25 December 2009



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


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
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



Pregnancy and the Inflammatory Bowel Disease

Pregnancy and the Inflammatory Bowel Disease
By:David G. Binion, M.D.
Director, IBD Center
Associate Professor of Medicine
Medical College of Wisconsin
Milwaukee, WI

Case 1: Pregnancy and IBD
Case 2: Pregnancy and IBD

Introduction: Pregnancy and IBD

* Highest age adjusted incidence rates of IBD (15 – 30) overlap peak reproductive years.
* Improved medical and surgical treatment of IBD has allowed patients with more significant illness to consider pregnancy and having children.
* Optimal treatment algorithms for IBD patients during pregnancy have not been defined, including issues regarding high risk pregnancy.
* Optimal management of reproductive heath in IBD patients is a challenge to gastroenterologists, obstetricians, IBD surgeons.

Goals: Pregnancy and IBD

* Fertility – becoming pregnant.
* Having an uneventful term pregnancy:
o Avoiding preterm delivery
o Avoiding severe flare r- isk for preterm delivery
* Use of safe medications to maintain remission in mother during pregnancy.
* Use of safe medications during post-partum and breast feeding to help mother maintain remission.


* Fertility/Fecundity Rates
* Pregnancy Outcomes
* Effects of Medications on Pregnancy
* Special situations - IBD Surgery during pregnancy

Infertility: UC

Pregnancy and ileoanal pouch - I
Olsen KO, et al. Gastroenterology 2002;122:15-19

IPAA: Cumulative Incidence of Pregnancy

Cumulative Incidence of Pregnancy

Time to Pregnancy (months)

After surgery

Before diagnosis


Before surgery

Female Infertility After IPAA for UC

Johnson P, et al. Dis Colon Rectum. 2004;47:1119-1126.

Success Rate in Becoming Pregnant (%)

Infertility Rate

UC Patients Managed
IPAA Patients
After surgery
After diagnosis
IPAA Patients
UC Patients Managed
Before surgery
Before diagnosis
Pregnancy and ileoanal pouch - II
Infertility: Crohn’s Disease
Summary: Female Fertility

* Ulcerative Colitis
o Similar to the general population prior to colectomy
o Significantly decreased after IPAA

* Crohn’s Disease
o Studies vary
o Infertility partly voluntary
+ (dyspareunia, illness, MD advise)
o Surgery: decreased fertility

Pregnancy Outcomes in IBD
IBD pregnancy complications and outcomes MCW 1998 - 2004

* Pregnancies in 37 of 416 women (CD 316;UC 110)
* 51 total pregnancies reviewed (CD 81%;UC 19%)
* Mean pregnancy age 28 y/o
* Obstetric and IBD related complications in 57% of pregnancies
* 6 pregnancies required hospitalization (12%)
* Spontaneous abortion in 11.8% (mean age 30.6 years
* Term pregnancy in 70% CD and 80% UC (all children reported healthy)

Beaulieau DB, et al. Gastroenterology 128: A316, 2005.

MCW IBD Center’s Pregnancies
Numbers of IBD pregnancies
Pregnancy trimester
Beaulieau DB, et al. Gastroenterology 128: A316, 2005.
Norgard et al, Am J Gastroenterol 2003;98:2006-10.

Outcomes: Crohn’s Disease
Predictors of Poor Outcome

Pregnancy outcomes in women with inflammatory bowel disease: population based cohort study
U Mahdevan, WJ Sandborn, S Azmi, S Kane, DK Li,D Corley

* Cohort study among members of the Northern California Kaiser Permanente population
* Identified 493 pregnant women with a pre-birth diagnosis of IBD and frequency matched 493 non-pregnant women for age and hospital of pregnancy
* Univariate analyses included chi-square and t-test; multivariate analyses used unconditional logistic regression. All analyses were two tailed.

