Amal
A. Jabra,
MD
Elliot
a
K. Fishman,
Crohn Disease CT Evaluation’
colonic
wall
thickening
(range,
6-15 mm) (n = 15), and small bowel dilation (n = 5). Mesentenic abnormalities such as adenopathy and focal fatty proliferation were seen in 11 and 18 patients, respectively. Extraluminal complications were easily identified with CT. Abscesses were noted in seven patients, inflammatony
masses
in
four,
and
penirectal on penineal inflammation in 10. Fistulas were detected in four patients. The authors conclude that CT should be the initial imaging study performed in children with known Cnohn disease and a changing pattern of clinical symptoms. Index
terms:
70.262
a
diseases,
Children,
Intestines,
gastrointestinal
CT,
70.1211
a
tract,
Intestines,
1991;
T
A. Taylor,
MD
Pediatric
Patient:
clinical value of abdominal computed tomography (CT) in the evaluation of inflammatory boweb disease in adults has been proved by a number of authors (1-13). However, its usefulness in the pediatnic population has not been well demonstrated (14,15). We reviewed the CT examinations of 25 pediatric patients with known Crohn disease to determine the value of CT and betten define the spectrum of abnormalities identified with this disease. HE
PATIENTS The
AND
abdominal
CT
METHODS scans
records of 25 consecutive pathologically proved
were
reviewed.
ranged years).
The
from 10 to The diagnosis
time
of scanning
later
teen
with
patients
were
referred
because
ages
pain also
with had
Two
patients
or without a limp and
were
bowel
(average, 15.6 known at the
referred
Of
the
dominal
masses,
CT studies
and
in these
one
had
patients
time, 230 thickness 125
kV,
Systems, parameters
I
From
the
Institutions, 21205. quested ary
Department
Science, 600 Received November
17,
1991;
of Radiology
The
Johns
N Wolfe October 26;
accepted
print requests to A.A.J. ,. RSNA, 1991
St.
Ra-
Medical
Baltimore,
MD
4, 1990, revision revision received January
and
Hopkins
28.
Address
reJanure-
All and
patients 1,000
istened contrast approximately
agent 30 and
the examination. tamed if there
was
tion of distal administered used routinely
mL
in divided 90 minutes
Delayed scans inadequate
a
typical scan
beadmindoses prior
at to
were obopacifica-
small bowel. Intravenously contrast material was but was administered
Bowel
wall
not in
position, positions
thicker
sidered thickened, with a diameter considered (phlegmon) by
the
like areas drainable air without
than
and greaten
dilated. were
scesses
Bowel Bowel
pen-
were given of orally
15 mm.
with
the
although were used
as
3 mm
Inflammatory distinguished
lack
conwas
masses from ab-
of hypodense/cystic-
that indicate the pus. The presence associated mass
a sign
was
a small bowel than 2.5 cm
of infection
presence of of pockets was consid-
but
not
Soft-tissue tracts bowel communicates
of
abscess
through to other
one
section sections.
on were In the
traced penianal
on or
The
attenuation
is usually
somewhat
of fatty
was intnaabdisplacing prohifera-
higher
than
that
fat.
RESULTS
mAs, 125 kV, and 8-mm section on 4-second scan time, 310 mAs, and 8-mm section thickness, re-
spectively. tween 500 diological
Isehin, NJ) with of 3-second
10 and
obtained
needed.
of normal
formed to identify the extent and possible complications of suspected inflammatory bowel disease. All patients were examined on either Somatom DR3 on DRH scanner (Siemens Medical scanning
in the supine on decubitus
tion
diarrhea.
were
patient prone
bowel.
four
patients in whom the diagnosis had not been established by the time of scanning, all had history of abdominal pain, three had weight loss, two had palpable ab-
179:495-498
routinely
changes. Focal fatty proliferation seen as focal areas of increased dominal fat surrounding and
One paleg pain.
for evaluation
obstruction.
