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Crohn'sdisease
EvaluationwithMRI
CarlPuylaert,JeroenTielbeekandJaapStoker
theAcademicMedicalCentre,Amsterdam,theNetherlands

PublicationdateFebruary17,2016

In this article we will discuss the MRIfeatures

used to evaluate Crohn's disease of the small
bowelandthecolon.

A systematic approach is presented to grade

disease activity resulting in a simple
classification of mild, moderate and severe
disease.
Thisissufficientformosttherapeuticdecisions.

Introduction

Crohn's disease is characterized by

inflammatory lesions in the gastrointestinal
tract,mostcommonlyintheterminalileumand
colon.
The lesions are usually transmural, which can
leadtocomplicationslikestenoses,fistulasand
abscesses.

While most patients first present with

inflammation only, about two thirds of patients
willdevelopcomplicationswithin10years(1).

ThereisnocureforCrohn'sdisease.
Immunosuppressivedrugscandecreasedisease
activity, maintain remission and prevent
relapse.
Eventually90%ofpatientswithileocolicdisease
requiresurgery(2).

MRIprotocol

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Boweldistention
There are two techniques to acquire distension
ofthesmallbowel:

MRenterography:oraladministrationof
contrast.
MRenteroclysis:administrationofcontrast
viaanasojejunaltube.

We routinely perform MR enterography as it
suffices in the large majority of patients while
beinglessburdensomeandmoretimeefficient.

Oralcontrast
Fororalcontrastseveraloptionsareavailable.
WeuseaMannitolinwatersolution(2%),which
provides good contrast between lumen and
bowel wall on both T1 and T2 sequences and is
wellacceptedbypatients.
There is one precaution: no colonoscopy with
electrocoagulation should be performed directly
aftertheMRIbecauseofmethaneresultingfrom
Mannitolbreakdown.

MRIsequences
Weusethefollowingsequences:

BalancedFFE(axialand/orcoronal)in
breathhold
T2withfatsat(axial)inbreathhold
T1preandpostcontrast(axial/coronal)
inbreathhold

Optionalsequences:

T2FSEwithoutfatsatforadditional
overviewandcomparisonwithT2withfat
sat.
DiffusionImaging(DWI).
BalancedFFEcinestudyformotility.

GradingCrohn'sdiseaseactivity

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There are several systems for grading disease

activityinCrohn'sdisease.

Thescoringsystem,thatweuse,gradesdisease
activityintonone,mild,moderateandsevere.

It is based on the score of the bowel wall

abnormalitiesandthepresenceofcomplications
aspresentedinthetable(3).

Additionalfindings
Other findings that should be mentioned in the
radiologyreportare:

Locationofthelesions
Exactwallthickness
Lengthofthedisease
Ulcerations
Combsign
Clickforenlargedview Creepingfat
Lossofhaustrationofthecolon
Partialstenosis
Sinustracts

MRIsignsofCrohnsdisease
Bowelwallthickness

Withadequatedistensionthenormalbowelwall
hasathicknessof13mm.
A common categorization is 35 mm for mild
thickening,57mmformoderatethickeningand
>7mmformarkedthickeningofthebowelwall.

T1weightedpostcontrastimagesornonfatsat
T2weightedimages(ifavailable)arepreferable
formeasurementofbowelwallthickness.

The image is a coronal postcontrast T1

Bowelwallthickeningwithdeepulceration(arrow)in weighted image showing disease activity in the
thetransversecolon. transversecolonwithmarkedwallthickeningof
morethan7mmanddeepulceration(arrow).

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Increased bowel wall thickness is one of the

most common signs of inflammatory activity,
butnotspecificforCrohn'sdisease.

For more information on the differential

diagnosisofbowelwallthickeningclickhere.

Bowel wall thickness correlates well with the

severityofthediseaseactivity.

Measurements are best performed on the

sequencewithgoodluminaldistension.

