Overview

Preferred examination

Plain abdominal radiographs (see the images below) are a useful adjunct to imaging in cases
of ulcerative colitis of acute onset. In severe cases, the images may show colonic dilatation,
suggesting toxic megacolon; evidence of perforation; obstruction; or ileus. Radiographic
imaging has an important role in the workup of patients with suspected IBD and in the
differentiation of ulcerative colitis and Crohn disease. Because of its ability to depict fine
mucosal detail, double-contrast barium enema examination is a valuable technique for
diagnosing ulcerative colitis and Crohn disease, even in patients with early disease.
Traditionally, barium enema examination has been the mainstay of radiologic investigation
for suspected ulcerative colitis.[1, 2, 3, 4]

Double-contrast barium enema studies in a 44-year-old man

known to have a long history of ulcerative colitis. Images show total colitis and extensive

pseudopolyposis. Plain abdominal radiograph in a patient (same as

in the previous image) who presented with an acute exacerbation of his symptoms. Image
shows thumbprinting in the region of the splenic flexure of the colon.

Plain abdominal radiograph obtained 2 days later in the same

patient as in the previous image shows distention of the transverse colon associated with
mucosal edema. The maximum transverse diameter of the transverse colon is 7.5 cm. The
patient was treated for toxic megacolon.

Transabdominal ultrasonography (US) is a noninvasive modality that may be helpful in the

diagnosis of IBD, but it cannot be used to distinguish between ulcerative colitis and Crohn
disease. US is also a useful technique in the investigation of biliary complications of the
disease.

Generally, CT has a limited role in the diagnosis of uncomplicated ulcerative colitis.

However, CT plays an important role in the differential diagnosis of ulcerative colitis, and it
is an excellent modality in the diagnosis of complications associated with the disease. Biliary
dilatation suggests primary sclerosing cholangitis.

Cross-sectional imaging studies such as CT, MRI, and US are useful for showing the effects
of these conditions on the wall of the bowel and for demonstrating intra-abdominal abscesses
and other extraluminal findings in patients with more advanced disease. Thus, barium studies
and cross-sectional imaging studies have complementary roles in the evaluation of ulcerative
colitis.

Radionuclide studies (see the image below) are useful in cases of acute fulminant colitis
when colonoscopy or barium enema examination is contraindicated. Radionuclide studies are
also useful in depicting disease activity and the extent of disease and in monitoring the
response to therapy.

Scan obtained with technetium-99m hexamethylpropylamine

oxime (HMPAO)labeled WBCs in a patient with active colitis involving the transverse and
descending colon.

Radiologic findings in cases of acute infective enterocolitis from infection caused by

Entamoeba histolytica (amebiasis), cytomegaloviral colitis, and Isospora, Salmonella,
Shigella, or Yersinia may be similar to the findings seen in cases of ulcerative colitis; this is
especially true with CT scans.

Etiology and pathophysiology

Ulcerative colitis is a type of inflammatory bowel disease (IBD) that characteristically

involves the large bowel (see the images below). It is a multifactorial polygenic disease; the
exact etiology is unknown. Included in the etiologic theories are environmental factors,
immune dysfunction, and a likely genetic predisposition. Some have suggested that children
of below-average birth weight who are born to mothers with ulcerative colitis have a greater
risk of developing the disease.

Double-contrast barium enema study shows changes of early disease.

Note the granular mucosa. Single-contrast enema study in a

patient with total colitis shows mucosal ulcers with a variety of shapes, including collar-
button ulcers, in which undermining of the ulcers occurs, and double-tracking ulcers, in

which the ulcers are longitudinally orientated. Postevacuation image

obtained after a single-contrast barium enema study shows extensive mucosal ulceration
resulting from Shigella colitis.

Histocompatibility human leukocyte antigen (HLA)B27 is identified in most patients with

ulcerative colitis, though this finding is not associated with the condition. Immune
dysfunction has been postulated as a cause, although the clear evidence of this is limited.
Ulcerative colitis might also be linked to diet, though diet is thought to play a secondary role.
Food or bacterial antigens might exert an effect on the already damaged mucosal lining,
which has increased permeability.