of between
were
from penine-
penirectal area, the presence of air on banurn within tracts was used to differentiate fistula formation from inflammatory
abdom-
fever. night
at intervals
Scans
fined on consecutive
abscesses
or changing
um
obtained to the
organs were considered fistulas, regardless of the presence of air on barium within these tracts, if they were clearly de-
of patients
suspected
patients. Scans were level of the diaphragm
formation. which the
21 patients and was in four patients. Nineknown Cnohn disease
with
five the
ered
medical
patients with Crohn disease
18 years was
of persistent
inal tient
and
in
documented
of small
70.262
Radiology
George
a
in the
Computed tomographic (CT) scans and medical records of 25 children (age range, 10-18 years) with pathologically proved Crohn disease were reviewed to better define the role of CT in the management of pediatric patients with Crohn disease. CT findings included small bowel thickening (range, 5-10 mm) (n = 20),
MD
Wall Thickening Dilation
and
Small
Segmental thickening
areas of bowel wall involving variable lengths of the terminal ileum were noted in 20 patients (Fig 1). Maximal thickness of bowel ranged from 5 to 10 mm (average, 8 mm). Two of these patients also showed focal wall thickening involving a few bowel loops of jejunum (average, 5 mm in thickness). Cobonic wall thickening of variable lengths was seen in 15 patients, with a range of 5-15 mm in maximal thickness (average, 9 mm) Fig 2). Small bowel dilation was present in five patients, two of whom had
495
Figure
1.
CT scan of a 10-year-old boy who with unexplained weight loss. CT enabled diagnosis of Cnohn disease by demonstrating a long segment of uniform wall thickening involving terminal ileum (anrows). Diagnosis was confirmed at endoscopic biopsy. presented
a.
b.
Figure
3.
CT scans
of a 13-year-old
girl with
Crohn
disease
who
had undergone
resection
of
an ileal stricture 19 days prior to scanning. The patient had fever and abdominal pain, and dihated small bowel was seen on plain nadiognaphs. (a) CT scan shows dilated small bowel loop with closely related low-attenuation mass with pockets of air, compatible with abscess (anrows). (b) Image obtained with the patient in the heft decubitus position at similar level as in
a helps
Figure
2.
Featureless
transverse
colon
confirm
findings.
Abscess
(arrows)
related
to anastomotic
leak
was
proved
at surgery.
with
diffuse wall 17-year-old
thickening (arrows) is seen in a boy with known Cnohn disease who was referred with a possible intraabdominal abscess. Note penicolic inflammatory changes.
clinical small bowel obstruction. The bevel of obstruction was correctly identified in both. Findings at CT, however, suggested that inflammatory stricture was the cause of obstruction in both; at operation one was found to have adhesions from prior surgery (6 months earlier) without intrinsic bowel disease. CT correctly enabled identification of nanrowing of the terminal ibeum that was the cause of small bowel dilation in a third patient who underwent elective surgery 3 weeks later. In the fourth patient, CT cleanly identified a bong terminal ileum stricture that was the cause of bowel dilation (Fig 1). In the fifth patient, focal dilation of a terminal ileal loop was noted in association with an adjacent abscess (anastomotic) at CT, and this was confirmed at surgery (Fig 3). A dilute appearance of the contrast material in the small bowel was noted in one patient with no evident dilation. This suggested partial small bowel obstruction. Ten days later, the patient underwent resection of a terminal ileum stricture and was reported to have mild bowel dilation proximal to
496
Radiology
#{149}
4. Figures
5.
4, 5. (4) CT scan of a 15-year-old boy with known Cnohn disease referred to rule out abdominal abscess. Targetlike appearance of bowel compatible with intussusception (probably ileoileal) is noted (black arrows). Focal low-attenuation area (white arrow) represents mesentenic fat. Finding resolved on repeat image obtained at a similar level following completion of scanning. (5) Focal fatty proliferation is seen on the night side of abdomen (anrows) in 17-year-old girl with known Cnohn disease.
the stricture. Transient ileoileal intussusception was noted in one patient (Fig 4). CT was the first imaging study to suggest the diagnosis of Cnohn disease in one patient who had presented with severe weight loss and occasionab abdominal pain and who was suspected clinically to have a lymphoma. CT showed a long, narrowed segment of terminal ibeum, with diffuse wall thickening measuring 10 mm and occasional mesenteric nodes measuring 5 mm on less. The diagnosis
of
Cmohn
disease
was
confirmed
Mesentenic Clusters ing
(Fig
or
measun-
present of
seen
in
focal in
18
absence
11
fatty
pro-
patients
of abdominal
phlegmon,
in the
four
inflammatory
mesenteny
were
noted
patients.
