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ImaginginCrohnDisease

ImaginginCrohnDisease
Author:YungHsinChen,MDChiefEditor:EugeneCLin,MDmore...
Updated:Oct24,2013

Overview
Crohndiseaseisnotadistincthistopathologicentity.Althoughdescribedandnamedafteritsauthorin1932,Crohn
diseasewasnotclinically,histologically,orradiographicallydistinguishedfromulcerativecolitisuntil1959.
Currently,thediagnosisofCrohndiseaseentailsananalysisofclinical,radiologic,endoscopic,pathologic,andstool
specimenresults.Contrastenhancedradiographyisusedtolocalizetheextent,severity,andcontiguityofdisease
CTscanningprovidescrosssectionalimagesforassessingmuralandextramuralinvolvementendoscopyenables
directvisualizationofthemucosaandprovidestheabilitytoobtainabiopsyspecimenforhistopathologic
correlationandultrasonographyandMRIareadjunctsthatprovidealternativecrosssectionalimagesinpopulations
inwhomradiationexposureisaconcern.
Forexcellentpatienteducationresources,visiteMedicineHealth'sDigestiveDisordersCenter.Also,see
eMedicineHealth'spatienteducationarticles,InflammatoryBowelDisease,CrohnDisease,andCrohnDisease
FAQs.
ExamplesofCrohndiseaseareprovidedintheimagesbelow.

Crohndisease.Aphthousulcers.DoublecontrastbariumenemaexaminationinCrohncolitisdemonstratesnumerousaphthous
ulcers.

CrohndiseaseoftheterminalileumwithCTandsonographiccorrelation.Smallbowelfollowthroughstudydemonstratesthestring
signintheterminalileum.Alsonotepseudodiverticulaoftheantimesentericwalloftheterminalileum,secondarytogreater
distensibilityofthislessinvolvedsegmentofthewall.

CrohndiseaseoftheterminalileumwithCTandsonographiccorrelation.Noteterminalilealwallthickeningandadjacentmesenteric
inflammatorystranding.

Crohndisease.Mesentericinflammation.CTscandemonstratesinflammatorymassintherightlowerquadrantassociatedwith
thickeningofthewallandnarrowingofthelumenoftheterminalileum.

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Crohndisease.Crohncolitis.Doublecontrastbariumenemastudydemonstratesmarkedulceration,inflammatorychanges,and
narrowingoftherightcolon.

Crohndisease.MRIwithCTcorrelation.MRIdemonstratesthickeningofthewalloftherightcolonwithintramuralincreasedsignal
onaT1weightedimage.Thiswasbelievedtorepresentintramuralfatdeposition.

Pathophysiology
TheetiologyofCrohndiseaseislargelyunknown.Genetic,infectious,immunologic,andpsychologicalfactorshave
allbeenimplicatedininfluencingthedevelopmentofthedisease.Thediseaseischaracterizedbychronic
inflammationextendingthroughalllayersoftheintestinalwallandinvolvingmesenteryaswellasregionallymph
nodes.
Earlymucosalinvolvementconsistsoflongitudinalandtransverseaphthousulcerations,whichareresponsiblefora
cobblestoneappearance.Asthediseaseprogress,deepfissures,sinuses,andfistulaedevelop.Eventually,
communicationbetweendiseasedbowelsegments,theabdominalwall,retroperitonealstructures,andtheurinary
tractoccurs.
Becauseofthetransmuralnatureofthedisease,mesentericandperianalmanifestationsarefairlycommon.
Becauseoftheinflammation,stricturesresultingfromedema,inflammation,and,ultimatelyfibrosisandscaring,
arefrequent.Crohndiseaseispervasive.Thebasicpathologicprocessofdiseasecanoccuratanysegmentofthe
alimentarytract.
Crohndiseaseandulcerativecolitissharesimilarinflammatorychanges.Cryptitisandsubsequentcryptabscesses
consistingofpolymorphonuclearcellsareidenticalforbothdiseases.However,duringtheinflammatoryflareups,
CrohndiseaseinvolvesincreasesinthenumberofcellscontainingimmunoglobulinG2(IgG2)andulcerativecolitis
involvesapredominantincreaseinimmunoglobulinG1(IgG1)andimmunoglobulinG3(IgG3)celltypes.
TheinflammatoryinfiltrateofthelaminapropriainCrohndiseaseleadstolooseaggregationsofmacrophages,and
theyorganizeintononcaseatinggranulomas,whichinvolvealllayersofthebowelwallfrommucosatoserosa.
Occasionally,theycanbeseenonlaparoscopyasmiliarynodules,andtheyfunctionascontiguousspreadofthe
diseasefromtheintestine.Withchronicinflammation,thebowelwallsbecomethickened,fibrotic,andstenoticin
Crohndisease,andanextensionofinflammationandfistulaformationoftenoccursasaresultofatransmural
fissure.
Inulcerativecolitis,hemorrhagicandulcerativeinflammationismostlylimitedtothemucosa,withrecurrence
leadingtoatrophicmucosa.Ulcersoftenhaveirregularborders,givingrisetoacollarstudeffect.Inrecurrent
disease,inflammatorypolypsdevelopfromexuberantepithelialregeneration.Wheninflammationinfiltrateextends
intothesubmucosaandmuscularispropria,itdoessoinadiffusepattern,incontrasttoCrohndisease,inwhich
theyappearaslymphoidaggregates.WhyCrohndiseasehasaskipdistributionasopposedtothatseenin
ulcerativecolitisisuncertain.

Epidemiology
FindingsfromstudiesintheUnitedStatesandWesternEuropeindicatethattheincidenceofCrohndiseaseis2
casesper100,000population.Theprevalenceisestimatedtobe2040casesper100,000population.Recentdata
showthatatleastinEurope,ratesinSouthernEuropeancountriesarecatchinguptothoseoftheirnorthern
neighbors.
Approximately15%ofthecasesofCrohndiseaseappearinpersonsolderthan50years.
Therelativeriskforadenocarcinomaoftheileumisatleast100foldgreaterinCrohndiseasepatientscompared
withageandsexmatchedcontrols.Smallbowelcancerstypicallyariseatsitesofmacroscopicdiseaseaftermean
ageof18years.

Mortalityandmorbidity
Crohndiseaseisassociatedwithhigherrateofmortality,ascomparedwiththatofthegeneralpopulation,
independentofGItractinvolvement.Theexcessmortalityismostpronouncedinthefirstfewyearsafterdiagnosis.
ThisobservationhasbeenattributedtocomplicationsofCrohndisease,whichincludeabscesses,fistulas,intestinal
obstructionsandperforations,andcolorectalcancer.
Approximately15%ofthecasesofCrohndiseaseappearinpersonsolderthan50years.Intheolderpopulation,
Crohndiseasetendstoinvolvethecolon,andmoreobstructiveandinflammatorycomplicationstendtodevelop.

