Ezekiel T.

Arteta

Imaging
PLAIN FILM Detects colonic obstruction, colonic ileus, and the toxic megacolon syndrome in IBD SINGLE CONTRAST
Demonstrates anatomy and tonus (contraction) of colon, along with most abnormalities

DOUBLE CONTRAST
Allows visualization of lumen with any polyps or lesions

CT Determines the presence and extent of extracolonic disease UTZ Rarely used because of intraluminal gas

Anatomy

Physiology
Function
Formation, transport, and evacuation of feces

Water absorption by the right colon

Colon Filling Defects/ Mass Lesions

Filling Defect
radiolucency in a barium pool caused by a protruding mass lesion.

May be caused by polyps, tumors, air bubbles, feces, mucus, or foreign objects.
Polyp Protrusions from the mucosa Does not imply a histologic diagnosis

Colorectal Adenocarcinoma
Most common malignancy of the GI tract Location:
Rectum and Rectosigmoid area (50%) Sigmoid Colon (25%)

Most developed from preexisting adenomas Most are annular constricting lesions, with raised everted edges and ulcerated mucosa. Spreads through

Colorectal Adenocarcinoma

Colorectal Adenocarcinoma
Spreads through:
Direct Invasion into pericolonic fat and adjacent organs

Lymphatic Invasion to regional nodes

Hematogenous Invasion through the portal veins to the liver and the systemic circulation

Most common complication is obstruction

Colorectal Adenocarcinoma
Risk factors:
Ulcerative colitis

Crohns disease
Familial Adenomatous Polyposis Peutz-Jeghers syndrome

Clinical Features
Peak age 50-70 years
Weight loss Blood in stool Loss of appetite Change in bowel habits

Colorectal Adenocarcinoma
Imaging Methods
Transrectal or Colononoscopic US: Local disease staging

CT and MR: For more advanced disease and to detect recurrence

CT is the method of choice for tumor recurrence because it can survey the whole abdominal cavity

Colorectal Adenocarcinoma
Cross-Sectional Findings
Polypoid Primary Tumor (usually >1 cm) Apple-core lesions Cystic, necrotic, and hemorrhagic areas within the tumor mass Linear soft tissue stranding into the pericolonic fat Enlarged regional lymph nodes

Distant metastases, especially in the liver

Thickening of the wall of the uninvolved colon proximal to the tumor

Annular Adenocarcinoma (Single Contrast Study)

Polyps
Localized mass that projects from the mucosa into the lumen. Presence is a major indication for barium studies of the colon

Rules of Thumb:
<5 mm: almost all hyperplastic, risk of malignancy <0.5% 5-10 mm: 90% adenomas, 1% risk of malignancy 10-20 mm: adenomas, 10% risk of malignancy

>20 mm: 50% malignant

Polyps
Hyperplastic polyps
Nonneoplastic; round and sessile, nearly all are smaller than 5 mm

Adenomatous polyps
Distinctly premalignant; major risk for developing adenocarcinoma Neoplasms with a core of connective tissue

Hamartomatous polyps (juvenile polyps)

common cause of rectal bleeding in children

Inflammatory polyps
usually multiple; associated with inflammatory bowel disease

Polyp

Polyp
Bowler Hat Sign

Polyp

Familial Adenomatous Polyposis Syndrome

2/3 inherited, 1/3 spontaneous Autosomal dominant Tubulovillous adenomas that becomes prominent at age 20 Colorectal cancer will eventually develop in nearly all patients Tx: total colectomy with rectal mucosectomy and ileoanal pouch construction

Familial Adenomatous Polyposis Syndrome

Lymphoma
Less commonly involved than the stomach or small bowel
Anal and rectal lymphoma= frequent in AIDS patients

Morphology
Multinodular (lymphomatous polyposis) Solitary (resemble a polypoid carcinoma)

Rectal Lymphoma

Lipoma
Most common submucosal tumor of the colon Most frequent in the cecum and ascending colon Nearly 40% present with intussusception Appearance:
Barium: smooth, well-defined, elliptic filling defect, usually 1 to 3 cm in diameter CT: fat-density tumor (definitive)

Colon Inflammatory Diseases

Ulcerative Colitis Crohns Disease Infectious Colitis Toxic Megacolon Pseudomembranous Colitis

Amoebiasis

Ulcerative Colitis
Idiopathic inflammatory disease involving primarily the mucosa and submucosa of the colon

Peak age: 20 to 40 years, onset after age 50 is common.

Superficial ulcerations, edema, and hyperemia Granular mucosa, confluent shallow ulcerations, symmetry of disease around the lumen, and continuous confluent diffuse involvement.

Ulcerative Colitis
Radiographic Hallmarks:
Granular mucosa Confluent shallow ulcerations Symmetry of disease around the lumen Continuous confluent diffuse involvement

Morphology:
Collar button ulcers: deeper ulcerations of thickened edematous mucosa with crypt abscesses extending in the submucosa Coarse granular pattern by replacement of diffusely ulcerated mucosa with granulation tissue

Collar Button Ulcers

Ulcerative Colitis
Late Changes:
Pseudopolyps= mucosal remnants in areas of extensive ulceration Inflammatory polyps= small islands of inflamed mucosa Postinflammatory polyps= mucosal tags that are seen in quiescent phases of the disease Filiform polyps= postinflammatory polyps with a wormlike appearance Hyperplastic polyps= may during healing after mucosal injury

Ulcerative Colitis
CT Findings
Halo sign: low-density submucosal edema with wall thickening