Abscesses
and
Abscesses seven patients
with
mesentery.
areas
were
changes
nodes
were
5). In the
abscess in
lymph
less
and
hiferation
fatty
the
or
patients,
surgery
in
of
1 cm
with CT in three other children suspected of having the disease. Findings in these children included diffuse thickening of the terminal ileum and/on colon, penirectal inflammation, phlegmon, abscess, and focal proliferation
Abnormalities
in
ileopsoas
Phlegmon
were seen on CT scans and were confirmed six.
Two
abscess
tients
had
tenor
abdominal
abscesses abscess.
left
quadrant
a bowel
had
6, 7).
one
One
anastomotic
abscess
an
Two
involving wall;
colostomy
lower
patients (Figs
in at pa-
the was
an-
a pen-
patient
had
a
associated leak
(Fig
May
1991
Figure
6.
mass. sound
and
CT scans
of an 1 1-year-old
Inflammatory
bowel
findings.
right
Figure
CT
psoas
7.
helped
abscess
CT
disease
scan
boy and
confirm
findings.
(arrowheads)
of
with
psoas are
a 13-year-old
girl
night
abscess
lower were
Thickening
quadrant suspected of
wall
of
pain
and
from
previous
terminal
a palpable iheum
ultra(arrows)
seen.
with
known Cnohn disease who presented with a limp and right lower quadrant and night leg pain. CT scan demonstrates wall thickening of terminal ileum with formation of a fistula to right ileopsoas muscle and abscess fonma-
Figure 9. CT scan of an 1 1-year-old girl with known Crohn disease and multiple draining penianal sinuses. Penianal fistuha (arrows) extending toward the bladder and right internal obturator muscle is seen. Images obtained at a lower level showed extension into night internal obturator muscle.
Figure
8. CT scan of 17-year-old history of subtotal colectomy and for Cnohn disease who presented A large interloop abscess is shown
girl with ileostomy with fever. (arrows).
tion.
3). Multiple abscesses were detected in one patient involving the lessen sac of the pemitoneal cavity, the root of mesentery, and the left lower quadrant (Fig 8). A penianal abscess was noted in one patient and was treated medically. Phlegmon on inflammatory
masses
four
patients.
right
lower
were
All quadrant
terminal
small
noted
were
in
in the
involving
bowel,
both. One contained air and was presumed patient underwent cal treatment.
located
the
cecum,
on
tiny pockets of infected. This successful medi-
Fistulas Fistulas
were
identified
in
four
pa-
multiple enterocutaneous fistuhas associated with an abscess involving the anterior abdominal wall, small bowel, and cohon. The second patient had multiple entemoentemic fistulas and a fistula from the terminal ileum to the right psoas muscle (Fig 7). The third patients.
tient
Volume
One
had
patient
an
179
Number
Penianal on Penirectal Inflammation Inflammatory changes in the penanal on peninectal area were noted in 10 patients, ranging from a single focal area of linearly increased attenuation to ill-defined bilaterally increased attenuation of penianal on perirectal fat. We reserved the diagnosis of penirectal or penianal fistuba to visualization of air on barium within a well-defined tract and included these with fistulas described in the previous section.
had
enterocutaneous
a
to the anterior abdominal wall along with a penirectal fistula. The fourth patient had multiple penianah fistulas to the skin and a fistula to the right internal obturator muscle (Fig 9).
fistula
2
DISCUSSION Information patients with and a changing symptoms
obtained with CT in known Crohn disease pattern of clinical has been shown to have a
significant
ment
effect
of adult
on
patients.