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However,despitethisfact,olderpatientshavebeenshowntotoleratemedicalandsurgicaltherapyaswellas
youngpatients.
Abscessesdevelopinapproximately1520%ofpatientswithCrohndiseaseasaresultofsinustrackformationoras
acomplicationofsurgery.Abscessescanbefoundinthemesentery,peritonealcavity,orretroperitoneumorinan
extraperitoneallocation.Themostcommonsitesofretroperitonealabscessesaretheischiorectalfossa,the
presacralspace,andtheiliopsoasregion.Theterminalileumisthemostcommonsiteoforiginofabscesses.Itis
oneofleadingcausesofmortalityinCrohndisease.
Obstructionoccursin2030%ofpatientsduringthecourseofthedisease.Earlyinthedisease,itappearsas
reversibleintermittentpostprandialobstructionduetoedemaandbowelspasm.Overseveralyears,thispersistent
inflammationgraduallyprogressestofibrostenoticnarrowingandstricture,whichmayrequireregionalresection.
FistulaformationisafrequentcomplicationofCrohndiseaseofthecolon.Fistulascanbecategorizedinto3
groups:benign,nuisance,andintractable.Benignfistulasaresimpleandincludeileoileal,ileocecal,andileosigmoid
fistulas,whichmightproduceonlymildormoderatediarrhea.Theymayevenremainasymptomaticforyears
withoutanytreatment.Nuisancefistulasmustbeclosedbecauseofannoyingsymptomsandtroublesome
pathophysiologicconsequences,butneitherthecomplicationsnortheunderlyingboweldiseaseissevereenoughto
requiresurgery.Thisintermediategroupincludesenterovesicular,enterocutaneous,cologastric,andcoloduodenal
fistulas.
Complicatedfistulaswithabscessesorsevereunderlyingboweldisease(eitherulceratinginflammationordistal
obstruction)arethemostdifficulttomanage.Theyoccurin50%ofpatientswithCrohndisease.Theroleofmedical
therapyissimplytocontroltheobstructing,inflammatory,orsuppurativeprocessesbeforedefinitivesurgeryis
performed.Thegoaloftheoperationisevacuationoftheabscessand,ifnotcontraindicatedbyassociatedsepsis,
resectionofthediseasedbowel.Thisformoffistulaleadstospontaneousintestinalperforationin12%ofpatients.
GIcancerhasbeentheleadingcauseofmortalityinCrohndisease.Adenocarcinomausuallyarisesinareasof
chronicdisease.Thecancerriskishigherinboththesmallintestineandthecolon,ascomparedwiththatofgeneral
population.Therelativeriskforadenocarcinomaoftheileumisatleast100foldgreaterinageandsexmatched
controls.Smallbowelcancerstypicallyariseatsitesofmacroscopicdiseaseaftermeanageof18years.
Unfortunately,mostcancersrelatedtoCrohndiseasearenotdetecteduntiladvancedstages,andthepatientshave
poorprognoses.MountingevidencefromstudiesindicatesthatCrohndiseaseisassociatedacancerriskequalto
thatofulcerativecolitis.Someextraintestinalcancers(eg,squamouscellcancerinpatientswithchronicperianal,
vulvar,orrectaldisease)andHodgkinornonHodgkinlymphomashavealsobeenshowntobemorecommonin
patientswithCrohndisease.

PreferredExamination
Thepreferredexaminationsareplainradiography,doublecontrastbariumenemaexamination,singlecontrastupper
GIserieswithsmallbowelfollowthoughorenteroclysiswithCT,anddoublecontrastevaluationofthesmallbowel.
UltrasonographyandMRIcanbeusedasadjunctsifradiationexposureisanissueinmonitoringdiseaseactivity. [1,
2,3]

Ingeneral,theclinicianshouldselectCTfirstinevaluationofCrohndisease.CThasisnotassensitivein
delineatingfissureorfistulaasbariumstudies,butitissuperiortobariumstudiesinshowingtheextraluminal
sequelaeofCrohndisease.ResidualcontrastmaterialfrombariumstudiesleadstoseverestreakartifactonCT
scansduetohyperattenuatingcontrastsuspensionusedinbariumstudies.Ontheotherhand,CTcontrastresidue
doesnotprecludeabariumstudy.
BariumcontraststudiesarelimitedintheevaluationoftransluminalinflammationinCrohndiseasedistentionof
smallbowelwithcontrastmaterialisrequiredforproperevaluation.Slowpassageofthecontrastagentthroughthe
pyloruscanresultinnonvisualizationofsmallbowellesionsinsmallbowelseries.Enteroclysisisonewayto
circumventthedilemmabypassingacathetertotheduodenaljejunaljunction.
AbdominalradiographicfindingsarenotspecificforCrohndisease.Radiographyisusefulinevaluationofbowel
loopdistentionandpneumoperitoneum.Sonographicfindingshavehighvariabilitybecauseofoperatordependence
indetectionofthebowelwallchangesseeninCrohndisease.Transmissionofultrasoundwavesthroughfatty
tissuesislimited,anddetectionmaybeseverelylimitedbythepatient'sbodyhabitus.
Traditionally,MRIwaslimitedintheevaluationoftheabdomenandpelvisbecauseofmotionartifact.Withstronger
gradients,breathholdimaging,andfastersequences,MRIoftheabdomenandpelviscanbereadilyperformedin
mostpatients.Itiscurrentlyactivelyusedinroutineassessmentofpelvisfistulaeandsinustracks.Inmanymedical
centers,MRIenterographyandenteroclysisareactivelyusedinsurveillanceofsmallboweldiseaseandextraluminal
mesentericdisease.MRIisanattractivealternativetotraditionalfluoroscopyandCTscanning,especiallyin
pediatricpopulationinwhichlongtermradiationexposureisaconcern.

CTguidedtherapy
CThasbecometheprocedureofchoicenotonlyindiagnosingCrohndiseasebutalsoinmanagingabscesses.A
growingbodyofliteratureshowsthatCTguidedpercutaneousabscessdrainagemayobviatesurgery.Instudies,CT
percutaneousabscessdrainagehasshowngreatsuccesseitherasatemporizingmeasureorasdefinitivetherapy
withadecreasedrateofrecurrence,ascomparedwiththatofsurgery.Becauseabout7090%ofpatientswith
regionalenteritiseventuallyrequiresurgery,avoidinganoperationtotreatanabscessisatangiblebenefitofCT. [4]

Complicationsandcontraindications
Theoraladministrationofcontrastmaterialistobeavoidedwhenmoderateorhighgradecolonicobstructionis
present.Doublecontrast(aircontrast)bariumenemaexaminationiscontraindicatedinpatientswithseverecolitis,
becauseinjectionofairwithcontrastagentmayprecipitatetoxicmegacolonorcolonicperforation.Bariumstudies
arecontraindicatedwhentherearesignsandsymptomsofperitonitisorwhenthereareradiographicsignsofgasin
thebowelwallorpneumoperitoneum. [5]
TheintravenousinjectionofcontrastmaterialforCTstudiesshouldbeavoidedwhenchronicrenalinsufficiencyis
present,whenthereiscontinueduseofGlucophage,orwhentherearesignsandsymptomsofacuterenalfailure.
CTandbariumstudiesuseionizingradiation,whichmayresultinconsiderableradiationburden.Thisexposureisa

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relativecontraindicationinpregnancyandchildhood.SonographyandMRImayprovetobeusefulalternative
imagingmodalities.

Radiography
TheroleofplainradiographywithbariumstudiesinCrohndiseaseisfairlylimited.The2majorpurposesthatit
servesare(1)toassessthepresenceofintestinalobstructionand(2)toevaluatepneumoperitoneumpriortofurther
radiologicalworkup.Additionalextraintestinalfindingsofsacroiliitisoroxalatekidneystonesmaybepresent.These
furthersupportthediagnosisofCrohndisease.

Crohndiseaseversusulcerativecolitis
Doublecontrastbariumenemastudyisusefulfordiagnosinginflammatoryboweldiseaseandfordifferentiating
Crohndiseasefromulcerativecolitis,especiallyintheearlyphaseofthedisease.Ondoublecontraststudies,early
Crohndiseaseischaracterizedbydiscreteaphthoidulcers,whichareseenaspunctateorslitlikecollectionsof
bariumsurroundedbyradiolucentmoundsofedema.Theaphthoidulcersareoftenseparatedbynormalboweland
presentasskiplesions.Onthecontrary,ulcerativecolitisextendsproximallyatvariousdegreesfromtherectumas
acontinuousareaofdiseasethateventuallyleadstopancolitis.Earlyulcerativecolitisischaracterizedbyagranular
appearanceondoublecontrastexaminationasaresultofedemaandhyperemiaofthemucosa.Thus,the2
diseasescanbedifferentiatedonbasisofradiographicfindings. [6]
Inacomparisonof23patientswithulcerativecolitiswith27patientswithCrohndisease,Lauferetalestablished
thedifferentiatingfeaturestheconditionsusingbariumstudy.Theyfoundthatulcerativecolitisinvolvesgranular
mucosa,diffuserectalinvolvement,andcontinuousinflammatorychangesinthebowelwithsparingoftheterminal
ileum.Crohndiseaseinvolvespatchyrectalinvolvementwithpunchedoutulcers,ulcersonnormalmucosa,and
discontinuousbowelinflammationtypicallywithinvolvementoftheterminalileum.Thesecriteriaaredistinguishing
in95%ofpatients.Thedifficultyindifferentiatingthe2illnessesoccursatlaterchronicstages,duringwhich
numerousremissionsandexacerbationscanresultindiscontinuousulcerativecolitis.Despitethisdifficulty,careful
examinationofthemucosalsurfacewithbariumstudyenablesthedistinction. [6]

Aphthoidulcers
Aphthoidulcers,asshownintheimagebelow,aredetectedonbariumstudiesin2550%ofpatientswithCrohn
disease.Theseareidentifiedinasmanyas75%ofsurgicalspecimenswithCrohndisease.Endoscopyisslightly
superiortobariumstudiesinthedemonstrationofisolatedorafewaphthoidulcers.