Black border artifacts on balanced FFE

BalancedFFEimageshowsmarkedbowelwall sequencescandistortthicknessmeasurements.
thickeningandluminalnarrowingoftheterminal
ileum.MeasurementonthebalancedFFEsequence
canbelessaccurateduetotheblackborderartifact
(arrows).

Enhancement

Abnormal bowel wall enhancement after

administration of gadolinium is the result of
increased vascular permeability and
angiogenesis.
Itisseenbothinactivediseaseandfibrosis.

Enhancement can be graded by comparing to

the precontrast images, to normal bowel loops
andnearbyvascularstructures.

Noabnormalenhancement
Equivalenttonormalbowelwall

Minorincreasedenhancement
Morethannormalbowelwall,but
significantlylessthannearbyvascular
Thickenedterminalileumsegmentwithmarked structures
enhancementonaxialpostcontrastT1Wimagewith

fatsat.
Moderateenhancement
Somewhatlessthannearbyvascular
structures

Markedenhancement
Equalormoreintensethannearby
vascularstructures

Patternofenhancement

Enhancement of the bowel wall can be

categorizedinoneofthefollowingpatterns:

1.Homogeneous
2.Mucosal
3.Layered

The latter two enhancement patterns can only

beappreciatedwhenthewallisthickened.
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Thereissomediscussionaboutthevalueofthe
enhancementpattern.

A layered pattern is regarded to depict more

severe disease activity compared to the
mucosal pattern, which in turn is more severe
thanahomogeneouspattern(4).

However, different degrees of inflammation and

fibrosis can be present at the same time and a
layered pattern of enhancement has also been
associated with fibrosis (5), although a more
recentstudydidnotfindthisassociation(6).

Homogeneousenhancement

Strong homogeneous enhancement is seen in
activeinflammation.

The image shows a terminal ileum with a

homogeneous enhancement pattern with
moderate(greenarrow)andmarked(redarrow)
enhancement on an axial postcontrast T1
image.

Mucosalenhancement

This is seen as bowel wall thickening with

increased enhancement of the mucosal layer
relativetotheouterlayers.

The image is a postcontrast T1 image with a

mucosal enhancement pattern in the terminal
ileum(arrow).

There is relatively low enhancement of the

middleandouterlayers
Mucosalenhancementpattern

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Layeredenhancementpatternoftherectumwith
somesurroundingfatstrandingonanaxialpost
contrastT1image(arrow).Continuedinflammation
withahomogeneousenhancementpatterncanbe
seeninthesigmoidcolon(greenarrow).Also,a
rightsidedadnexalcystispresentwithenhancing
rim(arrowheads).
Activelyinflamedterminalileumwithmarked
thickeningandmoderatemuralsignalintensity
(muraledema)onanaxialT2withfatsat.
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Layeredenhancementpattern
Thispatternsuggestsseverediseaseactivityor
longstandingchronicdisease(4,5).
The threelayered appearance is caused by
strong enhancement of the mucosa and the
serosawithnoenhancementofthemiddlelayer,
whichisthesubmucosaandthemuscularlayer.
This middle layer can consist of fat, edema or
fibrotictissue.
This can be distinguished using a fat sat T2
sequence.
T2muralsignalintensity
Increased mural signal intensity on fat
saturated T2 images indicates the presence of
muraledema,suggestingactivedisease.
Presence of bowel wall thickening with a low
mural T2 signal intensity is more suggestive of
fibroticdisease.
The psoas muscle can be used as a reference
whenassessingmuralT2signal.
Fatsuppressionisroutinelyusedtodifferentiate
between mural fat depositions and mural
edema.
Fat depositions are the result of chronic bowel
inflammation and therefore quite common in
Crohn'sdisease.
However, its presence does not indicate active
disease.
Perimural edema or fluid can be identified as
wellandisassociatedwithactivedisease(7).
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T2 mural signal intensity can be graded as

followsusingaT2sequencewithfatsat:

Noincrease
normalbowelwall

Minorincrease
bowelwallappearsdarkgray

Moderateincrease
bowelwallappearslightgray

Markedincrease
Inflamedsmallbowelshowingwallthickeningand bowelwallcontainsareasofwhitehigh
mildmuralT2signal(arrow)onanaxialT2withfat signalapproachingthatofluminalcontent.
sat.Prestenoticdilatationcanbeseenproximallyof
thediseasedsegment.

