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Cross-sectional Imaging in Crohn Disease¹

¹ From the Departments of Radiology (A.F., M.Y., K. Maeda, N.N., M.T., K. Murata) and Gastroenterology (T. Saotome, T.T., Y.F.), Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu Shiga 520-2192, Japan; and the Department of Radiology, Koga Public Hospital, Koga, Japan (T. Sakamoto). Recipient of a Certificate of Merit award for an education exhibit at the 2002 RSNA scientific assembly. Received April 29, 2003; revision requested June 19 and received September 5; accepted September 5. All authors have no financial relationships to disclose. Address correspondence to A.F. (e-mail: akira@belle.shiga-med.ac.jp).

View larger version (162K): [in a new window]   Figure 1.  Mesenteric border ulceration and ileoileal fistula. Image from an air double-contrast enteroclysis study demonstrates typical straightening of the mesenteric border, a finding that indicates linear ulceration or ulcer scar. A relatively long segment of the bowel is affected at several sites, and multiple stenoses are also identified. A fistula (arrow) extends from the ileum to the adjacent ileal loop.

View larger version (144K): [in a new window]   Figure 2a.  Use of positive intraluminal contrast medium. Contrast material-enhanced CT scans of the abdomen obtained at the level of the renal hilum (a) and lower pelvis (b) after oral administration of 1,500 mL of 2% barium suspension demonstrate uniform enhancement of the small bowel and colon.

View larger version (150K): [in a new window]   Figure 2b.  Use of positive intraluminal contrast medium. Contrast material-enhanced CT scans of the abdomen obtained at the level of the renal hilum (a) and lower pelvis (b) after oral administration of 1,500 mL of 2% barium suspension demonstrate uniform enhancement of the small bowel and colon.

View larger version (145K): [in a new window]   Figure 3a.  Use of positive intraluminal contrast medium. CT scans of the pelvis (b obtained caudad to a) clearly show wall thickening of the ileal loops and an ileoileal fistula (arrow in b).

View larger version (126K): [in a new window]   Figure 3b.  Use of positive intraluminal contrast medium. CT scans of the pelvis (b obtained caudad to a) clearly show wall thickening of the ileal loops and an ileoileal fistula (arrow in b).

View larger version (169K): [in a new window]   Figure 4.  Use of negative intraluminal contrast medium. Coronal contrast-enhanced reformatted CT scan of the abdomen obtained after oral administration of 1,500 mL of nonabsorbable liquid (Niflec; Ajinomoto Pharma, Tokyo, Japan) with a nasoenteric tube demonstrates uniform distention of the intestinal loops. Thickness of the bowel wall and degree of enhancement can clearly be assessed.

View larger version (169K): [in a new window]   Figure 5.  Imaging with a true FISP sequence. Coronal true FISP MR image clearly depicts fluid-filled bowel loops. The dark line surrounding the bowel represents black boundary artifact, which may hinder the precise assessment of bowel wall thickening.

View larger version (165K): [in a new window]   Figure 6a.  Imaging with a single-shot fast spin-echo sequence. (a) Coronal fat-suppressed single-shot fast spin-echo MR image shows motion artifact from intraluminal flow in the intestine (arrows). Because only fluid can produce bright signal intensity with this sequence, a thicker section can be obtained to demonstrate the course of the entire intestine on a single image. This sequence can be used for MR fluoroscopy. (b) Coronal non-fat-suppressed single-shot fast spin-echo MR image shows excellent contrast between the bowel wall and surrounding structures. Mesenteric structures are not clearly visible with this pulse sequence; however, bowel folds at the jejunum are well appreciated with both pulse sequences.