Crohndisease.Aphthousulcers.DoublecontrastbariumenemaexaminationinCrohncolitisdemonstratesnumerousaphthous
ulcers.

SevereCrohndisease
AsmoresevereCrohndiseasedevelops,thesmallulcersbecomeenlargedanddeeper,andtheyconnecttoone
another,formingstellate,serpiginous,andlinearulcers.Theseulcersarefoundmostfrequentlyinterminalileum
alongthemesentericborder.ThesearepathognomonicofCrohndisease.Onsmallbowelseriesorenteroclysis,a
mesentericborderulcerappearsasalong1to2mmbariumcollectionthatparallelsashort,straightmesenteric
border.Aradiolucentcollarusuallyparallelsthelinearbariumcollectionatthemarginoftheulcer.The
antimesentericborderofthebowelisusuallyuninvolvedandpulledintotheulcercollar,creatingradiatingfolds.

Cobblestoning
Asinflammationpenetratesthesubmucosaandmuscularislayers,deepknifelikelinearcleftsformthebasisof
"cobblestoning"andfissureorfistulaformation.Theyappearasabariumfilledreticularnetworkofgroovesthat
surroundroundorovoidradiolucentislandsofmucosa.Eventually,transmuralinflammationleadstodecreased
luminaldiameterandlimiteddistensibility.Thisleadstoaradiographicstringsignthatrepresentslongareasof
circumferentialinflammationandfibrosisresultinginlongsegmentsofluminalnarrowing.Seetheimagesbelow.

Crohndisease.Cobblestoning.Spotviewoftheterminalileumfromasmallbowelfollowthroughstudydemonstrateslinear
longitudinalandtransverseulcerationsthatcreateacobblestoneappearance.Alsonotetherelativelygreaterinvolvementofthe
mesentericsideoftheterminalileumandthedisplacementoftheinvolvedloopawayfromthenormalsmallbowelsecondaryto
mesentericinflammationandfibrofattyproliferation.

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Crohndisease.Spotviewoftheterminalileumfromasmallbowelfollowthroughstudydemonstratesseveralnarrowingand
stricturing,consistentwiththestringsign.Alsonoteasinustractoriginatingfromthemedialwalloftheterminalileumandthe
involvementofthemedialwallofthececum.

Enlargedvilli
Chronicinflammationinthelaminapropriaofthesmallintestineresultsinenlargedvilliradiographicallymanifested
as0.5to2mm,roundorpolygonalnodules.Thisfinemucosalnodularityoccursinthesmallintestineandshould
notbeconfusedwiththemucosalgranularityseeninthecolonofpatientswithulcerativecolitis.

Limitations
Mucosalnodularityorgranularityinasmallbowelseriesisanonspecificfindingthatcanbeseenindiseasesthat
infiltrateorinflamethelaminapropria,suchasamyloidosisorradiationenteritis.
Smallbowelfollowthoughexaminationislimitedbythespeedofbariumpassagethroughthepylorus.Iftooslow,
incompletedistentioninthelumenofthebowelcancauseshortskiplesions,masses,orobstructinglesionsinthe
smallboweltobemissed.
AdditionalbariumstudiesimagesofCrohndiseaseareshownbelow.

Crohndisease.Crohncolitis.Doublecontrastbariumenemastudydemonstratesmarkedulceration,inflammatorychanges,and
narrowingoftherightcolon.

Crohndisease.Singlecontrastbariumenemastudydemonstratesstricturingofthecaputcecum,thesocalledconedcecum.

Crohndisease.Enterocolicfistula.Doublecontrastbariumenemastudydemonstratesmultiplefistuloustractsbetweentheterminal
ileumandtherightcolonadjacenttotheileocecalvalve,thesocalleddoubletrackingoftheileocecalvalve.

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Crohndisease.Smallbowelfollowthroughstudydemonstratesnarrowingofthelumenandmultipleenteroentericfistulae,butitfails
toshowtheenterovesicalfistula.

Crohndisease.Cystogramdemonstratesafillingdefectandinflammatorychangesofthedomeofthebladder,butitfailsto
demonstratetheenterovesicalfistula.

Ingeneral,1820%offindingsarefalsenegativeonbariumstudy,ascomparedwithendoscopicdetection.
However,bariumenemahasa95%accuracyrateindistinguishingCrohndiseasefromulcerativecolitis.

ComputedTomography
TheroleofCTintheevaluationofCrohndiseaseiswellaccepted.TheabilityofCTtodepictbowelinvolvement
andextraluminalpathology(eg,abscess,obstruction,fistula)makesitanessentialimagingtoolforpatientcare.
TheearliestCTfindingofCrohndiseaseisbowelwallthickening,whichusuallyinvolvesthedistalsmallboweland
colon,althoughanysegmentoftheGItractcanbeaffected.Typically,theluminalthickeningis515mm. [7,8,9,10]
CTshouldbethefirstradiologicprocedureperformedinpatientswithacutesymptomsandsuspectedorknown
Crohndisease.Theabilitytodirectlydemonstratethebowelwall,adjacentabdominalorgans,mesentery,and
retroperitoneummakesCTsuperiortobariumstudiesindiagnosingthecomplicationsofCrohndisease.CTdirectly
demonstratesbowelwallthickening,mesentericedema,andlymphadenopathy,aswellasphlegmonandabscess.
Seetheimagesbelow.

CrohndiseaseoftheterminalileumwithCTandsonographiccorrelation.Smallbowelfollowthroughstudydemonstratesthestring
signintheterminalileum.Alsonotepseudodiverticulaoftheantimesentericwalloftheterminalileum,secondarytogreater
distensibilityofthislessinvolvedsegmentofthewall.

CrohndiseaseoftheterminalileumwithCTandsonographiccorrelation.Noteterminalilealwallthickeningandadjacentmesenteric
inflammatorystranding.

Crohndisease.Activesmallbowelinflammation.CTscandemonstratessmallbowelwallthickening,mesentericinflammatory
stranding,andmesentericadenopathy.

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Crohndisease.Mesentericinflammation.CTscandemonstratesinflammatorymassintherightlowerquadrantassociatedwith
thickeningofthewallandnarrowingofthelumenoftheterminalileum.

Althoughbariumismoresensitiveindemonstratingthepresenceoffissuresandfistulas,CTissuperiorin
demonstratingthesequelaeofthesetracks(eg,airintheurinarybladderinenterovesicalfistula).
ThesensitivityofCTforCrohndiseaseisestimatedtobe71%,withlowerdetectionofearlymucosaldiseaseas
comparedwithbariumstudies.ArecentstudybyPhilpottsetalhasshownthattheCTfindingsofCrohndisease
considerablyoverlapwiththoseofinfectious,radiation,ulcerative,andischemiccolitides. [11]
CertaindistinguishingfeatureshavebeencitedindelineatingCrohndiseasefromotherformsofenterocolitis,
includingdifferencesinwallthicknessandattenuationthedistributionofcolonicwallinvolvementandthepresence
orabsenceofabscesses,fistulas,smallboweldisease,andmesentericfibrofattyproliferation.Inusingthe
mentionedfeatures,CTcanattainpositivepredictivevalueabove90%andadiagnosticaccuracyashighas93%.
[11]Seetheimagebelow.