Narrowing of the lumen of the colon

Pseudopolyps Pneumatosis coli with megacolon

Complications:
Strictures
colorectal adenocarcinoma

Ulcerative Colitis
Complications:
Strictures

Colorectal adenocarcinoma
Toxic megacolon Massive hemorrhage

Strictures

Lead Pipe Sign

Crohns Disease
Involves the colon in two thirds of cases Isolated to the colon in approximately one third of all cases Hallmarks:
Early aphthous ulcers Later confluent deep ulcerations

Predominant right colon disease

Discontinuous, asymmetric involvement Strictures, fistulas, and sinus formation

Ulcerative Colitis vs. Crohns Disease

Ulcerative Colitis Circumferential disease Regional (continuous disease) Predominantly left-sided Crohn Colitis Eccentric disease Skip lesions (discontinuous disease) Predominantly right-sided

Rectum usually involved Confluent shallow ulcers

No aphthous ulcers Collar button ulcers Terminal ileum usually normal Terminal ileum patulous No pseudodiverticula No fistulas High risk of cancer Risk of toxic megacolon

Rectum normal in 50% of cases Confluent deep ulcers

Aphthous ulcers early Transverse and longitudinal ulcers Terminal ileum usually diseased Terminal ileum narrowed Pseudodiverticula Fistulas common Low risk of cancer No toxic megacolon

Infectious Colitis
Etiologic Agents:
Bacteria (Salmonella, Shigella, E. coli) Parasites Viruses (CMV, Herpes) Fungi (Histoplasmosis, Mucormycosis)

Most cause a pancolitis with edema and inflammatory wall thickening with infiltration of pericolonic fat Pericolonic fluid and intraperitoneal fluid may be present.

CMV Colitis

Toxic Megacolon
Potentially fatal Marked colonic distension and risk of perforation Complication of fulminant colitis Radiographic Findings:
Marked dilatation of the colon (transverse colon >6 cm) with absence of haustral markings

Edema and thickening of the colon wall

Pneumatosis coli Evidence of perforation

Barium studies must be avoided

Pseudomembranous Colitis
Inflammatory disease characterized by the presence of a pseudomembrane of necrotic debris and overgrowth of Clostridium difficile

Radiographic Findings:
Dilated colon Nodular thickening of the haustra Ascites

Pseudomembranous Colitis
CT findings:
marked wall thickening up to 30 mm (average 15 mm) with halo or target appearance characteristic stripes of intraluminal contrast media trapped between nodular areas of wall thickening (accordion sign) Mild pericolonic fat inflammation disproportionate with the marked colonic wall inflammation ascites

Pseudomembranous Colitis

Amoebiasis
Infection by the protozoan parasite Entamoeba histolytica Barium studies demonstrate a disease that closely mimics Crohn colitis Primary areas: cecum and rectum (terminal ileum is characteristically not involved)

Diverticular Diseases
Diverticulosis Diverticulitis

Diverticulosis
Acquired condition Mucosa and muscularis mucosae herniate through the muscularis propria of the colon wall, producing a saccular outpouching False diverticula Common with age over 75 years old Major risk factor: low-residue diet Most common site: sigmoid colon

Diverticulosis
Severely affected portions of bowel are usually shortened in length, resulting in crowding of the thickened circular muscle bundles. Diverticulosis without diverticulitis is a cause of painless colonic bleeding Radiographical Findings:
gas-filled sacs parallel to the lumen of the colon Barium studies show diverticula as barium or gas-filled sacs outside the colon lumen

Diverticulosis
CT Findings
Thickened colon wall and distorted luminal contour

diverticula are shown as well-defined gas-, fluid-, or contrastfilled sacs outside the lumen

Diverticulosis

Diverticulitis
inflammation of diverticula, usually with perforation and intramural or localized pericolic abscess

Complications:
Bowel obstruction Bleeding Peritonitis

Sinus tract and fistula formation

Diverticulitis
inflammation of diverticula, usually with perforation and intramural or localized pericolic abscess

Complications:
Bowel obstruction Bleeding Peritonitis

Sinus tract and fistula formation

Diverticulitis
Barium Studies
deformed diverticular sacs

demonstration of abscess
extravasation of barium outside the colon lumen

CT Findings
localized wall thickening

inflammation of pericolonic fat

pericolonic abscess diverticula at or near the site of inflammation

Diverticulitis

Appendix
Filling of the appendix is attained most reliably by single-contrast barium enema examination

Failure to fill the appendix with barium on barium enema examination is not definitive evidence of appendiceal disease.
Both CT and US have proven extremely useful in the diagnosis of appendiceal disease, especially acute appendicitis

Anatomy
arises from the posteromedial aspect of the cecum at the junction of the taenia coli, approximately 1 to 2 cm below the ileocecal valve. blind-ended tube that is 5 to 10 mm in diameter (on barium studies) and approximately 8 cm in length, although it may be up to 30 cm long. mucosa is heavily infiltrated with lymphoid tissue On CT and US, the normal appendix appears as a thin-walled tube less than 6 mm in diameter

Anatomy (CT Scan)

Acute Appendicitis
most common cause of acute abdomen results from obstruction of the appendiceal lumen Bacterial infection causes gangrene and perforation with abscess Most periappendiceal abscesses are walled off, but free perforation and pneumoperitoneum occasionally occur

Plain films will demonstrate an appendiceal calculus (appendicolith or fecalith) in approximately 14% of patients