clinical
manage-
In a series
of
80 patients, Fishman et al showed that CT findings altered management decisions in nearly 30% of adult patients (2). These findings enabled detection of unsuspected abscesses or fistulas, exclusion of suspected abscesses, as well as detection of unsuspected skeletal abnormalities (aseptic necrosis, osteomyelitis) and unsuspected femonal vein thrombosis that were the cause of the patients’ symptoms. CT has been shown to be excellent in enabling detection of small bowel disease and the complications of Crohn disease (1-13). The latter are typically extraluminal components of disease such as abscesses, phlegmon, and lymphadenopathy, which are at best inferred from findings on barium studies and are directly seen on CT scans. Focal fatty proliferation can be discovered as a palpable mass and can cause mass effect on barium studies. With CT, focal fatty proliferation can be identified and differentiated from previously mentioned complications that have similar findings at physical examination and on barium studies (3,7).
The usefulness of CT in the pediatnc patient with Cnohn disease has not been extensively evaluated. To our knowledge, there are only two available studies involving pediatric patients with Crohn disease. In a senies of 22 pediatric patients with small bowel disease and 110 control patients, Siegel et al found that identification and classification of small bowel disease were possible from analysis of bowel wall thickening, mesentenic masses, and penitoneah fat attenuation (14). Only seven patients
Radiology
a
497
with Cmohn disease were included in that series. In a second series reported by Riddlesberger, various examples of extraluminal complications were demonstrated in 10 patients with Crohn disease, but the abnormalities were not systematically meviewed (15). As in the adult patient, we found CT to be extremely useful in depicting complications of Crohn disease including abscesses, phlegmon, and focal fatty proliferation of the mesentemy in children. The presence and extension of fistulas were all well documented on these studies. The presence of mural disease is well seen, and, in agreement with the findings of Siegel et al (14), small bowel thickness in all our patients was 1 cm or less. Evaluation of the penianal disease, which is especially common in the pediatric group, is also clearly defined. We conclude that CT should be the initial study performed in the patient with known Cmohn disease with a changing pattern of clinical symptoms (eg, in-
creasing optimize
a
Radiology
pain or fever) management.
to
8.
Gore
RM,
for
We
secretarial
thank
Margaret
Stun-
9.
support.
Gore man
AJR RM, HL,
1.
tions
Onel SC, Rubesin SE, Bayless TM, Siegelman
Jones 55.
mognaphy
studies
vs barium
ly symptomatic
patient
ease. J Comput 11:1009-1016. 2.
Fishman
EK,
Siegelman disease:
AJR 3.
with
Assist
EK, to-
in the
acute-
Crohn
dis-
Tomogn
EJ, Jones
B, Bayless
CT evaluation
effect
on
patient
Fragen
DH,
Menine
Goldman
TM,
of Crohn’s
tions
Fishman
Beneventano
TC.
in Crohn disease. 1983; 7:819-824.
EK,
Kuhlman
JE,
Yousem
DM,
Cnohn
disease:
Fishman
at CT.
EK,
penirectal Radiology
Jones
and
D, Sottile
L, Redmond V. Computed
Cnohn’s
disease.
Am
P. Purow E, Megna tomography in
J Gastnoenterol
JM. of local
Radiol
1984;
CS, Kelley Crohn’s manifesta-
complications.
Castro-
77:914-920.
Rabinowitz
JG.
Granulomatous
findings bs’ ultrasonography tomography. Radiology
149:253-259. R, Dumoulin
signs
P, Vossen
of Crohn’s
P. et al.
J Beige
disease.
Radiol
1986; 69:151-155. 14.
perianal 167:331-
1985;
of
extraintestinal 1979;
Usewils CT
Rubin
HD, Melnyk Cooperative
perianal
HC,
1983; 13.
B.
1988;
Yeh
Sci
evaluation
Gastrointest
Study:
enterocolitis: and computed
Jones
334. Berliner
12.
M,
Dis
complications
GB, Watts National and
of complicaDig
Greenberg
enterology M,
detection
disease.
extraintestinal
Rankin ML Jr.
in ulcerindeterminate
Vogelzang RL, NeiValue of computed
tomography
Disease
management.
tomography Assist Tomogr D,
in the
Crohn’s disease. 9:143-148.
