NEW IMAGING TECHNIQUES IN THE EVALUATION OF CROHNS DISEASE

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

Imaging for Crohn Disease

Traditional Techniques
Newer Techniques
Imaging for Crohn Disease

Traditional Techniques
* Abdominal Radiographs
* Barium UGI
* Barium small bowel follow through
* Barium Enteroclysis
* Barium Enema

Imaging for Crohn Disease Newer Techniques

* CT
* CT Enteroclysis
* CT Enterography
* Magnetic Resonance
* Ultrasound
* Nuclear Medicine

Imaging for Crohn Disease Traditional Techniques

* Abdominal Radiographs
o Use for initial evaluation of acute pain
o Bowel obstruction
o Perforation
o Limited value

Imaging for Crohn Disease Traditional Techniques


* Barium UGI
o limited in the evaluation of milder cases of mucosal and transluminal inflammation in EGD region

Imaging for Crohn Disease Traditional Techniques

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

SIFT Crohn Disease

Ileo-vesical Fistula

SIFT still useful on occasion…

“Hunt the Capsule”

Imaging for Crohn Disease Traditional Techniques

* Enteroclysis
o Enteroclysis can improve small bowel distension by infusing barium contrast rapidly via a duodenal tube

o Unfortunately, the passing of the enteroclysis catheter into the distal duodenum is often difficult and unpleasant for the patient


o Time consuming procedure, difficult technique

Imaging for Crohn Disease Enteroclysis

Imaging for Crohn Disease
Traditional Techniques

* Barium Enema
o Used less frequently in recent years
o 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

Crohn’s Disease Imaging for Crohn Disease Newer Techniques

* CT
* CT Enteroclysis
* CT Enterography
* Magnetic Resonance
* Ultrasound
* Nuclear Medicine

Imaging for Crohn Disease Newer Techniques

* CT
* CT Enteroclysis
* CT Enterography
* Magnetic Resonance
* Ultrasound
* Nuclear Medicine

Imaging for Crohn Disease Newer Techniques


* CT
o Widely used to evaluate for abscess
o Mesenteric fatty proliferation
o May show strictures but wall thickening difficult to assess due to variable distension
o not as sensitive in delineating fissure or fistula as barium studies
o superior to barium in showing the extraluminal sequelae of Crohns

SBO – Crohn Disease

Enteropathic Arthropathy

SacroIliitis – see in 10-20% of Crohns

Imaging for Crohn Disease Newer Techniques

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

CT Enteroclysis

Active Crohns disease, not seen on SIFT done previously Imaging for Crohn Disease Newer Techniques


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

NORMAL SMALL BOWEL WITH VOLUMEN

View as stack of thin 4 mm images through entire abdomen
Coronal cuts simulate traditional SIFT view



* CT Enterography
o Enhanced wall seen better with negative lumen contrast
o Early studies show superiority to barium studies and conventional CT for detection of mucosal disease activity and strictures (Lee et al, AJR 03)
o 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


Crohn’s Disease Inflammatory Hyperemia and Reactive adenopathy
Evaluate all abdomen organs as well as bowel

* Crohn’s With Neo-TI & Colonic Disease
* Better evaluation of colon than with SIFT
ILEO-SIGMOID FISTULA
Coronals Show Definite Ileo-vesicular Fistula

* Chronic Crohns in TI
* Fat in bowel wall

CT Enterography

CT Enterography Post Op.
* Magnetic Resonance
Anorectal Crohns
MR of Ano-rectal disease
Bilateral severe complex trans-sphincteric fistulae
Liver Disease associated with Crohns/UC
Primary Sclerosing Cholangitis
PSC & Cholangiocarcinoma

* Ultrasound
o difficult to do, inconsistent results
o May be used to monitor therapy in kids

* Nuclear Medicine
o Indium scan
o Not often used
o May be incidental finding of increased activity in bowel

CT Colography (Virtual Colonoscopy)

Long sigmoid stricture: Adenocarcinoma

Imaging for Crohn Disease Conclusions
Traditional Techniques
Newer Techniques
Imaging for Crohn Disease Traditional Techniques

* Abdominal Radiographs
* Barium UGI
* Barium small bowel follow through
* Barium Enteroclysis
* Barium Enema

Imaging for Crohn Disease Newer Techniques

* CT
* CT Enteroclysis
* CT Enterography
* Magnetic Resonance
* Ultrasound
* Nuclear Medicine

Imaging for Crohns Disease Conclusion

* Useful Newer Techniques evolving
o CT Enterography
+ Comprehensive evaluation of all bowel & solid organs
o 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


NEW IMAGING TECHNIQUES IN THE EVALUATION OF CROHNS DISEASE.ppt