Teaching Case

This patient underwent a fluoroscopic serial study of small bowel, then a MR study of abdomen, because of continuous bowel troubles (diarrhoea, abdominal pain, sickness).

The patient underwent a fluoroscopic serial study of the small bowel after taking iodinated contrast agent. The examination showed a considerable deterioration of last ileal loops, which had a narrow lumen and as a consequence a difficult transit of contrast (string sign). Besides loops appeared thickened and sometimes stuck on each other and were not very displaceable. Other findings of last ileal loops were many entero-enteric fistulas and particularly there was a close connection between the last ileal loop and the descending colon and between the last ileal loop and the rectum, allowing the contrast transit and the precocious opacification of those intestinal parts. So Crohn’s disease was diagnosed and the patient underwent a MR examination that confirmed the last ileal loop affection (whose thickness was 17 mm) 20 cm far from ileocecal valve. Besides, after contrast administration, MR evaluation confirmed the fistulae presence and showed many adhesion’s areas between ileal loop and right colon, and between descending colon and sigmoid colon. Other findings were the mesenteric fat’s inflammation and numerous lymph nodes’ alterations along aortic-bis-iliac axis.

Crohn’s disease is a chronic inflammatory granulomatous intestinal disease which prevalently concerns the last part of small bowel, but it can involve the whole gastrointestinal tube, from the mouth to the anus. The aetiology is still unknown, but some inducing factors, as familiarity, viral and bacterial infections (above all mycobacterium para-tuberculosis and measles virus which can cause granulomatous vasculitis) hyperactivity of immune system are known. The most important features of Crohn’s disease are three: well bounded intestinal inflammatory transmural involvement combined with mucosal damage without caseation and presence of splitting and fistulae. Fatty tissue surrounding involved parts often is sore itself. Inflammatory involvement of intestinal mucosa causes oedema and afterwards fibrosis of the intestinal wall which become denser and provokes lumen narrowing and the string sign after barium contrast administration. Another feature is the making of aphtous ulcers which inclined to converge into long linear ulcers and from them can originate splitting and adhesions. Worst cases involve the making of fistulae with surrounding viscera and the skin.
The diagnosis is based on signs and symptoms recognition (as intermittent diarrhoea, vitamin B12 malabsorption in case of the last ileal loop involvement) which has to drive to the disease’s suspect; the serial small bowel’s study after barium contrast administration is fundamental to make a certain diagnosis and to highlight possible complications which need more in depth examination, as like as the MR, to plan a suitable therapy.
The therapy is based on anti-inflammatory drugs and eventually on immunosuppressants; the complications’ treatment needs surgical operation.