Crohndisease.Fibrofattyproliferation.CTscaninapatientwithCrohncolitisinthechronicphasedemonstrateswallthickeningof
therightcolon,anabsenceofadjacentmesentericinflammatorystranding,andalargeamountoffattyproliferationaroundtheright
colonseparatingthecolonfromtheremainderofthegut,socalledcreepingfat.

TheintroductionofmultidetectorrowCTscannerswiththinnercollimationandfasterintravenousinjectionsof
contrastmaterialhaveallowedmoredetailedevaluationofthebowel.Theenhancementofthebowelwallafter
intravenouscontrastenhancementiscorrelatedwiththeenlargementofthefeedingvesselandhyperemiaduring
activedisease.InanarticlebyDelCampoetal,patientswithactivediseasehadabowelwallattenuationof95HU,
ascomparedwith65HUinpatientswithdiseaseinremission. [12]Theabilitytomeasurebowelwallenhancement
mayprovevaluableintreatingpatientswithCrohndisease.
OnelimitationofCThasbeenintheareaofdelineatingactiveversusinactivedisease.Thepresenceofmesenteric
strandingdoesnotreliablysignifyactivediseasebecauseresidualmesentericthickeningcanremainduring
remission.

Ulcerations
UlcerationsinthemucosacanbedetectedonthinsectionCT,althoughsmallbowelseriesorenteroclysisismore
sensitivetotheearlymucosalchangesofCrohndisease.Inaddition,mesentericstranding,increaseinmesenteric
fat,localadenopathy,fistula,andabscessarereadilyandcommonlyidentifiedonCTscans.

Hazyfat
Edemaormildinflammationofthemesentericfatresultsinfatofincreasedattenuation,thesocalledhazyfaton
CT.GreaterinflammationorfibrosisoffatresultsonCTinattenuatinglinearbandsofsofttissuecoursingthrough
themesentery.OnCT,anilldefinedinflamedmassofmixedattenuationmayrepresentaphlegmonorearly
abscessformation.Enlargedlymphnodesareusuallyseeninproximitytothebowelwallalongthemesenteric
courseofthevascularbundle.Seetheimagebelow.

Crohndisease.Mesentericinflammation.CTscandemonstratesaninflammatorymassintherightlowerquadrantassociatedwith
thickeningofthewallandnarrowingofthelumenoftheterminalileum.

Abscesses
OnCTscans,abscessesappearaswelldefined,roundorovalmassesoffluidattenuation,andtheyareoften
multilocular.Pocketsorbubblesofgasusuallyresultfromfistulouscommunicationwithbowelor,lesslikely,from
infectionbygasproducingorganisms.

Crohndiseaseversusulcerativecolitis
ThereisconsiderableoverlapbetweenCTfindingsofulcerativecolitisandCrohndisease.Despitethisfact,certain
definingfeaturesofeachdiseasehavebeencharacterized.Ulcerativecolitisispredominantlyamucosaldisease.
However,withprogressionofillness,thereishypertrophyofthemuscularisoftenby40fold,increasesubmucosa
fattydeposition,andthickeningofthelaminapropriafromroundcellinfiltration,whichallleadstobowelwall
thickening.Onaverage,thickeningoftheluminalwallis7.8mminulcerativecolitis,whichislessthantheamount

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ofwallthickeningtypicallyseenwithCrohndisease.
Submucosalfatisaprominentfindinginchroniculcerativecolitisandisoneofthedefiningfeaturesofthemural
stratificationseeninulcerativecolitis.Incomparison,Crohndiseasehastransmuralinvolvementthatovertime
leadstoreplacementofsubmucosalfatwithfibrosisandlossofmuralstratification.Indistinctiontoulcerative
colitis,CrohndiseasealsohasseveralextraluminalCTfindings,includingmesentericfibrofattyproliferationand
abscess.
AdditionalimagesofCrohndiseaseonCTscanningareprovidedbelow.

Crohndisease.CTwithMRIcorrelation.CTscaninapatientwithchronicinactiveCrohndiseasedemonstratesthickeningofthewall
oftherightcolonwithintramurallucency.Thiswasbelievedtorepresentintramuralfatdeposition.

Crohndisease.MRIwithCTcorrelation.MRIdemonstratesthickeningofthewalloftherightcolonwithintramuralincreasedsignal
onaT1weightedimage.Thiswasbelievedtorepresentintramuralfatdeposition.

Crohndisease.Perianalabscesses.CTscandemonstratesmultiplefluid,contrastmaterial,andaircollectionsaroundthe
anorectum.Notethepresenceofarectaltube.

Crohndisease.Perianalabscesses.CTscandemonstratesmultiplefluid,contrastagent,andaircollectionsaroundtheanorectum.
Notethepresenceofarectaltube.

Crohndisease.Smallbowelobstructioninapatientwithrecurrenceproximaltoananastomosis.CTscaninapatientwithaprior
ileocolectomydemonstratessmallboweldilatationandwallthickeningofthesmallbowelproximaltotheanastomosis.

Crohndisease.Enteroentericfistula.CTscandemonstratesthetractofanenteroentericfistula.

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Crohndisease.Enterocutaneousfistula.CTscandemonstratesenterocutaneousandcolocutaneousfistulaformation.

MagneticResonanceImaging
Traditionally,MRIhashadawelldefinedroleinevaluationofanorectalcomplicationsofCrohndisease.Witha
regularfastspinechotechnique,thepathologicentitiesofafistula,asinustract,andanabscesscanbedetectedin
thestaticanorectalregionbyusingMRI. [13]Morerecently,MRIenterographyandenteroclysishasalloweddetection
ofsmallbowelCrohndiseasesimilartotheuseofsmallbowelseries,withtheadditionalbenefitsforassessmentof
extraluminaldisease. [14]HighresolutionimagingwiththecurrentMRItechnologyhasincreasedtheaccuracyof
assessingthegradeandseverityofpatientwithCrohndisease. [14,15,16,17,18]Itsincreaseduseandavailabilitywill
likelyrivaltraditionalimagingintheassessmentofCrohndisease.

Perianalsinustractsandfistulas
SinustractsandfistulasoftenappearhyperintenseonT1weightedimagesandhyperintenseonT2weighted
imagesbecauseoftheirfluidcontent.Withfatsuppression,thefluidsignalisfurtherintensifiedandeasilyseenas
beinghyperintenseonT2weightedimages.Anabscessoftenappearsasanisolatedcollectionofhighsignal
intensityareasontheT2weightedimage,especiallyinischioanalfossa.Definingwhetheranabscess,fistula,or
sinustractisaboveorbelowthelevatoranimuscleisimportantfordrainage,becauseanypartoftheabscess
abovethelevatoranimusclewillnotdrainadequatelyintheinferiordirection,andviceversa.

MRIsequences
Thedevelopmentoffasterpulsesequences(eg,singleshotfastspinecho,steadystatefreeprecession,and
gradientechosequences)andhighergradientsystemshasmadeT1andT2weightedbreathholdimaging
possible.Thisbreathholdimaginghasbeenamajorbreakthroughinovercomingphysiologicmotionartifactsin
abdominalimaging.IthasmaderoutineabdominalMRIfeasible.
Thesingleshotfastspinechosequence,inwhichT2weightedimagesareacquiredbyusinghalfFourier
transformationandalongechotrain.Eachimagesectionisacquiredindependentlyinlessthan1second,andthe
methodeliminatesphysiologicmotionfromthebowelandtheneedforbreathholds.Fatsuppressioncanbeadded
toincreasespecificityforbowelandmesentericedema.
Thesteadystatefreeprecessionimagingisbasedonalowflipanglegradientechoserieswithshortrepetitiontime.
ItisanotherseriesofsequencesthatisinsensitivetomotionartifactsandcanprovideT2typeimaging.Itcanhave
blackboundaryartifactsalongthebowelwallthatmasksmalllesions,butfatsuppressioncanreducetheartifact.
Themajorfeatureofthesequenceistheabilitytoacquireanentireserieswithinasinglebreathhold.Infact,MR
fluoroscopyisperformedwithcineofsteadystatefreeprecessionimagingandaframerateof0.52sectionsper
secondsalongthelongaxisoftheaffectedsegments.
Contrastevaluationisoftenimagedwith3dimensionalspoiledgradientechoT1fatsuppressedsequences.Images
areacquiredwithbreathhold.Forbowelimaging,seriesaretakenafterintravenousglucagonat30and70seconds
postcontrast.
Becauseofadecreaseincumulativeradiationexposureandbecauseofthecapabilityofattaininghighquality
coronalimagescorrelatingwithbariumstudies,MRIiscurrentlyanalternativeformonitoringdiseaseactivityin
Crohndisease.

