well demarcated margin of the ulcer crater; (2) edematous submucosa with acute and chronic inflammatory cells; () thickened muscularis. Fhe widened submucosa and muscularis form a mound of tissue projecting into the lumen; () serosa thickened bs cellular infiltrate and edema. one wall when viewed roentgenographicallv, on histologic examination all la ers of the bowel were seen to be involved. Eccentric ulcerations did not result in significant narrowing of the bowel. lilus, even in extremely short segments in colitis, tile transmural nature of the disease was manifest. Ihe recognition that in granuloni atrnis colitis short Segfllellts ma be ulcerated is important. Ihese ulcers difier froni those of ulcerative colitis. They form on a mound or tissue mass composed of edematous inflamed su bmucosa and muscularis. Thus, the appear to occur on an intraluminal mass and do not project beyond tile lumen. This development is comparable to that of a malignant ulcer in a gastric tumor, in which the crater also does not project beyond the lumen. This t pe of ulceration has not been illustrated in the literature. More typical of ulceration in granulomatous colitis is the serpiginous longitudinab ulcer, and the (beep transverse fissure penetrating all layers of bowel. #{176} Cone-shaped ulcers, a few millimeters in diameter, have also been described in earls granubomatous colitis.2 Diverticulitis and carcinoma are 2 other disease processes that may be confused with eccentric ulcerations of short segments. In diverticuli tis, extramural abscesses along one wall of bowel, associated with intramural abscesses, cause smooth filling defects of the wall, which may simulate the (leep ulcers of local granulomatous colitis. The presence of diverticula and the absence of ulcerations and of sharp overhanging 111 argins aid in di f Ferentiating diverticuhtis from tile focal eccentric ulcers of granulomatous colitis. Although sci rrhous carci flofll a 01 av be eccentric, associated ulcers with silarp overhanging Illargins would l)e unlikely. SUMMARY Two cases ol granulomatous colitis that involved short segments of bowel are presented. These illustrate that focal, eccentric, ulcerating lesions are one part of the

5 300 Henry I. Goldberg OCTOBER, 1967 spectrum of colon involvement that also includes universal colon disease. On roentgenograms, sharp overhanging margins of the ulcers did not appear to project beyond the lumen of the colon. Histologic examination showed that the ulcers arose on a mound of tissue composed of edematous submucosa and muscularis infiltrated by inflammatory cells. This mound projected into the lumen of the bowel. Correlative results between roentgenographic and histologic examinations are presented. Department of Radiology University of California San Francisco Medical Center San Francisco, California Gratitude is expressed to Drs. F. Frank Zboralske and Alexander R. Margulis for reviewing the manuscript. REFERENCES I. ANTON, H. C., and SUTHERLAND, D. H. Unusual presentation of segmental colitis. Brit. 7. Radiol., 1963,36, BRAHME, F. Granulomatous colitis: roentgenologic appearance and course of lesions. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1967, 99, BROOKE, B. N. Granulomatous disease of intestine. Lancet, 1959, 2, CORNES, J. S., and STECHER, M. Primary Crohn s disease of colon and rectum. Gut, 1961, 2, CROHN, B. B., and YARNIS, H. Granulomatous colitis: attempt at clarification. 7. Mt. Sinai Hosp., 1966,33, JANOWITZ, H. D., LINDNER, A. E., and MARS- HAK, R. H. Granulomatous colitis: Crohn s disease of colon. 7.A.M.A., 1965, 191, LINDNER, A. E., MAR5HAK, R. H., WOLF, B. S., and JANOWITZ, H. D. Granulomatous colitis: clinical study. New England 7. Med., 1963, 269, LOCKHART-MUMMERY, H. E., and MORSON, B. C. Crohn s disease (regional enteritis) of large intestine and its distinction from ulcerative colitis. Gut, 1960, I, LOCKHART-MUMMERY, H. E., and MoRsox, B. C. Crohn s disease of large intestine. Gut, 1964, 5, MARSHAK, R. H., and LINDNER, A. E. Ulcerative and granulomatous colitis. 7. Mt. Sinai Hosp., 1966,33, II. MARSHAK, R. H., LINDNER, A. E., and JANOwrrz, H. D. Granulomatous ileocolitis. Gut, 1966, 7, NEUMAN, H. W., BARGEN, J. A., and JUDD, E. S., JR. Clinical study of two hundred one cases of regional (segmental) colitis. Surg., Gynec. & Obst., 99, NEUMAN, H. W., and DOCKERTY, M. B. Pathology of regional (segmental) colitis. Surg., Gynec. & Obst., 1954, 99, REEVES, B. F., CARLSON, H. C., and DOCKERTY, M. B. Segmental ulcerative colitis versus segmental Crohn s disease of colon: roentgenographic and pathologic study. AM. J. ROENT- GENOL., RAD. THERAPY & NUCLEAR MED., 1967, 99, SUTCLTFFE, J. Crohn s disease of colon. Brit 7. Radiol., 1963,36, i6. WOLF, B. S., and MARSHAK, R. H. Granulomatous colitis (Crohn s disease of colon): roentgen features. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1962,

6 This article has been cited by: 1. Norman Joffe, Donald A. Antonioli, Michael A. Bettmann, Harvey Goldman Focal granulomatous (Crohn's) colitis: Radiologic-pathologic correlation. Gastrointestinal Radiology 3:1, [CrossRef]