Patient Characteristics

* N=324 non-IBD vs 305 IBD (preliminary)
* Mean Age at Conception: 30.1 vs 30.8
* Smokers 61 (19%) vs 51 (17%) [p = 0.46]
* 203 UC and 96 CD
o IBD Duration: 6.1 years
o Immunosuppressant Use: 12 (4%)
o Aminosalicylate Use: 142 (47%)
o Corticosteroid Use: 57 (19%)
IBD Pregnancy Outcomes
IBD Pregnancy Outcomes
* Preliminary Analysis
* IBD pts are more likely to have an adverse pregnancy outcome and complicated labor than women without IBD
* Adverse neonatal outcome not increased in IBD
* Impact of immunosuppressant medications is limited by a small sample size in available data

Medical Therapy in Conception and Pregnancy
Drugs in Pregnancy
* Limited data - Pharmaceutical trials almost never performed in pregnant women.
* PDRâ medicolegal disclaimer: use in pregnancy
is not recommended unless benefits justify risk to
the fetus.
* Half of all pregnancies are unplanned.
* FDA classification (A, B, C, D, X)
o Ambiguous
o Difficult to interpret and use in counseling

Koren G et al. N Engl J Med. 1998;338:1128.
FDA Teratogenicity Classification for Drugs during Pregnancy

* Category A: Controlled studies show no risk
o No IBD medications in Category A
* Category B: No evidence of risk in humans
* Category C:
o Animal reproduction studies show adverse effect
o No adequate studies in humans
o Drug’s benefits in pregnant women may be acceptable despite its potential risk
* Category D: Positive Evidence of Risk
* Category X: Contraindicated in Pregnancy

Nutritional Therapy

* Elemental Diet
o Case reports of effectiveness in acute flares during pregnancy [Teahon, Gut 1991]
o Important to maintain nutrition to the fetus
* Total Parenteral Nutrition
o Less desirable, but case reports of effectiveness [Gatenby, Human Nutrition 1987]

Fish Oil

* Essential Fatty acids (EFA) and Docosahexaenoic acid (DHA)
o Potential antithrombotic effect
o Prolong gestation
o No evidence of prevention of proteinuric pregnancy
* Mild benefit in Crohn’s disease
* Concern regarding risk of metal toxicity – USDA recommendation 8/03 to limit fish consumption during pregnancy

Pharmaceutical Therapy
Aminosalicylates - I

* Aminosalicylates – Category B
o Only controlled trial (Diav-Citrin 1998 Gastroenterology)
+ 165 pts. Prospectively followed, controls with smoking/Etoh NOT IBD: Mean daily dose 2 gm
+ No teratogenicity
+ Maternal weight gain significantly lower on 5ASA
+ preterm delivery, LBW
o Ludvigson (2002) LBW if mother treated with mesalamine or steroids during pregnancy

o Sulfasalazine should be given with folic acid 1 mg BID
+ Folic acid: neural tube defects, CV, urinary tract, cleft palate
+ Case reports of congenital malformation
o Placental and Breast Milk Transfer Occurs
+ Potential of allergic reaction in newborn with watery diarrhea
+ SAS not associated with kernicterus or displacement of bilirubin form albumin

Pharmaceutical Therapy
Aminosalicylates - II

* No evidence of teratogenicity in humans
o Poorer outcomes likely due to worse disease
* Theoretical concern of adrenal suppression in newborn
o Cross placenta
o 10-12% of maternal concentration
* Safe in breast feeding

* Metronidazol/Ciprofloxacin
o Low risk of teratogenicity
+ Metronidazole: case-control study and meta-analysis
+ Ciprofloxacin: prospective controlled study
o Growing cartilage may be a target for cipro toxicity’
o Breast feeding is not advised
o Minimal benefit in Crohn’s and UC
o No data on long-term safety

* Purine analogues
* Interfere with synthesis of adenine and guanine ribonucleosides, precursors of DNA and RNA
* Act predominantly on rapidly dividing cells
* Incorporation of TGN nucleotides into cellular nucleic acids (cytotoxicity)
* Controversy - Class D label for pregnancy but commonly used in IBD, RA and transplant