View larger version (173K): [in a new window]   Figure 6b.  Imaging with a single-shot fast spin-echo sequence. (a) Coronal fat-suppressed single-shot fast spin-echo MR image shows motion artifact from intraluminal flow in the intestine (arrows). Because only fluid can produce bright signal intensity with this sequence, a thicker section can be obtained to demonstrate the course of the entire intestine on a single image. This sequence can be used for MR fluoroscopy. (b) Coronal non-fat-suppressed single-shot fast spin-echo MR image shows excellent contrast between the bowel wall and surrounding structures. Mesenteric structures are not clearly visible with this pulse sequence; however, bowel folds at the jejunum are well appreciated with both pulse sequences.

View larger version (175K): [in a new window]   Figure 7a.  Imaging with a gadolinium-enhanced spoiled gradient-echo sequence. (a) Non-fat-suppressed single-shot fast spin-echo MR image shows a Crohn lesion with prominent wall thickening at the distal ileum (arrows). (b, c) On unenhanced (b) and contrast-enhanced (c) spoiled gradient-echo MR images, the involved ileal segment shows intense wall enhancement compared with normal bowel segments, a finding that indicates an inflammatory active lesion.

View larger version (171K): [in a new window]   Figure 7b.  Imaging with a gadolinium-enhanced spoiled gradient-echo sequence. (a) Non-fat-suppressed single-shot fast spin-echo MR image shows a Crohn lesion with prominent wall thickening at the distal ileum (arrows). (b, c) On unenhanced (b) and contrast-enhanced (c) spoiled gradient-echo MR images, the involved ileal segment shows intense wall enhancement compared with normal bowel segments, a finding that indicates an inflammatory active lesion.

View larger version (172K): [in a new window]   Figure 7c.  Imaging with a gadolinium-enhanced spoiled gradient-echo sequence. (a) Non-fat-suppressed single-shot fast spin-echo MR image shows a Crohn lesion with prominent wall thickening at the distal ileum (arrows). (b, c) On unenhanced (b) and contrast-enhanced (c) spoiled gradient-echo MR images, the involved ileal segment shows intense wall enhancement compared with normal bowel segments, a finding that indicates an inflammatory active lesion.

View larger version (198K): [in a new window]   Figure 8a.  Active Crohn lesions at the distal ileum with contiguous involvement from the ascending colon to the sigmoid colon. (a) Coronal reformatted CT scan from 1-mm-thick axial source images clearly shows bowel wall thickening at the distal ileum (arrowheads) and colon (arrows). The thickened wall has a stratified appearance. Increased mesenteric vascularity ("comb sign") is noted around the involved segment. These findings are suggestive of active lesions from Crohn disease. (b) Gadolinium-enhanced spoiled gradient-echo MR image shows markedly increased enhancement of the involved bowel wall segment and an increased number of mesenteric vessels around the segment (arrows).

View larger version (177K): [in a new window]   Figure 8b.  Active Crohn lesions at the distal ileum with contiguous involvement from the ascending colon to the sigmoid colon. (a) Coronal reformatted CT scan from 1-mm-thick axial source images clearly shows bowel wall thickening at the distal ileum (arrowheads) and colon (arrows). The thickened wall has a stratified appearance. Increased mesenteric vascularity ("comb sign") is noted around the involved segment. These findings are suggestive of active lesions from Crohn disease. (b) Gadolinium-enhanced spoiled gradient-echo MR image shows markedly increased enhancement of the involved bowel wall segment and an increased number of mesenteric vessels around the segment (arrows).

View larger version (164K): [in a new window]   Figure 9a.  Active Crohn lesions at the distal ileum. (a) Image from an air double-contrast enteroclysis study demonstrates deformity of the distal ileum associated with linear (arrows) and aphthoid (arrowheads) ulcers. (b) Fat-suppressed single-shot fast spin-echo MR image (70-mm section thickness) demonstrates similar deformity at the distal ileum (black arrowhead) as well as the entire course of the intestine (white arrowheads). (c) Coronal non-fat-suppressed single-shot fast spin-echo MR image (5-mm section thickness) clearly demonstrates bowel wall thickening at the involved segment (arrowheads). (d) On a gadolinium-enhanced spoiled gradient-echo MR image, the bowel wall demonstrates intense enhancement.