MRIenterographyandenteroclysis
Withthedevelopmentoffasterimagingsequenceandwiththeuseofintravenous0.2mgglucagontodecrease
bowelmotility,thesmallbowelisdistendedinbothMRIenterographyorenteroclysis,oftenwith1.52Lofsolution
containingbiphasicintraluminalcontrastagents(lowT1andhighT2).SomeoftheseagentsareVolumen(EZEM
Westbury,NY),mannitol(2.5%),methylcellulose,sorbitol(2%),andpolyethyleneglycol.Imageisperformedfor40
60minutessubsequenttoluminaldistensionforMRIenterographyandenteroclysis.
Oralingestionoftheintraluminalcontrastisperformedinenterography,whilenasojejunalintubationandinfusionof
intraluminalcontrastisperformedinenteroclysis.NasojejunalintubationunderfluoroscopyisrequiredforMRI
enteroclysisitprovidesexcellentboweldistentionandprovidesdetailedluminalinformation. [19]However,thereis
addedproceduretimeforthefluoroscopynasojejunalintubation,alongwithincreasedinvasivenessandpatient
discomfort. [20,21]Thesefactorscanbemajordrawback,especiallyinpediatricpopulation.
MRIenterographyhaslesspatientdiscomfort,butthebowelpreparationmaynotproducetheuniformdistention
achievedwithenteroclysis.Nevertheless,severalstudieshaveshownbetterpatienttoleranceofenterographyover
enteroclysis,andsomestudieshaveshownsimilarsensitivityforbothtechniques. [20]
Initialimagingwithserialcoronalsteadystatefreeprecessionforthesmallbowelcandemonstratedecreased
motilityinareasofsmallboweldisease,alongwithluminalthickening(wallthickness>4mm)whilemonitoring
adequatedistentionoftheileocecallumen.Afteradequateluminaldistention,intravenous0.2mgofglucagonor1
mgofintramuscularglucagonisadministeredtoreducemotionartifacts,followedbyT2weightedsingleshotfast
spinechoseries.ThecoronalandaxialT2weightedsingleshotfastspinechoimagescanshowedemainthesmall
bowelmesenteryandsmallbowelwalldeepulcers,whilefatsaturatedimagescandeterminechronicmuralfat
changes.Lastly,afteradministrationofagadoliniumbasedintravenouscontrastagent,coronalvolumegradient
echosequencesareacquiredtoassessvascularengorgement,mucosalhyperemia,muralenhancement,
inflammatoryhyperenhancinglymphnodes,abscess,andfistula.

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TherearecurrentlyongoinginvestigationsintotheuseofMRIenterographyandassessmentofactivediseaseinthe
colon.

ActiveCrohndisease
AssessmentofinflammatoryactivityisfundamentaltothemanagingCrohndisease.Thereisnosinglereference
standardfordefiningactivedisease.ClinicalscoressuchastheCrohndiseaseactivityindexandbiochemical
markerssuchasCreactiveproteinarewidelyused,buttheylackutilityforassessmentoftheentirebowel. [17]
Endoscopyisthecurrentreferencestandardforevaluationofdiseaseofthecolonandterminalileum.Ithasthekey
advantagesofdirectvisualizationandsamplingofdisease,butitislimitedinitsassessmentoftheentiresmall
bowel.MRIcurrentlyservesasaviablemethodforglobalassessment.
ManyofMRIcriteriaofdiseaseactivityarebasedonluminalandextraluminaldisease.Intermsofluminaldisease,
activediseaseincludesulcer,wallthickening,muralandperimuralT2intensity,andbowelwallenhancementwith
gadoliniumbasedcontrastagents. [17]Extraluminalactivediseaseincludesenlargedinflammatorylymphnodes,
fibrofattyproliferation,andmesentericedema.
Duringactiveinflammation,gadoliniumenhancementofthebowelwallcanbeseenonT1weightedimages,andit
iseasilydifferentiatedfromnormaladjacentbowel.Thereare3mainpatternsofenhancementindeterminingthe
levelofdisease.Thelayeredorstratifiedenhancementisseenwithenhancementofthemucosa,andrelatively
poorsubmucosalenhancementandsubmucosaledemaareseeninactivedisease. [22,23,24]Diffuseintense
homogenousenhancementoftheentirebowelwallthicknessoccursfromtransmuralinflammation. [25]Lowlevel
heterogeneousenhancementoccurswithfibrosis. [26]Seetheimagebelow.

MRIenterography3dimensionalgradientpostcontrastseriesdemonstratesstratifiedhyperenhancementofthemucosaofthedistal
ileuminapatientwithactiveCrohndisease.

Wallthickeningisvariableinactivedisease,asdescribedinmanyreports.Thegeneralconsensusisthatconcentric
bowelwallthickeninggreaterthan4mmissuggestiveofactivedisease.InstudybyMaccionietal,activediseaseis
characterizedbyathickenedbowelwallwithgadoliniumenhancement,butinactivediseaseisnot. [27]Withthe
adventofMRIenteroclysis,andtoalesserdegreeoptimalenterography,alterationoffoldsinearlyactiveCrohn
diseasecanbeseenasdiffusethickenedfoldsasinapicketfencepattern,reductionanddistortionoffolds
secondarytoulceration,andcobblestoningonsingleshotspinechoseries. [26]Seetheimagebelow.

MRIenterographywithcoronalfatsaturatedT2weightedsingleshotfastspinechoimagingdemonstratesmesentericedemaand
muralwalledemaandthickeninginapatientwithactiveCrohndiseaseinthedistalileum.

FatsuppressedT2weightedimagescanalsobeusedfordifferentiationbecausetheyshowhighsignalintensityin
activediseaseandloworabsentsignalintensityinnonactivedisease.MuralT2increasedsignalintensityisawell
validatedmarkerofdiseaseactivity. [23,27,28,29,30,31]Infact,thefatsuppressioninT2weightedimageshelps
differentiatefibrofattychangesofmuraldiseasefrommuralwalledema.
UlcerationinactiveCrohndiseaseishighlydependentonthequalityofluminaldistentionandisbestdepictedby
MRIenterographyandenteroclysis.Deepulcersappearasthinlinesofhighsignalwithinathickenedbowelwallon
singleshotfastspinechoseriesandcanbeseenmorereadilyonMRIenterography,whereasaphthousulcer,with
anidusofhighsignalwithsurroundingintermediatesignal,canbeseenonhighresolutionMRIenteroclysis.See
theimagebelow.

MRIenterographycoronalsingleshotfastspinechoimagesinapatientwithactiveCrohndiseasedemonstrateswallthickeningand
walldeepfissuringalonganascendinglimbofthedistalileumsmallbowelloopintherightlowerquadrantoftheabdomen.

FibrofattyproliferationishyperintenseonT2weightedimagesandisrelatedtoregionalmesenteritisoredemaand

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dilatationoflocalvessels.Thedilatationofthelocalvesselsisseensupplyingalocalinflamedbowelsegment,akin
tothecombsignseenonCTexaminationthisfindingiswelldepictedinpostcontrastgradientechoimagesand
steadystatefreeprocessionimages.Inclusiveinthetermfibrofattyproliferationisfatwrapping,wherebythereis
chronicenlargedmesentericfatleadingtoincreasedseparationofthemesentericbowelloops.Fatproliferationisa
distinguishingfeatureofCrohndiseaseandisindicativeofthediagnosis.Seetheimagebelow.