Teratogenicity of 6MP/AZA
* Teratogenic in animals (mice, rabbits, rats)
o Given IV/IP at supratherapeutic doses (low oral bioavailability: 47% AZA, 16% 6MP)
o Increased cleft palate, ocular, skeletal, urogenital anomalies, hydrocephalus
o Poor oral bioavailability may produce levels too low to have substantial teratogenic effect
* No consistent increase in human teratogenicity
* Fetal liver in early pregnancy lacks inosinate pyrophosphorylase to convert AZA to active metabolites

o Polifka and Friedman (Teratology 65:240-261. 2002)

Human Studies: 6MP/AZA
* Transplantation Experience
o Frequency of congenital anomalies in renal tx 0.0-11.8% in 27 clinical series
o No recurrent pattern of anomalies seen
o No increase in anomalies in NTPR (Armenti 1994) in kidney transplant recipients on AZA
o Immunosuppression is never stopped in setting of organ tranplant
* No congenital anomalies in rheumatic disease, SLE

Norgard (Aliment Pharm Ther 2003)

* Population based prescription registry, Denmark
o 9 pregnancies (30d before concept/1st trimester)
o 10 pregnancies (exposed entire pregnancy)
o Outcomes vs (1) 19,418 pregnancies no drugs (2) any drug (3) 6MP/AZA >3 mos before pregnancy
* 11 pts: 55% IBD, 45% other disease
o Congenital malform OR = 6.7 (95%CI 1.4-32.4)
o Mortality OR = 20 (2.5-161.4)
o Preterm Birth OR = 6.6 (1.7-25.9)
o LBW OR = 3.8 (0.4-33.3)
* After exclusion of most ill pt (AIH), no statistical significance in OR


* Experience in IBD

* Teratogenicity
o Not in animals, probably not in humans
o One case in humans, administered at 29 weeks.
o Healthy fetus at 34 weeks
o Used in fulminant colitis, better than emergent colectomy
* Breast feeding not advised
* Reserved for fulminant disease vs colectomy

Infliximab and pregnancy (Category B)
* Katz JA et al. (Am Journal Gastroenterol 2004)
* Infliximab Safety Database
o 146 identified pregnancies
o 82 CD, 1 UC, 10 RA, 3 unknown
* Outcome 96 pregnancies, n = 100 births
o Live birth 64 (67%)
+ 1 preterm 24 wks (died), 1 tetrology Fallot, 1 sepsis survived, 1 intestinal malrotation in twin
o Miscarriage 14(15%) (1 stillbirth on MTX)
o Therapeutic termination 18 (19%) (pts. choice)
* Data similar to expected for UC/CD note exposed to INF

Infliximab in Pregnancy: Outcomes of Women Exposed to Infliximab During Pregnancy

Therapeutic termination

Intentional Infliximab in Pregnancy
10 Crohn’s disease patients intentionally exposed to
infliximab during pregnancy
Mahadevan U, et al. Aliment Pharmacol Ther. 2005;21:733-738.
Parenteral iron therapy

* Oral iron may be poorly tolerated, abdominal pain
* Patients with obstructive symptoms may not tolerate prenatal vitamin. Consider for gastroduodenal CD.
* Hyperemesis gravidarum – poor oral tolerance
* Intravenous iron sucrose 100 mg dosage
* FDA class B

Contraindicated Medications
* Methotrexate
o Known abortifacient
o Teratogenic (skeletal defects, cleft palate)
o 3 month “washout” in females and males prior to planned pregnancy
* Thalidomide
o 20-30% Rate of Birth defects or fetal death
o limb malformation (phocomelia)

Special Consideration
* Perianal Crohn’s Disease
* Fulminant Ulcerative Colitis
* Patients with IPAA

Perianal Crohn’s Disease

* Active perianal disease: Caesarean section recommended
o No history (1/39) or inactive (0/11) perianal disease at birth, risk of relapse very low post-vaginal delivery
o 4/4 with active perianal disease worsened post-vaginal delivery [Ilnycky 1999 AJG Manitoba database]
* Episiotomy may predispose to perineal disease (17.9%) without prior history of disease