The severity of ulcerative colitis can be graded as follows:

 Mild Bleeding per rectum and fewer than 4 bowel motions per day

Moderate Bleeding per rectum with more than 4 bowel motions per day

Severe Bleeding per rectum, more than 4 bowel motions per day, and a systemic
illness with hypoalbuminemia (< 30 g/L)

Limitations of techniques

All imaging techniques lack specificity. Mucosal ulceration depicted on barium studies is
nonspecific and is encountered in a variety of colitides. In severe cases, barium enema may
precipitate toxic megacolon. Generally, barium enemas may be performed safely only in mild
cases. Thickening of the bowel wall, as seen on cross-sectional imaging (CT, MRI, and US),
is a nonspecific finding seen in a variety of bowel conditions besides IBD. Increased
radionuclide focal activity may be related to a variety of physiologic and pathologic
conditions unrelated to ulcerative colitis. Motion artifacts may interfere with cross-sectional
imaging. Although this is not a major problem with modern scanners, some investigators still
use a hypotonic agent to decrease bowel peristalsis.

Patient resources

For patient information resources, see the Crohn Disease Center and the Esophagus,
Stomach, and Intestine Center, as well as Crohn Disease and Crohn Disease FAQs.

Ulcerative Colitis: Surgical Perspective.

Double-contrast barium enema

studies in a 44-year-old man known to
have a long history of ulcerative
colitis. Images show total colitis and
extensive pseudopolyposis.
Plain abdominal radiograph in a patient
(same as in the previous image) who
presented with an acute exacerbation of his
symptoms. Image shows thumbprinting in
the region of the splenic flexure of the
colon.

Plain abdominal radiograph obtained 2 days

later in the same patient as in the previous
image shows distention of the transverse
colon associated with mucosal edema. The
maximum transverse diameter of the
transverse colon is 7.5 cm. The patient was
treated for toxic megacolon.

A 22-year-old man presented with

abdominal pain, passage of blood and
mucus per rectum, abdominal distention,
fever, and disorientation. Findings from
sigmoidoscopy confirmed ulcerative colitis.
Abdominal radiographs obtained 2 days
apart show mucosal edema and worsening
of the distention in the transverse colon.
The patient's clinical condition deteriorated
over the next 36 hours despite steroid and
antibiotic therapy, and the patient had to
undergo total colectomy and ileostomy.

Plain abdominal radiograph in a patient

with known ulcerative colitis who
presented with abdominal pain, peritonism,
and leukocytosis. At surgery, a perforated
toxic megacolon superimposed on
ulcerative colitis was confirmed.

Plain abdominal radiograph on a patient

with known ulcerative colitis who
presented with an acute exacerbation of his
symptoms. Image shows thumbprinting in
the region of the splenic flexure of the
colon.
Double-contrast barium enema study shows
pseudopolyposis of the descending colon.

Single-contrast enema study in a patient

(same patient as in the previous image)
with known ulcerative colitis in remission
shows a benign stricture of the sigmoid
colon.

Plain abdominal radiograph in a 26-year-

old with a 10-year history of ulcerative
colitis shows a long stricture/spasm of the
ascending colon/cecum. Note the
pseudopolyposis in the descending colon.
Single-contrast enema study in a patient
with total colitis shows mucosal ulcers with
a variety of shapes, including collar-button
ulcers, in which undermining of the ulcers
occurs, and double-tracking ulcers, in
which the ulcers are longitudinally
orientated.

Double-contrast barium enema study shows

total colitis. Note the granular mucosa in
the cecum/ascending colon and multiple
strictures in the transverse and descending
colon in a patient with a more than a 20-
year history of ulcerative colitis.
 Single-contrast barium enema study shows
burnt-out ulcerative colitis.

Postevacuation image obtained after a

single-contrast barium enema study shows
extensive mucosal ulceration resulting from
Shigella colitis.

Double-contrast barium enema studies

show granular mucosa associated with
Campylobacter colitis.

The earliest mucosal changes are best depicted on a good-quality double-contrast barium
enema study. Before ulcers appear, mucosal edema has a fine, granular appearance when the
radiographs are seen en face. When ulcers first appear, the mucosa may have a fine, stippled
appearance when seen en face. When mucosal ulcers become established and confluent, the
mucosa is replaced by granulation tissue; on double-contrast enema examination, the
characteristic appearance is coarsely granular.

In the acute and subacute phases of the disease, the ulcers may acquire a variety of shapes:
collar-button ulcers occur with undermining of the ulcers; double-tracking ulcers are
longitudinally orientated and are sometimes several centimeters long.

Symmetrical thickening of haustral folds may produce the appearance of thumbprinting.

Pseudopolyps are a consequence of severe mucosal disease; they appear as multiple filling
defects of varying sizes. These may develop rapidly, and they tend to persist, even when
ulcerative colitis is quiescent. Occasionally, mucosal bridges are formed between
pseudopolyps, which may be radiologically demonstrable.