MRIenterography,steadystatefreeprocessionimage,demonstratesvascularengorgementofthevasarectaor"comb"signina
thickenedileumbowelloopduringactivedisease.

Mesentericedemainactivediseaseisseenaccompanyingbowelwalledemaandhyperenhancementandisseen
oftenwiththecombsignofthemesentery.
Activelymphnodesareenlarged,hyperenhancing,andedematous,typicallyalongthevascularsupplyofaffected
bowelsegment.Thenodalenhancementisusuallyhomogenousandisgreaterthanorequaltooneoftheadjacent
lymphnodeforactivedisease. [23]
Lowetal[32]andMarcosandSemelka[33]havefoundgradientechoimagingtobemoresensitivethanother
methodsindeterminingtheseverityofCrohndisease,andtheyfavortheuseofgadoliniumenhancedgradientecho
MRI.
GadoliniumenhancedspoiledgradientechoMRIhasareportedsensitivityof8589%,aspecificityof9694%,and
anaccuracyof9491%foractivedisease,ascomparedwithsingleshotfastspinechoMRI,whichhasasensitivity
of5152%,specificityof9896%,andaccuracyof8384%. [32]

ChronicCrohndiseaseandcomplicationsofCrohndisease
Thereare3majorformsofchronicCrohndisease:fistulaandperforatingdisease,fibrostenoticdisease,reparative
orregenerativedisease.Fistulaearesequelaeofdeeptransmuralulcersthatextendthroughthemusculature,
leadingtotheformationofsmallabscessesandsinustracts.Thesinustractcaninvolveandcommunicatewith
adjacentholloworganandformfistulae.MRIdepictionoffistulaeisoftenseenasfibroticstarshapedreactionsof
themesentery,withtetheringoftheadjacentcommunicatingstructures.Ithasavidenhancementpostcontrastand,
onoccasion,showsalinearT2hyperintensetract.Thechronicmesentericinflammationcaneventuallyformfibrous
bandswithenhancementsimilartosinusesandfistulas.However,theyoftenleadtotentingandsegmental
obstructionwithMRfluoroscopy,showingkinkingandstretchingoftheadjacentbowelloops.
Fibrostenoticdiseaseisoftendepictedasbowelobstructionwithoutbowelwallthickening.Thebowelstricturehas
lowT1andT2muralsignalandhasmildnonhomogenousenhancement.Withasymmetricbowelwallinvolvement,
pseudosacculationcanoccur.
RegenerativediseaseisdepictedonMRIasluminalnarrowingwithoutinflammationorobstruction.Onsteadystate
freeprocessionimaging,filiformpolyposismaybesuggestedwithoutenhancementorobstruction.Neoplasiaisalso
aconcerninchronicdisease,sinceCrohndiseasepatientsareatincreasedriskofdevelopingadenocarcinomaof
theaffectedbowelsegment. [34,35]Eccentricbowelwallthickeningorshouldering,mesentericinfiltration,and
lymphadenopathyonMRIenterographyorenteroclysisareoftenearlysignsofmalignancy.

Warningaboutgadoliniumbasedcontrastagents
Gadoliniumbasedcontrastagents(gadopentetatedimeglumine[Magnevist],gadobenatedimeglumine
[MultiHance],gadodiamide[Omniscan],gadoversetamide[OptiMARK],gadoteridol[ProHance])havebeenlinkedto
thedevelopmentofnephrogenicsystemicfibrosis(NSF)ornephrogenicfibrosingdermopathy(NFD).Thedisease
hasoccurredinpatientswithmoderatetoendstagerenaldiseaseafterbeinggivenagadoliniumbasedcontrast
agenttoenhanceMRIorMRangiographyscans. [36]NSF/NFDisadebilitatingandsometimesfataldisease.
Characteristicsincluderedordarkpatchesontheskinburning,itching,swelling,hardening,andtighteningofthe
skinyellowspotsonthewhitesoftheeyesjointstiffnesswithtroublemovingorstraighteningthearms,hands,
legs,orfeetpaindeepinthehipbonesorribsandmuscleweakness.

DegreeofconfidenceandimpactofMRI
GadoliniumenhancedspoiledgradientechoMRIhasareportedsensitivityof8589%,aspecificityof9694%,and
anaccuracyof9491%foractivedisease,ascomparedwithsingleshotfastspinechoMRI,whichhasasensitivity
of5152%,aspecificityof9896%,andanaccuracyof8384%. [32]MRIenterographyandenteroclysiscompared
withconventionalimaginghassensitivityof8898%andspecificityof78100%. [14]Inarecentretrospectivestudy,
MRIenterographyhasbeenconfirmedtoimpactthemanagementofpatientcarewithadditionalinformationfrom
endoscopyandclinicalassessment.Inaretrospectivestudyof120MRIenterographypatients,53%underwent
additionalmedicaltreatmentofactivediseaseand16%underwentsurgerywithintraoperativefindingsconcordantto
MRenterography. [37]

Ultrasonography
UltrasonographycanbeanalternativetoCTintheevaluationoftheintraluminalandextraluminalmanifestationsof
Crohndisease.ThenormalGIwallappearsas5concentric,alternatingechogenicandhypoechoiclayersthis
appearanceisknownasthegutsignature.TheGIwallhasanaveragethicknessoflessthan5mm. [38,39]

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InthecaseofactiveCrohndisease,thewallthicknesscanrangefrom5mmto2cmwitheitherpartialortotalloss
oflayering,whichreflectstransmuraledema,inflammation,orfibrosis.Withsevereinflammation,thewallappears
diffuselyhypoechoicwithacentralhyperechoiclinethatcorrespondstothenarrowedlumen.Peristalsisisreduced
orabsent,andthediseasedsegmentisnoncompressibleandrigidwithalossofhaustra.
Ultrasonographycandepictballooningofthelessinvolvedsegments,whichisseenasfocalsacculationor
outpouching.ThesefindingsreflecttheskiplesionsfoundinCrohndisease.Theaccuracyofultrasonographyis
furtherimprovedwiththeuseofcolorDopplerimaging.TheuseofDopplerimagingishelpfulinthedetectionof
hyperemiaofaninflamedbowelwallandadjacentfatduringactivedisease.
Withtransmuralinflammation,edemaandfibrosisoftheadjacentmesenteryoccurs,leadingtofingerlikeprojections
ofmesentericfatthatcreepsovertheserosalsurfaceofthebowel.Thiscreepingfateventuallyenvelopsthe
diseasedbowelsegment.Onsonograms,thisappearsasauniformhyperechoicmass,whichisclassicallyseenat
thecephalicmarginoftheterminalileum.Withlongstandingdisease,thisbecomesmoreheterogeneousoreven
hypoechoic.
InactiveCrohndisease,reactivemesentericnodesareenlargedandmaycoalescetoformaconglomeratemass.
Onsonograms,enlargednodescanbeseenasovalhypoechoicmassesinthemesentery.Withconfluence,they
becomelobulatedmassesofvarioussizes.
ManycomplicationsofCrohndiseasecanalsobeseenintheirultrasonographicforms.Phlegmonappearsasa
hypoechoicmasswithirregularbordersandnoidentifiablewallorfluid.Abscessappearsasafluidcollectionwitha
thickenedwallcontainingairorechogenicdebris.Obstructionappearsasdilatedhyperperistalticfluidfilled
segments.Perforationappearsasbrightechoeswithdistalacousticshadowsoutsidetheboundariesofbowelloops.
Afistula,ontheotherhand,appearsasahypoechoictract.Ifgasispresentinthefistuloustract,itcontains
hyperechoicfociwithacousticshadowing.Palpationofdiseasedloopsduringsonographyenablestract
identification.Inaddition,sonographyshouldbeabletoidentifygasbubblesinabnormallocations,suchasairin
thebladderorvaginalvault,theretroperitoneum,thesubcutaneoustissue,andtheurachalremnant.
Thedetectionofbowelwallthickeningvarieswidely.Detectionratesrangefrom2289%.Thelargevariation
presumablyreflectsdifferencesintechnique,operatorexperience,andultrasoundequipment.Determinationofthe
extentofthediseaseisnotalwayspossible,andcorrelationbetweenwallthickeningandtheclinicalactivityof
diseaseispoor.
Thelossofgutsignatureandbowelwallthickeningisanonspecificfinding.Itisfoundininfectious,ischemic,
neoplastic,andradiationinducedconditions.Inaddition,thedetectionofbowelwallchangesinCrohndisease
variessignificantlybecauseofoperatordependence.
Seetheimagesbelow.

