Multi-detector CT-colonography in inflammatory bowel disease: prospective analysis of CT-findings to high-resolution video colonoscopy

AIM: Prospective analysis of multi-detector CT-colonography (MDCTC) in patients with inflammatory bowel disease (IBD) compared to high-resolution video-endoscopy (HRVC). MATERIALS AND METHODS: Twenty-one patients (mean age 49.6 years) with Crohn's disease or ulcerative colitis underwent MDCTC (Somatom Volume Zoom, Siemens, Erlangen; 1mm collimation, Pitch 8, 100 mAs, 120 kVp). HRVC was performed within 2 h after MDCTC. MDCTC was analyzed by two blinded readers. MDCTC-findings including bowel wall alterations and extraintestinal changes were compared to results of HRVC. RESULTS: Over-all-sensitivity was 100% for endoluminal lesions with correct diagnosis of two cancers. Acute and chronic IBD were correctly identified by MDCTC in 63.6%, and 100%, respectively, with a specificity of 75%, and 100%. Sensitivity, specificity, positive and negative predictive values of MDCTC for diagnosis of acute and chronic disease were best for chronic disease. Sensitivity was worst for acute ulcerative colitis and specificity was worst for acute Crohn's disease. Haustral loss was seen only in ulcerative colitis. Pseudopolyps and fistulae were findings exclusive to Crohn's disease. Particularly extraintestinal findings as increased vascularization and local lymphadenopathy correlated well with endoscopic definition of acute disease. Because of the possibly more vulnerable colonic wall in acute inflammatory bowel disease, the air inflation for MDCTC should be performed most carefully to avoid any risk of colonic perforation. CONCLUSION: MDCTC may help to distinguish between patients with acute and chronic IBD. Especially extraintestinal complications, tumorous as well as pseudo-tumorous lesions can be detected with high sensitivity and specificity.     

Inflammatory bowel diseases: clinical update of practical guidelines

Idiopathic inflammatory bowel disease (IBD) includes a collection of disorders of the gastrointestinal tract of unknown aetiology, characterized by intestinal inflammation and a chronic relapsing course associated with local and systemic complications. Traditionally, IBD comprises two prototype entities, ulcerative colitis (UC) and Crohn's disease (CD) and an intermediate variant of these diseases, indeterminate colitis which shows overlapping features of the two major forms. Over the last few years, considerable progress has been made in our knowledge of the pathogenesis of IBD, which is complex and derives from genetic, environmental and immunological interactions. The aetiology remains unclear, but it is well established that the lesions and symptoms are associated with over-production of pro-inflammatory cytokines. In this paper we briefly review the pathophysiology and the new therapeutic approaches to IBD, since from these, new achievement depends the appropriate diagnostic exams to be performed and diagnostic flow charts.     

Abdominal pain and bowel dysfunction: the diagnostic role of ultrasonography

PURPOSE: To evaluate the role of intestinal ultrasound (US) in differentiating organic from functional bowel disease. MATERIAL AND METHODS: We examined with abdominal and intestinal US 313 consecutive outpatients presenting abdominal pain and bowel dysfunction, lasting more than 3 months, with no symptoms or signs of alarm and with no previous diagnosis of organic disease. Our population consisted of 191 women and 122 men, with average age at diagnosis of 36.5 years; 236 of these patients had irritable bowel syndrome, 61 Crohn's disease, and 16 ulcerative colitis. Intestinal wall thickness exceeding 7 mm was considered diagnostic for inflammatory bowel diseases. We compared US findings with the diagnosis made with the conventional diagnostic workup of radiological and endoscopic examinations. RESULTS: Sensitivity of intestinal US for diagnosis of inflammatory bowel diseases was 74% and specificity 98% (respectively 84% and 98% for the diagnosis of Crohn's disease and 38% and 98% for ulcerative colitis), and positive and negative predictive values were both 92%; efficacy was also 92%. The likelihood ratio was 35 if US was positive for inflammatory bowel diseases and 0.26 if bowel wall thickness was less than 7 mm. Diagnostic efficacy was 95% for Crohn's disease and 94% for ulcerative colitis. DISCUSSION: Intestinal US proved to be a valuable tool in diagnosing Crohn's disease. As the first step examination US can show the disease site and suggest further instrumental tests. CONCLUSIONS: In our experience intestinal US is an important diagnostic examination for the approach to young patients without symptoms or signs suggestive of organic diseases and can help avoid invasive instrumental examinations.     

Angiography in Crohn's disease revisited.