Fatsuppressionisroutinelyusedtodifferentiate
between mural fat depositions and mural
edema.

Fat depositions are a result of chronic bowel

inflammation,butnottypicalofactivedisease.

Thesefatdepositionscanbediffusebutcanalso
presentasalayeredpattern.

Wallthickeningoftheterminalileumina67yearold
TheCTequivalentforthispatternisthe'fathalo
malewithCrohn'sdiseasesince11years.Layered sign'.
enhancementisseenonanaxialpostcontrastT1
imagewithfatsat(left).T2withfatsat(middle)
showsthesamepatternwithamiddlelayeroflow
intensity.T2withoutfatsatshowsanincreased
signalinthemiddlelayer,suggestingfatdepositions.
Endoscopyshowedonlysuperficialdisease.

Ulceration

Moderate to deep ulceration can be seen on T1

and T2 images, but small ulcerations can be
difficult to distinguish from mucosal folds
dependingonthedegreeofluminaldistension.

Ulcerationsareactivespotsofinflammationand
usually there is increased enhancement on the
postcontrastT1images.

CoronalpostcontrastT1andT2fatsatimagesshow
multiplesmallulcerationsintheterminalileum.

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Lossofhaustration

WhenthecolonisinvolvedinCrohn'sdiseasea
decreaseofhaustralfoldscanbeseen.

A complete loss of haustration results in a

smoothsurface.

Thisisalsoacommonfindinginulcerativecolitis
andknownas'leadpipe'colon.

The coronal postcontrast T1 image shows loss

of haustral folds throughout the colon in a
patientwithchronicCrohn'sdisease.

Combsign

Increased vascularity of the mesentery is seen

inactiveinflammation.
Theengorgedvesselshavealinearappearance,
resembling the teeth of a hair comb (comb
sign).

CoronalpostcontrastT1imageshowsmarked
enhancementoftheterminalileumwithaprominent
combsign.

Creepingfat

Creeping fat, also called fibrofatty proliferation

or fat wrapping, are different names for
hypertrophyofthesubserosalfat.

It is a common finding in longstanding Crohn's

disease.

The image shows creeping fat surrounding the

descendingcolon.
It isolates the colon from surrounding bowel
loops.

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Skiplesions

Skip lesions and patchy inflammation are a

typical finding in Crohn's disease, in contrast to
the continuous inflammation, which is seen in
ulcerativecolitis.

Skip lesions refers to the interspersed

inflammation "skipping" parts of the bowel,
whichareleftunaffected(greenarrows).

The coronal T1 postcontrast image (left) and

the T2 image (right) show skip lesions in the
terminalileum.
The affected lesions show increased
enhancement with a layered pattern (yellow
arrows), while another part is unaffected or
skipped(greenarrows).

Complications

Stenosis

Stenosis can present as bowel wall thickening

combinedwithlumennarrowing.
The presence of a prestenotic dilatation
increasesthelikelihoodofastenosis.
Abnormal contrast enhancement of the affected
bowelsegmentisusuallypresent.

In the grading system, only severe stenosis is

includedasacomplication,whichisdefinedasa
stenosis with prestenotic dilatation and a
moderatetomarked increase in mural T2
CoronalpostcontrastT1imagewithastenosisatthe signal.
ileocecaljunction(left).Noobviousprestenotic
dilatationisseen.Thestenosiswasnonpassable
usingendoscopy(right).