Fulminant Ulcerative Colitis

* 2005 – look for C. Difficile infection
* Nutrition
* Intravenous corticosteroids
o 75% successful
* Infliximab
* Heparin compounds
* Cyclosporine
o 1 case report. IV CSA 10 days, 34th wk delivery
* Colectomy
o 50-60% fetal mortality reported
o Rare to have fulminant colitis in pregnancy
o Surgery in 2nd trimester is preferable
o Tocolytic therapy – high risk obstetrics in OR

Pouch Function and Pregnancy

* Reversible deterioration of pouch function during pregnancy
* No long-term detriment to pouch function
* Mode of delivery determined by obstetric indications
* Ravid Dis Col Rec 2002

Summary: IBD and pregnancy

* Fertility
o IPAA Surgery clearly reduces fertility rates in women
o Role of medications in fertility unclear
* Pregnancy Outcomes
o Complicated pregnancies occur in majority of patients
o Increased rates Preterm birth, SGA LBW
o No increase in congenital anomalies
o Aggressive management of IBD flare during pregnancy with medications is warranted
* Medications

Pregnancy and the Inflammatory Bowel Disease


Pancreatic Cancer: The Use of Endosonography

Endoscopy in Crohn’s Disease
By:Peter Darwin, MD
Director of Gastrointestinal Endoscopy
University of Maryland Hospital
Division of Gastroenterology

* Case histories
* Diagnosis
* Assessment of response
* Dysplasia and surveillance
* Bleeding
* Stricture management
* Emerging technology

Case 1
Case 2


* Asymmetric patchy inflammation
* Skip lesions
* Rectal sparring
* Ulcerations
* Biopsy
o Erosions and normal mucosa
o Granulomas in 15 to 35% of specimens

Assessment of Response
* Endoscopic monitoring may have a role with biologic agents
* Subgroup of the ACCENT-1 trial
o Mucosal healing with infliximab, time to relapse is significantly prolonged
+ 9 with endoscopic healing remained in remission for a median of 20 weeks
+ 4 clinical remission only, relapse after a median of 4 weeks

Dysplasia and Surveillance
* Extensive colitis > 8 years
* Accuracy in predicting dysplasia correlates with # of biopsies
* Annual colonoscopy with multiple biopsy specimens
o 4 circumferential each 10 cm

Approach to Polypoid Lesions
Adenoma like DALM
Outside colitis
Within colitis
Regular surveillance
No dysplasia
No carcinoma
Flat dysplasia
Increased surveillance

Chawla A, Lichtenstein G. Gastrointest Endoscopy Clin N Am 12 (2002) 525-534

Hemorrhage in Crohn’s

* Acute major hemorrhage is uncommon
* Bleeding can occur in any segment
* Massive hemorrhage is usually from an ulcer eroding into a vessel
* Resuscitation
* Endoscopy vs tagged RBC scan to localize a bleeding segment
* Avoid embolization if possible

Hemorrhage in Crohn’s
* No data to support cautery or injection therapy
* Surgical intervention
* Consider tattooing of the site

* Database review from 1989 to 1996
o 1739 patients / 31 (1.8%) due to IBD
o 3 with UC and 28 with CD / 1 UGI source
o None hematemesis
o GI hemorrhage in 0.1% UC and 1.2% CD
* Diagnostic evaluation
o Source found by colonoscopy in 25 patients (25%) and EGD in 2 patients

Pardi D, Loftus E, et al. Gastrointest Endosc 1999;49:153-7.

