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Home , Toxic megacolon, Ulcerative colitis

ULCERATIVE - CT Author Nina Le Editor Ilse Castro-Aragon CASE HISTORY

10 year old male otherwise healthy presents to GI clinic for follow up of vomiting, , , and . He endorses , bloody diarrhea, and tenesmus. Labs show fecal occult test (+), C. diff. (-), CRP (9.4), ESR elevated (46), GGT wnl, elevated (1470.5). MRE of

MR enterography of the abdomen with contrast of a 10 year old male shows bowel wall thickening (yellow arrow) and mild enhancement of the cecum and ascending colon without signs of skip lesions or abscess consistent with ulcerative colitis. MRE of ULCERATIVE COLITIS

MR enterography of the abdomen with oral contrast of a 10 year old male shows diffuse mild enhancement of the colonic wall in the cecum (yellow arrow), without signs of skip lesions or abscess consistent with ulcerative colitis. MRE of ULCERATIVE COLITIS

MR enterography of the abdomen with contrast of a 10 year old male shows bowel wall thickening (yellow arrow) of the cecum and ascending colon without signs of skip lesions or abscess consistent with ulcerative colitis. CLINICAL FOLLOW UP

Follow up with EGD and showed congested, erythematous, friable (with contact bleeding) and vascular-pattern- decreased mucosa in the entire examined colon consistent with Mayo 1 pancolitis. revealed colonic mucosa showing epithelitis, cryptitis, rare crypt abscesses, crypt architectural distortion, basal plasmacytosis and gland branching from the cecum to the . IN A NUTSHELL Most important findings include; Wall thickening (>4 mm) Mucosal or submucosal enhancement Other relevant findings include; Loss of haustral markings Increased signal of surrounding colonic Potential complications include; Toxic Perianal disease Lower GI bleed Remember of the entire colon may lead to edema of the terminal and cause backwash VOICE RAD MRE AND ULCERATIVE COLITIS by Dr. Castro-Aragon (2020) OLA

A 14 year old girl with a history of ulcerative colitis undergoes MR enterography for correlation with a prior colonoscopy. What would you expect to see on MRE?

a. Transmural colonic wall thickening b. Continuous diffuse colonic wall enhancement c. Skip lesions d. Segmental wall enhancement of the small bowel OLA A 9 year old boy with a history of chronic diarrhea presents to the ED with abdominal pain and bloody stool. He has had no sick contacts and no . Abdominal ultrasound shows no signs of but reveals bowel wall thickening of the descending and sigmoid colon. Follow up MRE shows this (see image) at the level of the sigmoid colon. What is the most likely diagnosis? a. Colitis b. c. Large d. Intussusception IMAGING SPECTRUM of UC

MRE of the abdomen of an 11 year old male shows circumferential wall thickening (yellow arrow) of the sigmoid colon and rectum, with loss of haustrations and enhancement after contrast, consistent with a diagnosis of ulcerative colitis. includes Crohn’s disease and gastroenteritis. IMAGING SPECTRUM of UC

MRE of the abdomen of an 11 year old male shows circumferential wall thickening (yellow arrow) of the sigmoid colon and rectum, with loss of haustrations, consistent with a diagnosis of ulcerative colitis. Differential diagnosis includes Crohn’s disease and gastroenteritis. IMAGING SPECTRUM of UC

MRE of the abdomen of an 11 year old male shows circumferential wall thickening of the sigmoid colon and rectum, with loss of haustrations and enhancement after contrast (yellow arrow), consistent with a diagnosis of ulcerative colitis. Differential diagnosis includes Crohn’s disease and gastroenteritis. IMAGING SPECTRUM of UC

Axial CT scan of the abdomen shows wall thickening of the sigmoid colon (yellow arrow), consistent with a diagnosis of ulcerative colitis. Differential diagnosis includes Crohn’s disease. IMAGING SPECTRUM of CROHN’S Disease

MRE of the abdomen with contrast of a 10 year old male shows transmural thickening and enhancement of a long segment of distal ileum (yellow arrows) and cecum with inflammatory changes of the adjacent fat, consistent with a diagnosis of Crohn’s disease. Differential diagnosis includes ulcerative colitis and gastroenteritis. IMAGING SPECTRUM of CROHN’S Disease

MRE of the abdomen with contrast of a 10 year old male shows transmural thickening of a long segment of distal ileum (yellow arrow) with inflammatory changes of the adjacent fat, consistent with a diagnosis of Crohn’s disease. Differential diagnosis includes ulcerative colitis and gastroenteritis. IMAGING SPECTRUM of CROHN’S Disease

MRE of the abdomen with contrast of a 10 year old male shows transmural thickening and enhancement (yellow arrow) of a long segment of distal ileum with inflammatory changes of the adjacent fat, consistent with a diagnosis of Crohn’s disease. Differential diagnosis includes ulcerative colitis and gastroenteritis. IMAGING SPECTRUM of CROHN’S Disease

Ultrasound of the abdomen of a 14 year old male shows wall thickening of the terminal ileum (yellow arrows), consistent with a diagnosis of Crohn’s disease. Differential diagnosis includes ulcerative colitis and gastroenteritis. IMAGING SPECTRUM of CROHN’S Disease

Ultrasound of the abdomen of a 14 year old male shows wall thickening of the ascending colon (yellow arrow), consistent with a diagnosis of Crohn’s disease. Differential diagnosis includes ulcerative colitis and gastroenteritis. IMAGING SPECTRUM of CROHN’S Disease

MRE of the abdomen of a 14 year old male shows bowel wall thickening extending from the cecum to the terminal ileum (yellow arrows), consistent with a diagnosis of Crohn’s disease. Differential diagnosis includes ulcerative colitis and gastroenteritis. DISCUSSION

Ulcerative colitis is a chronic disease that most commonly presents in children and adolescents <20 years old. The etiology is unknown but the symptoms generally include abdominal pain and bloody diarrhea. MR enterography is used to image patients with suspected UC and diagnosis is confirmed by EGD and colonoscopy with showing cryptitis. The disease is associated with increased risk of colon , thus patients should receive surveillance every 2-3 years starting 8 years after initial onset of UC. LINKS AND REFERENCES National Guidelines ACR Guidelines – CRC Screening ACR Guidelines – Crohn Disease Consistent References: Radiopedia RadioGraphics Videos Radiology Capsules Other Journals and Texts Radiographical evaluation of ulcerative colitis OLAS