The diagnostic value of angiography was studied in 116 patients with Crohn's disease. Angiograms showed abnormalities in over 90% of the cases. Many angiographic features were nonspecific; only the "zoning sign" and the presence of paraintestinal mesenteric neovasculature were considered diagnostic. Crohn's colitis could be distinguished from ulcerative colitis in only 30% of the cases. Angiography, as a diagnostic adjunct to barium studies, will reveal the presence of lesions and their extent. This is particularly important in suspected postoperative recurrence of Crohn's disease. Angiography is a potential differential diagnostic aid in doubtful cases of inflammatory and malignant bowel disease.     

Value of sonography in the diagnosis and follow-up of patients with cryptogenic inflammatory bowel diseases in current practice: review of a 10-year experience in a community hospital

Inflammatory bowel diseases (IBD) are chronic inflammatory diseases of the bowel that are of unknown etiology. These diseases either progress with intermittent flare-ups interrupted by periods of remission or on a chronic active progressive mode. IBDs include Crohn disease (CD) and ulcerative colitis (UC). Clinical and imaging diagnosis often is challenging, hence explaining the frequent time delay between onset of disease and initiation of therapy. Clinical evaluation is characterized by three consecutive steps: consider a diagnosis of IBD; exclude other causes of inflammatory bowel disease; differentiate CD from UC since a definitive curative surgical treatment is available for UC. US is non-invasive, widely available, easy to perform, and relatively inexpensive and thus represents a significant advance in the evaluation of these three steps. The role of US in the evaluation of patients with suspected IBD will be reviewed.     

Ultrasonography of chronic inflammatory bowel diseases

Advances in the understanding of bowel appearances with high-resolution sonography have led to consideration of this technique as an important tool for bowel disease assessment. Ultrasonography may display the transformation of the intestinal wall from normal to pathological state in inflammatory diseases. Furthermore, intestinal ultrasonography may serve as a diagnostic clue if typical patterns of the bowel wall are demonstrated. Thus, Crohn's disease, ulcerative colitis, diverticulitis, or infectious ileocolitis may be specifically demonstrated in the majority of cases. Besides showing the parietal signs of inflammation, ultrasonography also shows the perigut abnormalities and may demonstrate complications such as fistulas and abscesses. Finally, with the help of Doppler, some additional information may be obtained about the activity of chronic inflammatory diseases. In clinical practice, used in combination with other imaging modalities, such as CT or endoscopy, bowel ultrasonography appears to be a non-invasive and effective diagnostic tool for the diagnosis and follow-up of Crohn's disease and ulcerative colitis. Electronic Publication     

Colitis in the elderly: ischemic colitis mimicking ulcerative and granulomatous colitis.

Eight patients over age 60 years had sudden onset of acute abdominal pain and rectal bleeding in the absence of prior inflammatory bowel disease. Several improved on medical therapy alone; those who required surgery suffered no recurrence up to 6 years. Although the pathologic specimens on these patients were first considered to represent ulcerative colitis or Crohn's disease, their histories and clinical courses are much more consistent with ischemic colitis. Since there are only a limited number of reactions that the bowel can muster against a host of damaging processes, histologic criteria alone are usually not sufficient to separate ischemic disease of the colon from ulcerative colitis and Crohn's disease. This is also true of radiographic features. Thus the diagnosis of ischemic colitis rests on clinical onset and course after treatment.     

111In-oxine-labelled autologous leucocytes in inflammatory bowel disease: new scintigraphic activity index

The usefulness of scintigraphy with 111In-oxine-labelled autologous leucocytes was investigated in 27 patients with inflammatory bowel disease (IBD): 16 with ulcerative colitis and 11 with Crohn's disease. Scans were performed 2-4 h (early scan) and at 24 h (late scan) after leucocyte reinjection. No false-negative results occurred in the early scan; however, in the late scan, 2 patients with Crohn's disease had a normal scintigram. A new index of activity (Il) based on the number and relative activity of abnormal 111In-leucocyte zones was used for scan quantitation. All patients with clinically active IBD had Il greater than or equal to 2. The scintigraphic index showed a significant correlation with the Harvey clinical index, especially in patients with ulcerative colitis. Our results suggest that an early scan (2-4 h) provides useful information in cases of IBD, and that Il greater than or equal to 2 is indicative of the degree of disease activity in such patients.     