Narrowing can be due to contraction and

therefore check other sequences before making
thediagnosisofastenosis.

There may be a role for motility sequences to

demonstratethepresenceorabsenceofmotility
todifferentiateacontractionfromastenosis.
The video shows a motility sequence (BTFE
dynamic) showing wall thickening in the cecum
andterminalileum.
Thereissomedecreasedmotilityintheterminal
ileum,butthereisnostenosis.

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A 48yearold female, who was under antiTNF

treatment,underwentacolonoscopy.
Inthesigmoidcolon,astenosiswasseen,which
couldnotbepassed.

MRenterographywasperformedtoexaminethe
extensionofthestenosis.

Scrollthroughtheimages.

The small bowel is normal, but stenotic

segments are seen in the descending and
transversecolon.
Both stenotic segments display wall thickening
up to 8 mm and marked enhancement with a
mucosal pattern in the descending colon and a
layeredpatterninthetransversecolon.
A prestenotic dilatation is seen before both
segments.

Since these stenoses were not present at a

colonoscopy before antiTNF treatment, they
hadmostlikelydevelopedduringthetreatment.

Therefore it was decided to perform a subtotal

colectomywithanileosigmodalanastomosis.

PostcontrastT1images.Therearestenosesinthe
descendingandtransversecolon.

Infiltrate

Infiltrate can be seen as creeping fat between

bowel loops with replacement of the fat signal
intensity and tethering and kinking of bowel
loops.

Obstructive symptoms due to adhesions,

inflammatorynarrowingorfibrosisarecommon.

Fistulasandabscessesareoftenpresent.
Duetothecomplexstructure,theexactpathof
afistulacanbedifficulttodefine.

PostcontrastT1imageofapatientwithalarge
infiltrateinvolvingmultiplesmallbowelloops.

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CoronalBalancedFFEimageshowsanenterovesical
fistula(arrow)originatingfromthesmallbowel.
PostcontrastT1imageshowsmarkedenhancement
ofthesmallbowelandthe'tramtrack'atthesiteof
thefistula.
Multiplefistulasintheterminalileumonpost
contrastT1images(arrows).Theterminalileum
showswallthickening(12mm)andmarked
enhancementwithalayeredpattern.
Smallabscessmedioposteriorfromthickenedand
inflamedterminalileum.Notetherimenhancement
onthepostcontrastT1image(upper)andmarked
muralsignalonthefatsatT2image(lower)
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Fistula
Sinus tracts and fistulas are common
complicationsinpatientswithCrohn'sdisease.
Both show marked enhancement on T1 images
afteradministrationofgadolinium.
A fistulous track can present with a layered
'tram track' configuration or as a linear
enhancingstructure.
It can be seen going from one bowel loop to
another bowel loop, to another hollow organ or
totheskin.
A50yearoldfemalewithCrohn'sdiseasesince
10 years presented with bloody diarrhea and
underwent a MRenterography and a
colonoscopy.
At colonoscopy, a normal colon was seen, but
theileocecalvalvewasstenotic.
Scrollthroughtheimages.
Severe disease activity can be seen at the
terminalileumwithpresenceofmultiplefistulas.
This examination prompted the gastro
enterologisttostartantiTNFtreatment.
Abscess
Abscesses are often seen in patients with
severeactiveCrohn'sdisease.
Abscesses are characterized by rim
enhancement on postcontrast T1 images and
centralhighsignalintensityonT2images.
The abscess is frequently surrounded by fat
stranding.
DiffusionImaging
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DiffusionImaging
Bowel inflammation, fistulas and abscesses
show restricted diffusion high on DWI, low on
ADC.
B values of 600 1000 are most commonly
used.

Maybe DWI can replace contrastenhanced

series,butitsroleisnotdefinedyet.
Crohn'sdiseaseoftheterminalileumwithhighsignal
onaxialDWIandlowsignalonADCmapindicating
diffusionrestriction(b=600).

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