Crohn’s disease of the colon

Clinical History

A 25-year-old male presented with fever, abdominal cramps, constipation, and pneumaturia.

Imaging Findings

A 25-year-old male presented with fever, abdominal cramps, constipation, and pneumaturia. A barium enema done showed irregular stenotic segments and strictures involving the descendent and the transverse colon. An enteroclysis investigation showed a narrowing of the terminal ileum with a relative rigidity and separation of adjacent loops and an enterovesical fistula.

Discussion

In 1931, Crohn, Ginzburg, and Oppenheimer first described the chronic granulomatous disease of the bowel that was termed as ‘regional enteritis’. It was their belief that this was a disease of the terminal ileum, since the area of involvement was the bowel in the 14 patients who were examined in their initial report. Only two years later, in 1934, Culp reported the first case of granulomatous colitis in a patient in whom of both the cecum and the terminal ileum were invovled. Subsequently, it had become apparent that Crohn’s disease can involve any part of the digestive tract, from the mouth to the anus. The colon may become involved in the granulomatous process in several ways: a) the colon may be the site of granulomatous disease b) both the colon and the small bowel may be involved in granulomatous disease. In such patients, the disease appears to begin at about the same time in the two areas, for both,, small bowel and colon are involved when the patient is first examined radiologically. c) whether the colon may become involved only after an ileocolic anastomosis has been performed for treatment of Crohn’s disease of the small bowel. The diseased segment of the colon is almost always immediately adjacent to the anastomosis. d) Finally, the colon may be involved directly by the fistula formation from an adjacent loop of the diseased small bowel. Patients may present with fever, abdominal cramps, diarrhoea or constipation. The presence of gross blood in the stools is unusual, however, and when it does occur, it tends to be infrequent and is is not a prominent feature of the illness. Perianal fistulas and inflammatory anal disease are common and may appear before any of the other clinical features of the disease. Colonic involvement tends to be right sided and segmental, and the rectum is usually spared. Fistulas are commonly found and occur at some tpoint of time during the course of the illness in about one-half of the cases. Most of these fistulas are located perianally. The pathology is that of Crohn’s disease elsewhere in the gastrointestinal tract. There is a chronic inflammation extending through the entire wall, especially involving the submucosa. The bowel wall is rigid, with a narrowing of the lumen,which may lead to stricture formation. Ulcers are deep, and tend to present as long, linear ulcerations intersecting with deep, transverse fissures. The intervening mucosa is swollen, and the luminal surface has a coarsely nodular appearance. One of the striking radiologic features of granulomatous colitis is the frequency of a concomitant and similar disease in the small bowel. The radiologic features are those that have been recognized in the small bowel in patients with regional enteritis. These findings include tiny ulcers (aphthae), punched out ulcers, small nodular defects, skip lesions, contour defects, longitudinal ulcers, transverse fissures, deep and ragged ulcers (abscesses), eccentric involvement, pseudodiverticula, narrowing and stricture formation, pseudopolypoid changes with a coarse and cobblestone-like mucosal pattern, sinus tracts, and fistulas. The earliest Roentgen findings are tiny ulcerations frequently associated with small irregular nodules along the contours of the bowel. These ulcers are best demonstrated with air contrast studies utilizing high density barium. Other early alterations are thickening of the haustral septa, slight rigidity and increased secretions. In the later stages of the disease, the entire mucosa may be sloughed off because of diffuse ulcerations. In some patients, large, irregular, nodular contour defects with hazy margins are seen. These lesions primarily reflect mucosal and submucosal oedema associated ulcerations. Thickening of the bowel produces irregular stenotic segments and strictures. Uncommonly, granulomatous colitis presents as a single stricture of the colon. The patiet in our case presented an enterovesical fistula. These fistulas are infrequently found and occur more often in men than in women, in whom the uterus serves as a barrier to the spread of inflammation. Enterovesical fistulas typically present with pneumaturia.

Differential Diagnosis List

Final Diagnosis

Crohn's disease of the colon.

URL:	https://www.eurorad.org/case/3176
DOI:	10.1594/EURORAD/CASE.3176
ISSN:	1563-4086