1987; 148:537-540.
findings 6.
and
Vogelzang
143:279-284. MI, TK.
of Crohn’s
30:701-709. Kerber CW,
DF,
and
1984;
Computed
1987;
B, Bayless TM, Siegelman S. Bladder involvement in Cnohn disease: role of CT in detection and evaluation. J Comput Assist Tomogn 1989; 13:90-93. 5.
10.
11. Wolf
SS.
Computed J Comput 4.
B, Fishman Computed
Kirby
CT findings
Cohen Tsang
tomography
References
CS,
HL.
granulomatous.
colitis.
Acknowledgment: gill
Marn
RL, Neiman
U
ative,
15.
Siegel
MJ,
bowel
disease
Evans
CT. Radiology Riddlesberger inflammatory Pediatr
Radiol
SJ. in
Balfe
children:
DM.
Small
diagnosis
with
1988; 169:127-130. MM Jr. CT of complicated bowel disease in children. 1985;
15:384-387.
1982;
77:548-553.
7.
498
abdominal patient
Goldberg HI, Cone RM, Margulis Moss AA, Baker EL. Computed phy in the evaluation of Crohn AJR 1983; 140:277-282.
AR, tomogradisease.
May
1991
A. Jabra,
MD
Elliot
a
K. Fishman,
Crohn Disease CT Evaluation’
colonic
wall
thickening
(range,
6-15 mm) (n = 15), and small bowel dilation (n = 5). Mesentenic abnormalities such as adenopathy and focal fatty proliferation were seen in 11 and 18 patients, respectively. Extraluminal complications were easily identified with CT. Abscesses were noted in seven patients, inflammatony
masses
in
four,
and
penirectal on penineal inflammation in 10. Fistulas were detected in four patients. The authors conclude that CT should be the initial imaging study performed in children with known Cnohn disease and a changing pattern of clinical symptoms. Index
terms:
70.262
a
diseases,
Children,
Intestines,
gastrointestinal
CT,
70.1211
a
tract,
Intestines,
1991;
T
A. Taylor,
MD
Pediatric
Patient:
clinical value of abdominal computed tomography (CT) in the evaluation of inflammatory boweb disease in adults has been proved by a number of authors (1-13). However, its usefulness in the pediatnic population has not been well demonstrated (14,15). We reviewed the CT examinations of 25 pediatric patients with known Crohn disease to determine the value of CT and betten define the spectrum of abnormalities identified with this disease. HE
PATIENTS The
AND
abdominal
CT
METHODS scans
records of 25 consecutive pathologically proved
were
reviewed.
ranged years).
The
from 10 to The diagnosis
time
of scanning
later
teen
with
patients
were
referred
because
ages
pain also
with had
Two
patients
or without a limp and
were
bowel
(average, 15.6 known at the
referred
Of
the
dominal
masses,
CT studies
and
in these
one
had
patients
time, 230 thickness 125
kV,
Systems, parameters
I
From
the
Institutions, 21205. quested ary
Department
Science, 600 Received November
17,
1991;
of Radiology
The
Johns
N Wolfe October 26;
accepted
print requests to A.A.J. ,. RSNA, 1991
St.
Ra-
Medical
Baltimore,
MD
4, 1990, revision revision received January
and
Hopkins
28.
Address
reJanure-
All and
patients 1,000
istened contrast approximately
agent 30 and
the examination. tamed if there
was
tion of distal administered used routinely
mL
in divided 90 minutes
Delayed scans inadequate
a
typical scan
beadmindoses prior
at to
were obopacifica-
small bowel. Intravenously contrast material was but was administered
Bowel
wall
not in
position, positions
thicker
sidered thickened, with a diameter considered (phlegmon) by
the
like areas drainable air without
than
and greaten
dilated. were
scesses
Bowel Bowel
pen-
were given of orally
15 mm.
with
the
although were used
as
3 mm
Inflammatory distinguished
lack
conwas
masses from ab-
of hypodense/cystic-
that indicate the pus. The presence associated mass
a sign
was
a small bowel than 2.5 cm
of infection
presence of of pockets was consid-
but
not
Soft-tissue tracts bowel communicates
of
abscess
through to other
one
section sections.
on were In the
traced penianal
on or
The
attenuation
is usually
somewhat
of fatty
was intnaabdisplacing prohifera-
higher
than
that
fat.