Inflammatory bowel disease. Pathophysiology and medical treatment

Summary Recent studies indicate that the normal intestinal flora, an exagerated reaction of the intestinal immun system and a decreased epithelial barrier function of the gut play an important role in the pathogenesis of Crohn's disease and ulcerative colitis. The medical therapy of inflammatory bowel disease aims to correct these alterations. Aminosalicylates, corticosteroides, immunsuppressants and antibiotics are the four main groups of substances which are currently used for the therapy of inflammatory bowel diseases. Slow release formulation allow specific targeting of 5-aminosalicylic acid to the inflamed sections of the gut; with budesonid a corticosteroide therapy with minimal systemic side effects is possible. Future therapeutic options include specific immuno-modulatory therapy with cytokines or cytokine antibodies. Maintenance therapy may, conceivably, be performed with probiotics or antioxidants. Therefore, despite continued uncertainty about the cause of inflammatory bowel diseases, recent advances nourish the hope for further improvement of the control of disease activity and a better quality of life for patients with inflammatory bowel diseases.      

Malignancy complicating inflammatory bowel disease

There is now general agreement that both ulcerative colitis and Crohn's disease predispose patients to the development of malignancy. Many controversies still remain concerning the incidence of this complication as well as the diagnostic approach to be taken with these patients. This article reviews the topic and examines the contribution the radiologist can make in evaluating the patient with chronic inflammatory bowel disease.     

Diagnosis of inflammatory bowel disease with ultrasound. An in vitro study

Transabdominal ultrasound is frequently used to detect complications of inflammatory bowel disease. It has been proposed that ultrasound can distinguish between ulcerative colitis and Crohn's disease based on the degree of thickening and changes in the layered structure of the intestine. The authors evaluated the ability of ultrasound to distinguish between ulcerative colitis, Crohn's colitis, and normal colon by blindly comparing images made of resected colon specimens. The histologic interpretation of precisely the same area of tissue that was imaged was compared with the blinded image interpretation. Images from all 18 colitis specimens were correctly interpreted as being abnormal because of increased submucosal and overall wall thickness. Published ultrasound criteria for distinguishing between Crohn's disease and ulcerative colitis based on overall wall thickness and indistinctness of layers were inaccurate in 4 of 15 specimens and indeterminate in 3 cases. Ultrasound appears to be accurate in distinguishing normal from inflamed colon, but ultrasound findings alone should not be used to determine the cause of bowel inflammation.     

Ultrasonic patterns in inflammatory bowel disease.

Ultrasound examination was performed in 90 patients with varying bowel pathology. Ultrasound reliably demonstrated thickening of the bowel. In addition, the pattern of abnormality seen in Crohn's disease and ulcerative colitis was different, and corresponded to the pathological changes seen in these disease processes. The pattern of bowel abnormality seen in other bowel diseases with an inflammatory aetiology generally corresponded to either the Crohn's or ulcerative colitic pattern. The appearances are described, together with findings in other non-neoplastic diseases of the bowel.     

The epidemiology and the pathogenesis of inflammatory bowel disease

The etiology of inflammatory bowel disease (IBD) is still unknown. However, a satisfactory solution cannot be far away. IBD actually encompasses two diseases, i.e. Crohn's disease (CD) and ulcerous colitis (UC). These diseases resemble each other so closely that they cannot be distinguished even pathologically, but differ from each other sufficiently to regard them as independent entities. Epidemiological observations may be helpful in identifying the true causative factors of this evasive disease. Geographically, the prevalence of the disease has a slope from North to South and, to a lesser degree, from West to East. The Western-Eastern discrepancy can be attributed to a difference in Western life styles. The incidence of the disease has been increasing world-wide of late, but its spread has been slowing down in highly affected countries. Racial and ethnic relations in different populations and immigration studies offer interesting data which can reflect genetic, inherited, environmental and behavioural factors. The disease seems to have a characteristic racial-ethnic distribution: the Jewish population is highly susceptible everywhere, but its prevalence in that population nears that of the domestic society in which they live. In Hungary, the Roma (Gypsies) have a considerably lower prevalence than the average population. This can be attributed to a genetic or environmental influence. According to age, the onset of the disease occurs more often in the second or the third decade of life, but there also is another peak in the 60s. Regarding sexual distribution, there is a slight preponderance of colitis ulcerosa in men and of Crohn's disease in women. It may correspond to the stronger auto-immune affection in the process of Crohn's disease. Environmental factors and behavioural influences also are investigated. Diet, the role of the early ages, smoking habits and the influence of hormonal status and drugs are viewed as useful contributing factors in the manifestation of the disease. Genetic studies show that one-fourth of IBD patients have an affected family member. HLAB27 histocombatibility also plays an important, but not determining role in the development of the disease. Genetic factors seem to have a stronger influence in Crohn's disease than ulcerative colitis. The existence of multiple sclerosis-IBD families may reflect the common genetic background or the similar microbial effect as well. A great number of bacterial and viral factors has been suspected of being infectious factors in IBD, mostly in CD. Mycobacteria, Yersinia, Campylobacter, Clostridium, Clamidias, etc. as well as bacteria and some viruses such as herpes and rotavirus and the primary measles virus. None of them has been proven as a real and exclusively pathogenic factor. Immunological background has an important function in the manifestation of the disease. If an individual has a genetic susceptibility to infections, the down regulation of an inflammation in the bowel wall does not occur in a proper way. This initiates the auto-immune process which is a self-increasing cycle. Extra-intestinal manifestations of IBD are of high importance because they can not only follow intestinal symptoms, but precede them by years. Hepatic and biliary disturbances (primary sclerosing cholangitis), are the most serious complications. Mucocutaneous manifestations can be the first appearance of the main disease (in the mouth). Auto-immune consequences (erythema nodosum) or complications caused even by the therapy can occur. Ocular and musculoskeletal manifestations supposedly have the same genetic background and often precede the intestinal symptoms. Considering the epidemiological, genetic and immunological data, we can conclude that ulcerative colitis and Crohn's disease are heterogeneous disorders of mutifactorial etiology in which hereditary (genetic) and environmental (microbial, behaviour) factors interact to produce the disease.     

