1. A Case of Crohn’s Disease Rich Rames, M3 May/June 2013 Dr. Joy Sclamberg, Dr. James Cameron, Dr. Aditi Gulabani

2. CC: RLQ abdominal pain, constipation, nausea HPI: 24 y/o male presents to the ED with 4-6 week h/o progressive vague abd pain with 2 weeks of constipation and watery stool with regular laxative use. PMH: Pyloric stenosis (2-3 months old) PSH: Pyloroplasty Pertinent negatives: vomiting, dysuria, blood in stool, no recent travel, weight loss Pertinent positives: fever, chills, fatigue Clinical History 2

3. Focused PE: – Abd: Horizontal scar noted over RUQ Soft, non-tender, not distended Bowel Sounds-positive Pain to deep palpation of RLQ No rebound or guarding Notable Labs: – C-Reactive Protein: 181.6 – WBC: 11.68 Clinical History

4. Inflammatory Bowel Disease Bowel obstruction Chronic appendicitis Plan – UA- negative – Abdominal X-ray (obstruction?) – CT Pelvis/Abd with contrast (IBD, Chronic appendicitis?) – Colonoscopy DDx

5. Bowel wall thickening Mesenteric inflammation (“fat stranding”) Lymph node size and number Extra-luminal collections – Fistulae, abscesses, sinuses What are we looking for on CT?

6. Pelvic Region Post-contrast Pelvic/Abdominal CT Axial MRN: 6561716 Accession: 5273942 Diffuse Wall Thickening of Segment of Terminal Ileum

7. Pelvic Region Post-contrast Pelvic/Abdominal CT Axial MRN: 6561716 Accession: 5273942 Normal Small Bowel

8. Pelvic Region Post-contrast Pelvic/Abdominal CT Axial MRN: 6561716 Accession: 5273942 Enterocolic Fistula

9. Pelvic Region Post-contrast Pelvic/Abdominal CT Axial MRN: 6561716 Accession: 5273942 Adjacent Inflammatory Fat Stranding

10. Abdomen-Pelvis Post-contrast Pelvic/Abdominal CT Coronal MRN: 6561716 Accession: 5273942

11. Appropriateness Criteria 11

12. CT – Radiation concerns – GI wall thickening – Extraluminal manifestations (e.g. abscesses) – Quick- minutes, often used in ED settings – Contrast allows differentiation of lumen and gut wall, no fistula visualization without it MR – Avoids radiation risks, allows for serial f/u – GI wall thickening – Slow (45 min-1 hr)  images not as sharp with patient moving and normal gut peristalsis – Difficult to pick up subtle findings – Improving with anti- perstaltic agents and ultrafast scans CT vs. MR Enterography- Crohn’s

13. CT MR- T2 Weighted http://www.mghradrounds.org/index.php?src=gendocs&link=2009_september

14. MR Enterography http://www.radiology.ucsf.edu/patient-care/sections/pediatric/advanced-techniques/imaging2 T2 Weighted, Coronal MR Abdomen

15. Inflammatory Bowel Disease Transmural inflammation of lining of digestive tract Common Signs and Symptoms – Diarrhea – Abdominal Pain and Cramping – Blood in stool – Ulcers – Decreased appetite and weight loss Crohn’s Disease

16. Complications – Bowel Obstruction – Ulcers – Fistulas – Anal Fissure – Malnutrition – Colon Cancer Crohn’s Disease

17. Following CT- patient admitted Colonscopy – Ileocecal valve: severe ulceration, granularity and erythema with deformation of the valve – Single ulcer in sigmoid colon, polyp Discharged after with appropriate medication- repeat labs in 2 weeks Follow Up

18. learningradiology.com/notes/ginotes/crohnsdis easepage.htm www.mayoclinic.com/health/crohns- disease/DS00104 http://emedicine.medscape.com/article/367666 -overview http://www.mghradrounds.org/index.php?src= gendocs&link=2009_september References

19. Questions?