View larger version (173K): [in a new window]   Figure 9b.  Active Crohn lesions at the distal ileum. (a) Image from an air double-contrast enteroclysis study demonstrates deformity of the distal ileum associated with linear (arrows) and aphthoid (arrowheads) ulcers. (b) Fat-suppressed single-shot fast spin-echo MR image (70-mm section thickness) demonstrates similar deformity at the distal ileum (black arrowhead) as well as the entire course of the intestine (white arrowheads). (c) Coronal non-fat-suppressed single-shot fast spin-echo MR image (5-mm section thickness) clearly demonstrates bowel wall thickening at the involved segment (arrowheads). (d) On a gadolinium-enhanced spoiled gradient-echo MR image, the bowel wall demonstrates intense enhancement.

View larger version (161K): [in a new window]   Figure 9c.  Active Crohn lesions at the distal ileum. (a) Image from an air double-contrast enteroclysis study demonstrates deformity of the distal ileum associated with linear (arrows) and aphthoid (arrowheads) ulcers. (b) Fat-suppressed single-shot fast spin-echo MR image (70-mm section thickness) demonstrates similar deformity at the distal ileum (black arrowhead) as well as the entire course of the intestine (white arrowheads). (c) Coronal non-fat-suppressed single-shot fast spin-echo MR image (5-mm section thickness) clearly demonstrates bowel wall thickening at the involved segment (arrowheads). (d) On a gadolinium-enhanced spoiled gradient-echo MR image, the bowel wall demonstrates intense enhancement.

View larger version (149K): [in a new window]   Figure 9d.  Active Crohn lesions at the distal ileum. (a) Image from an air double-contrast enteroclysis study demonstrates deformity of the distal ileum associated with linear (arrows) and aphthoid (arrowheads) ulcers. (b) Fat-suppressed single-shot fast spin-echo MR image (70-mm section thickness) demonstrates similar deformity at the distal ileum (black arrowhead) as well as the entire course of the intestine (white arrowheads). (c) Coronal non-fat-suppressed single-shot fast spin-echo MR image (5-mm section thickness) clearly demonstrates bowel wall thickening at the involved segment (arrowheads). (d) On a gadolinium-enhanced spoiled gradient-echo MR image, the bowel wall demonstrates intense enhancement.

View larger version (168K): [in a new window]   Figure 10a.  Inactive Crohn lesion at the terminal ileum. (a) Image from a barium study demonstrates typical straightening of the mesenteric border at the terminal ileum. (b) Non-fat-suppressed single-shot fast spin-echo MR image clearly shows asymmetric bowel deformity at the terminal ileum. No bowel wall thickening is seen at the involved segment (cf Fig 9c).

View larger version (189K): [in a new window]   Figure 10b.  Inactive Crohn lesion at the terminal ileum. (a) Image from a barium study demonstrates typical straightening of the mesenteric border at the terminal ileum. (b) Non-fat-suppressed single-shot fast spin-echo MR image clearly shows asymmetric bowel deformity at the terminal ileum. No bowel wall thickening is seen at the involved segment (cf Fig 9c).

View larger version (132K): [in a new window]   Figure 11a.  High-grade small bowel obstruction at the distal ileum caused by Crohn disease. Contrast-enhanced axial (a, b) and coronal reformatted (c) CT scans demonstrate luminal narrowing at the distal ileum in a relatively long bowel segment (straight arrows) associated with prominent dilated proximal loops (curved arrow in c). The wall of the involved segment has a stratified appearance associated with an increased number of adjacent mesenteric vessels (comb sign) (arrowheads in a and c).

View larger version (133K): [in a new window]   Figure 11b.  High-grade small bowel obstruction at the distal ileum caused by Crohn disease. Contrast-enhanced axial (a, b) and coronal reformatted (c) CT scans demonstrate luminal narrowing at the distal ileum in a relatively long bowel segment (straight arrows) associated with prominent dilated proximal loops (curved arrow in c). The wall of the involved segment has a stratified appearance associated with an increased number of adjacent mesenteric vessels (comb sign) (arrowheads in a and c).