Active inflammatory bowel disease: evaluation with 99mTc (V) DMSA scintigraphy

PURPOSE: To evaluate the use of pentavalent (V) technetium 99m (99mTc) dimercaptosuccinic acid (DMSA) scintigraphy for the assessment of disease activity in patients with inflammatory bowel disease (IBD). MATERIALS AND METHODS: 99mTc (V) DMSA scintigraphy was performed in 76 patients. There were 36 patients with active IBD (11 with ulcerative colitis, 25 with Crohn disease), 28 patients with inactive disease (eight with ulcerative colitis, 20 with Crohn disease), and 12 patients with miscellaneous bowel disease. Sensitivity and specificity of 99mTc (V) DMSA scintigraphy in the diagnosis of IBD were calculated. In the group with active IBD, the disease activity and laboratory indices, as well as the endoscopic and histologic activity, were compared with the scanning activity index. Correlation coefficients between them were calculated with the Spearman rank test. RESULTS: 99mTc (V) DMSA scintigraphy had a 92% (33 of 36) sensitivity and an 86% (24 of 28) specificity in the detection of active IBD. A significant correlation between disease activity indices and scintigraphy score was demonstrated. Endoscopic and histologic activity was significantly correlated (P =.005 and.02, respectively, overall disease activity) with the scanning activity score. Of the group of patients with miscellaneous bowel disease, three with ischemic colitis had negative findings at scintigraphy. CONCLUSION: 99mTc (V) DMSA scintigraphy provides a noninvasive, practical, and accurate assessment of IBD activity.     

Inflammatory bowel disease in children and young adults: correlation of sonographic and clinical parameters during treatment

OBJECTIVE: The objective of this study was to evaluate the sonographic findings of inflammatory bowel disease activity in children undergoing treatment. SUBJECTS AND METHODS: Eighty-eight sonograms were obtained of 23 bowel segments in 17 children and young adults (age range, 10-21 years; mean, 16 years) with new or recurrent inflammatory bowel disease. Sixteen segments were involved with Crohn's disease and seven with ulcerative colitis. Serial sonography (range, two to eight examinations; mean, four per segment) was performed while patients underwent treatment. Bowel wall thickness measurements and color and power Doppler sonography grading were recorded and compared with clinical data. RESULTS: All 17 patients had at least one abnormal bowel segment on initial sonography. The correlation was significant (p < 0.01). Agreement was 91% on direction of change over time between bowel wall thickness and Doppler grades, with 100% correlation between color and power Doppler sonography grades. In patients with Crohn's disease, the correlation was significant (p < 0.05) between bowel wall thickness and Doppler grades with two of seven and four of seven clinical parameters, respectively. In patients with ulcerative colitis, the correlation was significant (p < 0.05) between bowel wall thickness and Doppler sonography grades with four of seven and three of seven clinical parameters, respectively. The erythrocyte sedimentation rate correlated with all sonographic measurements in both patient groups. Combining bowel wall thickness and Doppler sonography, the percentage of agreement was significant in the direction of change, with five of seven clinical parameters in both patient groups. CONCLUSION: Gray-scale and color or power Doppler sonography can show changes in disease activity in children and young adults undergoing treatment for inflammatory bowel disease.     

