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Man with abdominal pain.

Our appreciation is extended to Dr. Remy Lobo,
Indiana University Department of Radiology,
for contributing this case.

History:  Man with abdominal pain.


Review the image below. Which choice best depicts the abnormal structure, if any?

Gallbladder.Portal venous system.Small bowel.Mesentery.Peritoneum.Image
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Man with abdominal pain.

Here are some additional images. Click to enlarge.

Click for galleryClick for galleryClick for galleryClick for galleryPlease respond to the following with TRUE or FALSE.
There are extraluminal fluid collections

True or False
There is an intussussception

True or False
There is stenotic bowel

True or False
There is abnormal mucosal enhancement of small bowel

True or False
There is a positive "comb sign"

True or False
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Man with abdominal pain.

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Findings:

Axial Image 1:  Long segment stenosis of the distal pelvic ileum, inflammation of the terminal ileum at the ileocecal valve.  Prominent vasculature, mucosal enhancement

Axial Image 2:  Comb sign, dense vessels in the RLQ, feeding active inflammation in distal ileum

Axial Image 3:  Small bowel target (double halo) sign in RLQ.  Also a fibrostenotic lesion right of midline seen just anterior/medial to external iliac artery, showing enhanced wall, narrowing, with near occlusion of lumen, .

Axial Image 4:  Dilated small bowel with stenotic transition point right lower quadrant with mild mesenteric inflammation.


Differential diagnosis:

  • Crohn's disease
  • Ulcerative colitis
  • Infection (Yersinia, AIDS patients get mycobacterium / CMV)
  • Ischemic changes and mesenteric adenitis (unlikely, wrong age groups)
  • Radiation enteritis, metastatic disease
Diagnosis:  Crohn’s disease
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Man with abdominal pain.


Key points - Crohn's disease:
 

  • Chronic, recurrent, segmental, granulomatous inflammatory bowel disease
  • Can occur anywhere along GI tract. Terminal ileum in 95%, colon in one-fourth, rectum in up to half.
  • Skip lesions, noncaseating granulomas, cobblestone mucosa
  • Pertinent ancillary findings include sinus tract or fistulae, abscess, adhesions, strictures, and "active" inflammation or not.
  • Discontinuous asymmetric wall thickening > 1 cm
  • Small bowel wall thickening and hyperemia with mesenteric fat proliferation are very suggestive of Crohn's.
  • Minimal narrowing in acute or noncicatrizing phase
    • Soft tissue inner ring (mucosa)
    • Low-density middle ring (submucosal edema/fat)
    • ST density outer ring (muscularis propria serosa)
    • Proliferation of mesenteric fat ± lymphadenopathy
    • "Target" or "double halo" sign
      • Intense enhancement of mucosa, muscularis propria
      • ? attenuation in edematous thickened submucosa
  • Increased luminal narrowing; no "target" sign in chronic or cicatrizing phase
    • Mural stratification lost: Indistinct mucosa, submucosa, muscularis propria
    • Homogeneous attenuation of thickened bowel wall
    • Abscesses, fistulas, sinus tracts
    • Mesenteric changes: Abscess, fibro-fatty areas, nodes
    • Perianal disease, enlarged mesenteric lymph nodes
    • "Comb" sign: Mesenteric hyper-vascularity (dilatation, tortuosity, wide spacing)
    • ST density inner ring (mucosa)
  • Immunology vs. nutritional vs.genetic basis for disease
  • Varied presentation, treatment includes diet and immune modulators

References: 

  1. CT enteroclysis in small bowel Crohn's disease, MD Kohli, DD Maglinte.  Eur J Radiol. 2009 Mar;69(3):398-403..
  2. CT Enteroclysis. DDT Maglinte, K Sandrasegaran, JC Lappas, M Chiorean. December 2007 Radiology, 245, 661-671.
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Man with abdominal pain.


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