RESULTS
mAs, 125 kV, and 8-mm section on 4-second scan time, 310 mAs, and 8-mm section thickness, re-
spectively. tween 500 diological
Isehin, NJ) with of 3-second
10 and
obtained
needed.
of normal
formed to identify the extent and possible complications of suspected inflammatory bowel disease. All patients were examined on either Somatom DR3 on DRH scanner (Siemens Medical scanning
in the supine on decubitus
tion
diarrhea.
were
patient prone
bowel.
four
patients in whom the diagnosis had not been established by the time of scanning, all had history of abdominal pain, three had weight loss, two had palpable ab-
179:495-498
routinely
changes. Focal fatty proliferation seen as focal areas of increased dominal fat surrounding and
One paleg pain.
for evaluation
obstruction.
of between
were
from penine-
penirectal area, the presence of air on banurn within tracts was used to differentiate fistula formation from inflammatory
abdom-
fever. night
at intervals
Scans
fined on consecutive
abscesses
or changing
um
obtained to the
organs were considered fistulas, regardless of the presence of air on barium within these tracts, if they were clearly de-
of patients
suspected
patients. Scans were level of the diaphragm
formation. which the
21 patients and was in four patients. Nineknown Cnohn disease
with
five the
ered
medical
patients with Crohn disease
18 years was
of persistent
inal tient
and
in
documented
of small
70.262
Radiology
George
a
in the
Computed tomographic (CT) scans and medical records of 25 children (age range, 10-18 years) with pathologically proved Crohn disease were reviewed to better define the role of CT in the management of pediatric patients with Crohn disease. CT findings included small bowel thickening (range, 5-10 mm) (n = 20),
MD
Wall Thickening Dilation
and
Small
Segmental thickening
areas of bowel wall involving variable lengths of the terminal ileum were noted in 20 patients (Fig 1). Maximal thickness of bowel ranged from 5 to 10 mm (average, 8 mm). Two of these patients also showed focal wall thickening involving a few bowel loops of jejunum (average, 5 mm in thickness). Cobonic wall thickening of variable lengths was seen in 15 patients, with a range of 5-15 mm in maximal thickness (average, 9 mm) Fig 2). Small bowel dilation was present in five patients, two of whom had
495
Figure
1.
CT scan of a 10-year-old boy who with unexplained weight loss. CT enabled diagnosis of Cnohn disease by demonstrating a long segment of uniform wall thickening involving terminal ileum (anrows). Diagnosis was confirmed at endoscopic biopsy. presented
a.
b.
Figure
3.
CT scans
of a 13-year-old
girl with
Crohn
disease
who
had undergone
resection
of
an ileal stricture 19 days prior to scanning. The patient had fever and abdominal pain, and dihated small bowel was seen on plain nadiognaphs. (a) CT scan shows dilated small bowel loop with closely related low-attenuation mass with pockets of air, compatible with abscess (anrows). (b) Image obtained with the patient in the heft decubitus position at similar level as in
a helps
Figure
2.
Featureless
transverse
colon
confirm
findings.
Abscess
(arrows)
related
to anastomotic
leak
was
proved
at surgery.
with
diffuse wall 17-year-old
thickening (arrows) is seen in a boy with known Cnohn disease who was referred with a possible intraabdominal abscess. Note penicolic inflammatory changes.
clinical small bowel obstruction. The bevel of obstruction was correctly identified in both. Findings at CT, however, suggested that inflammatory stricture was the cause of obstruction in both; at operation one was found to have adhesions from prior surgery (6 months earlier) without intrinsic bowel disease. CT correctly enabled identification of nanrowing of the terminal ibeum that was the cause of small bowel dilation in a third patient who underwent elective surgery 3 weeks later. In the fourth patient, CT cleanly identified a bong terminal ileum stricture that was the cause of bowel dilation (Fig 1). In the fifth patient, focal dilation of a terminal ileal loop was noted in association with an adjacent abscess (anastomotic) at CT, and this was confirmed at surgery (Fig 3). A dilute appearance of the contrast material in the small bowel was noted in one patient with no evident dilation. This suggested partial small bowel obstruction. Ten days later, the patient underwent resection of a terminal ileum stricture and was reported to have mild bowel dilation proximal to
496
Radiology
#{149}
4. Figures
5.