CrohndiseaseoftheterminalileumwithCTandsonographiccorrelation.Noteterminalilealwallthickeningandadjacentmesenteric
inflammatorystranding.

CrohndiseaseoftheterminalileumwithCTandsonographiccorrelation.Notehypoechoicwallthickening,lossofthegutsignature,
andthehyperechoiclinerepresentingthenarrowedlumen.

CrohndiseaseoftheterminalileumwithCTandsonographiccorrelation.Notehypoechoicwallthickening,lossofthegutsignature,
andthehyperechoiclinerepresentingthenarrowedlumen.

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Crohndisease.Sonogramofathickenedbowelwalldemonstratesthesocalledpseudokidneyappearance.

Theliteraturestatesthatthedifferentiationbetweenhypoechoicfocifromcreepingfatandthatfromphlegmonor
edemamaybedifficultornearlyimpossible.ProponentsofCThavealsostatedthatthespecificityofcolorDoppler
imagingisstillunknown.Ingeneral,theconfidenceleveloftheradiologistininterpretingtheresultsisoperator
dependent,anditisoftenlowerthanthatofCT.Forthesereasons,ultrasonographyhasnotbeenthefavored
modalityforimagingCrohndisease.

NuclearImaging
Leukocyteslabeledwitheithertechnetium99mHMPAO(hexamethylpropylamineoxime)orindium111canbeused
toassessforactivebowelinflammationininflammatoryboweldisease.Comparedtothe111Inlabel,the99m Tc
HMPAOlabelhasbetterimagingcharacteristicsandcanbeimagedmuchsoonerafterinjection.However,imaging
musttypicallybedonewithinanhourafterinjectionof 99m TcHMPAOlabeledleukocytes,asthereisnormal
excretionintothebowelafterthistime,unlikewith111labeledleukocytes,whichhavenonormalbowelexcretion.
Molnaretalfoundthata99m TcHMPAOleukocytescaninactiveCrohndiseasehadasensitivityof76.1%anda
specificityof91.0%,ascomparedtoCTsensitivityof71.8%andspecificityof83.5%.Whileleukocytescansmaybe
betterinthedetectionofsegmentalinflammatoryactivity,CTissuperiorforthedetectionofcomplications. [40]
Falsepositivebowelactivitycanbeseenwithgastrointestinalbleeding,swallowedleukocytes(eg,fromuptake
relatedtosinusitisornasogastrictubes),oractivityrelatedtoindwellingenterictubes.Inaddition,leukocyteuptake
isnotspecificforCrohndiseaseandwillbeseeninmostinfectiousorinflammatorybowelprocesses.Asmentioned
above,thereisoftennormalbowelexcretionof 99m TcHMPAOleukocytesifimagingoccurswithinthefirsthour
afterinjection.

ContributorInformationandDisclosures
Author
YungHsinChen,MDDirectorofMRI,SectionChiefofMusculoskeletalRadiology,AllianceMRINorton
AssistantClinicalProfessor,TuftsUniversitySchoolofMedicine
YungHsinChen,MDisamemberofthefollowingmedicalsocieties:AmericanRoentgenRaySociety,
RadiologicalSocietyofNorthAmerica,andSocietyofSkeletalRadiology
Disclosure:Nothingtodisclose.
Coauthor(s)
DahuaZhou,MDStaffPhysician,DepartmentofRadiology,NassauUniversityMedicalCenter
DahuaZhou,MDisamemberofthefollowingmedicalsocieties:RadiologicalSocietyofNorthAmerica
Disclosure:Nothingtodisclose.
DavidIWeltman,MDConsultingStaff,S&DMedical,LLPDirector,DepartmentofRadiology,Southside
Hospital
DavidIWeltman,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofRadiology,American
RoentgenRaySociety,AssociationofProgramDirectorsinRadiology,NewYorkCountyMedicalSociety,and
RadiologicalSocietyofNorthAmerica
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
BernardDCoombs,MB,ChB,PhDConsultingStaff,DepartmentofSpecialistRehabilitationServices,Hutt
ValleyDistrictHealthBoard,NewZealand
Disclosure:Nothingtodisclose.
SpencerBGay,MDProfessorofRadiology,DepartmentofRadiologyandMedicalImaging,Universityof
VirginiaSchoolofMedicine
Disclosure:Nothingtodisclose.
RobertMKrasny,MDResolutionImagingMedicalCorporation
RobertMKrasny,MDisamemberofthefollowingmedicalsocieties:AmericanRoentgenRaySocietyand
RadiologicalSocietyofNorthAmerica
Disclosure:Nothingtodisclose.
ChiefEditor
EugeneCLin,MDAttendingRadiologist,TeachingCoordinatorforCardiacImaging,RadiologyResidency
Program,VirginiaMasonMedicalCenterClinicalAssistantProfessorofRadiology,UniversityofWashington
SchoolofMedicine
EugeneCLin,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofNuclearMedicine,
AmericanCollegeofRadiology,RadiologicalSocietyofNorthAmerica,andSocietyofNuclearMedicine
Disclosure:Nothingtodisclose.
AdditionalContributors
JohnLHaddad,MDClinicalAssociateProfessor,DepartmentofRadiology,WeillMedicalCollegeofCornell
UniversityDirectorofBodyMRI,DepartmentofRadiology,MethodistHospitalinHouston
JohnLHaddad,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofRadiology,American
MedicalAssociation,andRadiologicalSocietyofNorthAmerica

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Disclosure:Nothingtodisclose.