Imaging inflammatory bowel disease in the pediatric patient

Idiopathic inflammatory bowel disease in childhood was once considered rare but is now being increasingly recognized. Although ulcerative colitis and Crohn's disease, the two most common types, have some features in common with the adult form, in all of these diseases the differential diagnoses, presentation, and therapy differ in many important ways from those in adults. Infants are also susceptible to diseases not seen in older children. These differences and the often extremely young age of the patient markedly affect the choice and performance of diagnostic imaging techniques. These techniques have to be modeled more to the individual's requirements than in adults, and infants need a different approach even from older children.     

Scintigraphic assessment of indium-111-labeled granulocyte splenic pooling: a new approach to inflammatory bowel disease activity

We have conducted a prospective study into the sensitivity and the specificity of the fall in splenic activity (FSA) as an index of activity in inflammatory bowel disease (IBD). FSA was measured on scintiscans obtained at 3 and 24 hr postinjection of indium-111-labeled granulocytes. One hundred and twenty-two scans were acquired in 96 patients who were divided into six groups: Gr. I = normal volunteers (n = 10); Gr. II = inflammatory rheumatism (n = 10); Gr. III = abscesses (n = 17); Gr. IV = ulcerative colitis (UC: n = 23); Gr. V = colonic Crohn's disease (CCD: n = 22); and Gr. VI = ileal Crohn's disease (ICD: n = 14). FSA for Groups I and II was constantly below 10%, but it was increased in the other four groups (abscesses: 39% +/- 12%; UC: 35% +/- 13.5%; CCD: 23.7% +/- 14.7%; ICD: 21.5% +/- 11.7%). There was a significant correlation between fecal excretion of 111In (FEI) and FSA in patients with IBD (UC: r = 0.71, p less than 0.001; CCD: r = 0.74, p less than 0.001; ICD: r = 0.43, p less than 0.001). FSA was followed in 16 patients with IBD after medical treatment and there was a significant correlation between variations in FSA and in FEI (r = 0.879, p less than 0.001). FSA is a very sensitive although nonspecific index of disease activity in IBD and may replace FEI in the assessment of IBD activity.     

Double contrast barium enema in Crohn's disease and ulcerative colitis.

Double contrast barium enema examinations in 24 patients with Crohn's disease of the colon and 29 patients with ulcerative colitis were reviewed without knowledge of the clinical diagnosis. The radiologic diagnosis of Crohn's disease agreed with the clinical diagnosis in 98% of patients. In this condition the most common radiologic findings were discontinuous or asymmetric disease (88%) and discrete ulcers (67%) often on a normal mucosa. The latter are characteristic of early Crohn's disease and may enable the radiologist to be the first to suggest the diagnosis, particularly when both sigmoidoscopy and small bowel examination are normal. Of the patients with ulcerative colitis, a positive radiologic diagnosis was made in 83% on the basis of a granular mucosal pattern (79%) and continuous distal involvement (86%). The high accuracy of the double contrast technique, especially in Crohn's disease, and the relative specificity of the signs that it can demonstrate suggest that this is the preferred examination in the radiologic evaluation of inflammatory bowel disease.     

Colitis: radiographic features and differentiation of idiopathic inflammatory bowel disease

It is important clinically to be able to differentiate ulcerative colitis from Crohn's colitis because they differ considerably in the nature of complications and prognoses. Radiographically, it is possible to render a specific diagnosis in the vast majority of cases using criteria described in this article. The problem of the underlying process in inflammatory bowel disease in elderly patients and indeterminate colitis is also discussed.     

Ultrasonography in the diagnosis of chronic inflammatory intestinal disease

The accuracy of ultrasonography (US) in diagnosing active inflammatory bowel disease (IBD) is assessed on the basis of a randomized prospective study of 61 patients. Twenty-six of the patients were affected with Crohn's disease (CD) and 12 with ulcerative colitis, while the remaining 23 patients were control subjects with no specific chronic IBD. The US signs considered as significant for active CD and UC were: --visualization of a typical target image, that is a hyperechoic center corresponding to luminal bowel content, surrounded by a hypoechoic ring corresponding to loop walls; --at least 2 of the following: solid abdominal mass, distended loops, luminal narrowing, reduced peristalsis, stiff loops, and accumulation of fluid between the loops. US sensitivity and specificity for CD were 77% and 95.6%, respectively. As for UC, no significant results were obtained. In our experience, US is a reliable method for detecting alterations and, especially, complications typical of CD in its active phase. Considering the young age of the patients affected with CD and the number of exams they must undergo, US is considered as a useful tool in disease follow-up.