Acute Major GI hemorrhage in IBD

Endoscopic Therapy for Patients with CD and Focal Sites of hemorrhage
Patient Site Stigmata Endoscopic Rx Medical Rx

1 Duodenum clot Injection Corticosteroids ranitidine

2 Jejunum oozing ulcer Injection Corticosteroids ranitidine

3 Colon clot Injection with Corticosteroids

coagulation metronidazole

Clinical Course
Balloon Dilation of Strictures

Descending Colon Stricture

Colonic Strictures
* No randomized clinical trials
* Consider nonsurgical management if:
o Endoscopically accessible
o Multiple prior resections
o Shorter strictures (less than 5 cm)
o Steroid injection if significant inflammation

Malignant Potential
* Increased incidence of colonic and small bowel carcinoma
* Higher risk with longer duration of disease
* Stricture biopsy required
* Utilize thin caliper scopes to evaluate proximal to the stenosis

Balloon Dilation of Strictures
* High success rate for anastamotic strictures
* Used for colonic and duodenal stenosis
* TTS balloons 15 to 18 mm for 1 minute
* Fluoroscopy only if needed
* Successful if scope passed post
* Medical treatment
* Complications

Injection of Corticosteroids
* Post dilation
* Sclerotherapy needle
* Triamcinolone 40 mg/ml – 1 cc in 4 quadrants at site of maximal inflammation/stenosis

Intestinal Stents
* Limited data
* Migration is common
* Coated metal enteral stents / plastic stents may be of benefit

Endoscopic Balloon Dilation of Ileal Pouch Strictures

* Aim: evaluate outpatient ileal pouch stricture dilation
* Methods: Nonfluroscopy, nonsedated dilation with 11-18 mm TTS balloons in 19 consecutive patients

Shen B, Fazio V, Remzi F, et al. Am J Gastro 2004;99:2340-47.

Inlet and Outlet Strictures

Clinical Presentation
n (%)
Abdominal pain
Perianal pain
Nausea or vomiting
Daily use of antidiarrheal agents
Weight loss

Types of Strictures
Number Inlet Outlet of cases strictures strictures
Crohn’s disease of the pouch Cuffitis

Pouch Disease Activity Index

Strictures Scores
Cleveland Global Quality of Life Scores

Emerging Technology

* Double balloon enteroscopy
* Endoscopic ultrasound
* Optical coherence tomography
* Magnification chromoendoscopy

Takayuki Matsumoto, Tomohiko Moriyama, et. al.
Gastrointest Endosc 2005;62 :392-8

Optical Coherence Tomography
* Based on low-coherence

* High resolution imaging
* Uses light (not sound)
* Resolution 10X greater than EUS
* No acoustic coupling

Magnification Chromoendoscopy
* Utilizes magnifying endoscopes with tissue stains to better characterize the mucosa
* May improve efficacy of surveillance colonoscopy
o 165 patients with UC randomized to conventional screening vs CE.
o Targeted biopsies
o Identified more areas of dysplasia

Kiesslich R, Fritch J, et. al. Gastro 2002;124:880-8.

Colonic Pit Pattern
Huang Q, Norio F, et. al. Gastrointest Endosc 2004; 60:520-6.

Case 1

* The patient is a 28 year old man with isolated iliocolonic Crohn’s disease resected 8 years prior.
* Was without symptoms but has developed intermittent abdominal distension, bloating and emesis requiring admission.
* SBFT shows a 1 cm tight anastamotic stenosis
* Is attempt at endoscopic management appropriate?

Case 2

* 19 year old student presents with several months of vague epigastic discomfort, night sweats and weight loss.
* Evaluation shows a microcytic anemia and thrombocytosis.
* Abdominal CT shows a thickened mid-ileum without lymphadenopathy. Attempts to intubate the TI during colonoscopy were unsuccessful.
* Is tissue needed prior to treatment ?

Pancreatic Cancer: The Use of Endosonography

All links posted here are collected from various websites. No video or powerpoint files are uploaded on this blog. If you are the original author and do not wish to display your content on this blog please Email me anandkumarreddy at gmail dot com I will remove it. The contents of this blog are meant for educational purpose and not for commercial use. If you use any content give due credit to the original author.

This site uses cookies from Google to deliver its services, to personalise ads and to analyse traffic. Information about your use of this site is shared with Google. By using this site, you agree to its use of cookies.

  © Blogger templates Newspaper III by Ourblogtemplates.com 2008

Back to TOP