References
1. LeeSS,KimAY,YangSK,ChungJW,KimSY,ParkSH,etal.CrohnDiseaseoftheSmallBowel:
ComparisonofCTEnterography,MREnterography,andSmallBowelFollowThroughasDiagnostic
Techniques.Radiology.Mar102009[Medline].
2. LevineMS,RubesinSE,LauferI.Bariumstudies.GastrointestEndosc.Jun200255(7Suppl):S1624.
[Medline].
3. RubesinSE,ScotiniotisI,BirnbaumBA.RadiologicandendoscopicdiagnosisofCrohn'sdisease.Surg
ClinNorthAm.Feb200181(1):3970,viii.[Medline].
4. LichtensteinGR,HanauerSB,SandbornWJ.ManagementofCrohn'sdiseaseinadults.AmJ
Gastroenterol.Feb2009104(2):46583quiz464,484.[Medline].
5. CosnesJ.Crohn'sdiseasephenotype,prognosis,andlongtermcomplications:whattoexpect?.Acta
GastroenterolBelg.JulSep200871(3):3037.[Medline].
6. LauferL,HamiltonJD.Theradiologicadifferentiationbetweenulcerativeandgranulomatouscolitisby
doublecontrastradiology.AmJGastroenterol.197666:259269.
7. GoreRM,BalthazarEJ,GhahremaniGG.CTfeaturesofulcerativecolitisandCrohn'sdisease.AJRAmJ
Roentgenol.Jul1996167(1):315.[Medline].
8. HortonKM,FishmanEK.CTangiographyoftheGItract.GastrointestinalEndoscopy.200255(7
Suppl):S3741.[Medline].
9. JaceneHA,GinsburgP,KwonJ,NguyenGC,MontgomeryEA,BaylessTM,etal.Predictionoftheneed
forsurgicalinterventioninobstructiveCrohn'sdiseaseby18FFDGPET/CT.JNuclMed.Nov
200950(11):17519.[Medline].
10. MazzeoS,CaramellaD,BattollaL.Crohndiseaseofthesmallbowel:spiralCTevaluationafteroral
hyperhydrationwithisotonicsolution.JComputAssistTomogr.JulAug200125(4):6126.[Medline].
11. PhilpottsLE,HeikenJP,WestcottMA.Colitis:useofCTfindingsindifferentialdiagnosis.Radiology.Feb
1994190(2):4459.[Medline].
12. DelCampoL,ArribasI,ValbuenaM.SpiralCTfindingsinactiveandremissionphasesinpatientswith
Crohndisease.JComputAssistTomogr.SepOct200125(5):7927.[Medline].
13. IppolitoD,InvernizziF,GalimbertiS,PanelliMR,SironiS.MRenterographywithpolyethyleneglycolas
oralcontrastmediuminthefollowupofpatientswithCrohndisease:comparisonwithCTenterography.
AbdomImaging.Jul72009[Medline].
14. SinhaR,RajiahP,MurphyP,HawkerP,SandersS.UtilityofhighresolutionMRimagingin
demonstratingtransmuralpathologicchangesinCrohndisease.Radiographics.Oct200929(6):184767.
[Medline].
15. SinhaR,VermaR,VermaS,RajeshA.MRenterographyofCrohndisease:part1,rationale,technique,
andpitfalls.AJRAmJRoentgenol.Jul2011197(1):769.[Medline].
16. SinhaR,VermaR,VermaS,RajeshA.MRenterographyofCrohndisease:part2,imagingand
pathologicfindings.AJRAmJRoentgenol.Jul2011197(1):805.[Medline].
17. MakanyangaJC,TaylorSA.CurrentandfutureroleofMRenterographyinthemanagementofCrohn
disease.AJRAmJRoentgenol.Jul2013201(1):5664.[Medline].
18. GeenenRW,HussainSM,SiersemaPD,PoleyJW,KuipersEJ,KrestinGP.CurrentstatusofMRIin
patientswithinflammatoryboweldiseasecolitis.AppliedRadiology.200736:1021.
19. KuehleCA,AjajW,LaddSC,MassingS,BarkhausenJ,LauensteinTC.HydroMRIofthesmallbowel:
effectofcontrastvolume,timingofcontrastadministration,anddataacquisitiononboweldistention.AJR
AmJRoentgenol.Oct2006187(4):W37585.[Medline].
20. NegaardA,PaulsenV,SandvikL,etal.AprospectiverandomizedcomparisonbetweentwoMRIstudies
ofthesmallbowelinCrohn'sdisease,theoralcontrastmethodandMRenteroclysis.EurRadiol.Sep
200717(9):2294301.[Medline].
21. NegaardA,SandvikL,BerstadAE,PaulsenV,LygrenI,BorthneA.MRIofthesmallbowelwithoral
contrastornasojejunalintubationinCrohn'sdisease:randomizedcomparisonofpatientacceptance.Scand
JGastroenterol.Jan200843(1):4451.[Medline].
22. KohDM,MiaoY,ChinnRJ,AminZ,ZeegenR,WestabyD.MRimagingevaluationoftheactivityof
Crohn'sdisease.AJRAmJRoentgenol.Dec2001177(6):132532.[Medline].
23. MaccioniF,BruniA,ViscidoA,etal.MRimaginginpatientswithCrohndisease:valueofT2versusT1
weightedgadoliniumenhancedMRsequenceswithuseofanoralsuperparamagneticcontrastagent.
Radiology.Feb2006238(2):51730.[Medline].
24. PunwaniS,RodriguezJustoM,BainbridgeA,GreenhalghR,DeVitaE,BloomS.Muralinflammationin
Crohndisease:locationmatchedhistologicvalidationofMRimagingfeatures.Radiology.Sep
2009252(3):71220.[Medline].
25. MiaoYM,KohDM,AminZ,HealyJC,ChinnRJ,ZeegenR.Ultrasoundandmagneticresonanceimaging
assessmentofactivebowelsegmentsinCrohn'sdisease.ClinRadiol.Oct200257(10):9138.[Medline].
26. TolanDJ,GreenhalghR,ZealleyIA,HalliganS,TaylorSA.MRenterographicmanifestationsofsmall
bowelCrohndisease.Radiographics.Mar201030(2):36784.[Medline].

http://emedicine.medscape.com/article/367666overview#a19

14/15

1432543718075.868

ImaginginCrohnDisease

27. MaccioniF,ViscidoA,BrogliaL,etal.EvaluationofCrohndiseaseactivitywithmagneticresonance
imaging.AbdomImaging.MayJun200025(3):21928.[Medline].
28. MadsenSM,ThomsenHS,SchlichtingP,DorphS,MunkholmP.Evaluationoftreatmentresponsein
activeCrohn'sdiseasebylowfieldmagneticresonanceimaging.AbdomImaging.MayJun199924(3):232
9.[Medline].
29. RimolaJ,RodriguezS,GarciaBoschO,OrdasI,AyalaE,AceitunoM.Magneticresonancefor
assessmentofdiseaseactivityandseverityinileocolonicCrohn'sdisease.Gut.Aug200958(8):111320.
[Medline].
30. ZappaM,StefanescuC,CazalsHatemD,etal.Whichmagneticresonanceimagingfindingsaccurately
evaluateinflammationinsmallbowelCrohn'sdisease?Aretrospectivecomparisonwithsurgicalpathologic
analysis.InflammBowelDis.Apr201117(4):98493.[Medline].
31. MaccioniF,StaltariI,PinoAR,TibertiA.ValueofT2weightedmagneticresonanceimaginginthe
assessmentofwallinflammationandfibrosisinCrohn'sdisease.AbdomImaging.Dec201237(6):94457.
[Medline].
32. LowRN,SebrechtsCP,PolitoskeDA,BennettMT,FloresS,SnyderRJ.Crohndiseasewithendoscopic
correlation:singleshotfastspinechoandgadoliniumenhancedfatsuppressedspoiledgradientechoMR
imaging.Radiology.Mar2002222(3):65260.[Medline].
33. MarcosHB,SemelkaRC.EvaluationofCrohn'sdiseaseusinghalffourierRAREandgadoliniumenhanced
SGEsequences:initialresults.MagnResonImaging.Apr200018(3):2638.[Medline].
34. RichardsME,RickertRR,NanceFC.Crohn'sdiseaseassociatedcarcinoma.Apoorlyrecognized
complicationofinflammatoryboweldisease.AnnSurg.Jun1989209(6):76473.[Medline].
35. RibeiroMB,GreensteinAJ,SacharDB,BarthJ,BalasubramanianS,HarpazN.Colorectal
adenocarcinomainCrohn'sdisease.AnnSurg.Feb1996223(2):18693.[Medline].
36. TaylorSA,PunwaniS,RodriguezJustoM,etal.MuralCrohndisease:correlationofdynamiccontrast
enhancedMRimagingfindingswithangiogenesisandinflammationathistologicexaminationpilotstudy.
Radiology.May2009251(2):36979.[Medline].
37. MessarisE,ChandoliasN,GrandD,PricoloV.Roleofmagneticresonanceenterographyinthe
managementofCrohndisease.ArchSurg.May2010145(5):4715.[Medline].
38. RipollesT,MartinezMJ,ParedesJM,BlancE,FlorsL,DelgadoF.Crohndisease:correlationoffindings
atcontrastenhancedUSwithseverityatendoscopy.Radiology.Oct2009253(1):2418.[Medline].
39. SarrazinJ,WilsonSR.ManifestationsofCrohndiseaseatUS.Radiographics.May199616(3):499520
discussion5201.[Medline].
40. MolnarT,PaposM,GyulaiC,etal.Clinicalvalueoftechnetium99mHMPAOlabeledleukocyte
scintigraphyandspiralcomputedtomographyinactiveCrohn'sdisease.AmJGastroenterol.May
200196(5):151721.[Medline].
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