View larger version (173K): [in a new window]   Figure 11c.  High-grade small bowel obstruction at the distal ileum caused by Crohn disease. Contrast-enhanced axial (a, b) and coronal reformatted (c) CT scans demonstrate luminal narrowing at the distal ileum in a relatively long bowel segment (straight arrows) associated with prominent dilated proximal loops (curved arrow in c). The wall of the involved segment has a stratified appearance associated with an increased number of adjacent mesenteric vessels (comb sign) (arrowheads in a and c).

View larger version (115K): [in a new window]   Figure 12.  Fibrofatty proliferation. Contrast-enhanced CT scan of the lower abdomen shows a proliferation of fat tissue around the ascending colon. The tissue has a heterogeneous appearance with increased attenuation. The wall of the ascending colon is thickened and demonstrates intense enhancement (arrow).

View larger version (126K): [in a new window]   Figure 13.  Abscess in the small bowel mesentery. Contrast-enhanced CT scan of the pelvis shows a loculated fluid collection in the mesentery surrounded by a thin wall.

View larger version (122K): [in a new window]   Figure 14.  Abscess in the abdominal wall. Contrast-enhanced CT scan shows the right abdominal rectus muscle and subcutaneous fat tissue with increased enhancement. Air bubbles are seen within the abdominal wall.

View larger version (113K): [in a new window]   Figure 15.  Iliopsoas muscle abscess. Contrast-enhanced CT scan of the pelvis shows an air-containing abscess in the right iliopsoas muscle (arrow).

View larger version (127K): [in a new window]   Figure 16.  Perianal abscess. Contrast-enhanced CT scan obtained at the bottom of the pelvis demonstrates a fluid-containing abscess around the anus.

View larger version (168K): [in a new window]   Figure 17.  Duodenocolic fistula. Single-shot fast spin-echo MR image demonstrates a fistula (arrow) between the duodenum and the ascending colon.

View larger version (174K): [in a new window]   Figure 18a.  Enterocutaneous fistula. Conventional fistulogram (a) and fat-suppressed single-shot fast spin-echo MR fistulogram (b) clearly demonstrate an enterocutaneous fistula (arrows).

View larger version (156K): [in a new window]   Figure 18b.  Enterocutaneous fistula. Conventional fistulogram (a) and fat-suppressed single-shot fast spin-echo MR fistulogram (b) clearly demonstrate an enterocutaneous fistula (arrows).

View larger version (89K): [in a new window]   Figure 19a.  Sinus tracts. (a) Image from a barium enema study shows sinus tracts at the descending colon (arrowheads). (b) Coronal single-shot fast spin-echo MR image demonstrates the descending colon with wall thickening and containing a tract (arrowhead).

View larger version (94K): [in a new window]   Figure 19b.  Sinus tracts. (a) Image from a barium enema study shows sinus tracts at the descending colon (arrowheads). (b) Coronal single-shot fast spin-echo MR image demonstrates the descending colon with wall thickening and containing a tract (arrowhead).

View larger version (113K): [in a new window]   Figure 20.  Mural stratification. Contrast-enhanced CT scan of the pelvis shows Crohn disease involvement of the distal ileum. The thickened bowel wall has low attenuation owing to fluid in the lumen and is surrounded by alternating layers of higher or lower attenuation in a concentric pattern.

View larger version (136K): [in a new window]   Figure 21.  Comb sign. Contrast-enhanced CT scan of the lower pelvis shows a diseased segment of the distal ileum (arrowheads) with prominently dilated adjacent mesenteric vessels.

View larger version (130K): [in a new window]   Figure 22.  Prominent wall thickening. Contrast-enhanced CT scan demonstrates prominent, strongly enhanced wall thickening with a stratified appearance at the ascending colon. An inflammatory lesion extends beyond the wall to the adjacent region.