With increased severity and duration of disease, the involved colon may become narrow,
shortened, and loose in terms of its normal redundancy and haustral pattern. On lateral
projections, rectal narrowing is easily recognizable as increased retrorectal space. When the
entire colon is involved, changes in the terminal ileum may be seen (backwater ileitis); this
involves 4-25 cm of the terminal ileum. The ileocecal valve appears patulous. The mucosa is
granular and is usually associated with the absence of peristalsis.

Benign strictures occur in 1-11% of patients with long-standing disease. Such strictures are
predominantly found in the left colon. Carcinomas that complicate ulcerative colitis are
usually annular and may be difficult to differentiate from benign strictures. Often, however,
malignant strictures are eccentric, with nodular narrowing and shouldered edges. Multiple
carcinomas are not rare in the setting of ulcerative colitis. About 50% of these tumors are not
detected on clinical or radiologic examination; instead, they are diagnosed at colectomy or
autopsy.

Degree of confidence

Although many radiographic findings are nonspecific, many other features are typical, if not
pathognomonic, of ulcerative colitis.

The diagnostic signs of various colitides overlap considerably. Similar radiographic signs
may be seen in cases of infective diarrhea, Crohn disease, ischemic colitis, drug-induced
colitis, and amebic colitis. Infective diarrhea is occasionally the presenting feature of IBD.

***************************************

Ischemic Colitis Imaging

Overview

Ischemic colitis encompasses a number of clinical entities, all with an end result of
insufficient blood supply to a segment or the entire colon. This disease results in ischemic
necrosis of varying severities that can range from superficial mucosal involvement to full-
thickness transmural necrosis.[1]

Marston et al introduced the term ischemic colitis in their article published in 1966.[2] This
report was preceded by the description of reversible colonic vascular occlusion by Boley and
colleagues in 1963.[3]

Bowel ischemia is mainly a disease of old age caused by atheroma of mesenteric vessels.
Other causes include embolic disease, vasculitis, fibromuscular hyperplasia, aortic aneurysm,
blunt abdominal trauma, disseminated intravascular coagulation, irradiation, and
hypovolemic or endotoxic shock.[4]

Occlusive mesenteric infarction (embolus or thrombosis) has a 90% mortality rate, whereas
nonocclusive disease has a 10% mortality rate.

Venous infarction occurs in young patients, usually after abdominal surgery.[5] Patients may
present with colicky abdominal pain, which becomes continuous. It may be associated with
vomiting, diarrhea, or rectal bleeding.[6, 7, 8, 9]

Elramah et al conducted a case control retrospective study to determine mortality and risk
factors for associated bowel ischemia in cocaine users. The study revealed cocaine-related
ischemic colitis has a high mortality. The authors findings suggest that cocaine-related
ischemia should be considered in young patients presenting with acute abdominal pain and/or
rectal bleeding with evidence of bowel wall thickening or pneumatosis on either imaging or
colonoscopy. The authors went on to propose that testing for cocaine in these patients may
help identify patients at high risk of sepsis and death.[10]

See the images of ischemic colitis below.

Arterial blood supply to the large

bowel shows the potential site of
ischemia.
Double-contrast barium enema study
shows a stricture of the proximal
descending colon secondary to
ischemia.

Plain abdominal radiograph in a 65-year-

old man presenting with acute abdominal
pain and the passage of blood per rectum.
Note the thumbprinting in the region of the
splenic flexure and also the proximal small-
bowel dilatation.

Left: Plain abdominal radiograph in a 58-

year-old man who underwent an upper GI
barium study for nonspecific dyspepsia a
few days earlier. The patient presented with
vague abdominal discomfort and the
passage of blood per rectum. Note the
thumbprinting in the region of the distal
transverse colon and splenic flexure. Right:
Another radiograph obtained 24 hours later
shows mild dilatation of the distal
transverse colon with more obvious
mucosal edema. (See also the next image.)

Six days later (see the previous image), the

clinical condition of the patient
deteriorated, with increasing abdominal
pain and signs of peritonism. Note the
bowel relief sign. At surgery, a perforated
ischemic bowel segment at the splenic
flexure was confirmed.

Left: Chest radiograph of a 45-year-old

woman with mitral valve disease and atrial
fibrillation who presented with acute
abdominal symptoms. Note the
cardiomegaly and blood diversion in the
upper lobe, which is suggestive of cardiac
decompensation. Right: Plain radiograph
shows several dilated loops of the jejunum.
Note also the stricture of the proximal
transverse colon. At surgery, a gangrenous
small bowel loop secondary to a mesenteric
artery embolus was resected. The patient
had a similar episode a year earlier, which
was managed conservatively; this approach
accounts for the ischemic stricture of the
proximal transverse colon.