4, 5. (4) CT scan of a 15-year-old boy with known Cnohn disease referred to rule out abdominal abscess. Targetlike appearance of bowel compatible with intussusception (probably ileoileal) is noted (black arrows). Focal low-attenuation area (white arrow) represents mesentenic fat. Finding resolved on repeat image obtained at a similar level following completion of scanning. (5) Focal fatty proliferation is seen on the night side of abdomen (anrows) in 17-year-old girl with known Cnohn disease.
the stricture. Transient ileoileal intussusception was noted in one patient (Fig 4). CT was the first imaging study to suggest the diagnosis of Cnohn disease in one patient who had presented with severe weight loss and occasionab abdominal pain and who was suspected clinically to have a lymphoma. CT showed a long, narrowed segment of terminal ibeum, with diffuse wall thickening measuring 10 mm and occasional mesenteric nodes measuring 5 mm on less. The diagnosis
of
Cmohn
disease
was
confirmed
Mesentenic Clusters ing
(Fig
or
measun-
present of
seen
in
focal in
18
absence
11
fatty
pro-
patients
of abdominal
phlegmon,
in the
four
inflammatory
mesenteny
were
noted
patients.
Abscesses
and
Abscesses seven patients
with
mesentery.
areas
were
changes
nodes
were
5). In the
abscess in
lymph
less
and
hiferation
fatty
the
or
patients,
surgery
in
of
1 cm
with CT in three other children suspected of having the disease. Findings in these children included diffuse thickening of the terminal ileum and/on colon, penirectal inflammation, phlegmon, abscess, and focal proliferation
Abnormalities
in
ileopsoas
Phlegmon
were seen on CT scans and were confirmed six.
Two
abscess
tients
had
tenor
abdominal
abscesses abscess.
left
quadrant
a bowel
had
6, 7).
one
One
anastomotic
abscess
an
Two
involving wall;
colostomy
lower
patients (Figs
in at pa-
the was
an-
a pen-
patient
had
a
associated leak
(Fig
May
1991
Figure
6.
mass. sound
and
CT scans
of an 1 1-year-old
Inflammatory
bowel
findings.
right
Figure
CT
psoas
7.
helped
abscess
CT
disease
scan
boy and
confirm
findings.
(arrowheads)
of
with
psoas are
a 13-year-old
girl
night
abscess
lower were
Thickening
quadrant suspected of
wall
of
pain
and
from
previous
terminal
a palpable iheum
ultra(arrows)
seen.
with
known Cnohn disease who presented with a limp and right lower quadrant and night leg pain. CT scan demonstrates wall thickening of terminal ileum with formation of a fistula to right ileopsoas muscle and abscess fonma-
Figure 9. CT scan of an 1 1-year-old girl with known Crohn disease and multiple draining penianal sinuses. Penianal fistuha (arrows) extending toward the bladder and right internal obturator muscle is seen. Images obtained at a lower level showed extension into night internal obturator muscle.
Figure
8. CT scan of 17-year-old history of subtotal colectomy and for Cnohn disease who presented A large interloop abscess is shown
girl with ileostomy with fever. (arrows).
tion.
3). Multiple abscesses were detected in one patient involving the lessen sac of the pemitoneal cavity, the root of mesentery, and the left lower quadrant (Fig 8). A penianal abscess was noted in one patient and was treated medically. Phlegmon on inflammatory
masses
four
patients.
right
lower
were
All quadrant
terminal
small
noted
were
in
in the
involving
bowel,
both. One contained air and was presumed patient underwent cal treatment.
located
the
cecum,
on
tiny pockets of infected. This successful medi-
Fistulas Fistulas
were
identified
in
four
pa-
multiple enterocutaneous fistuhas associated with an abscess involving the anterior abdominal wall, small bowel, and cohon. The second patient had multiple entemoentemic fistulas and a fistula from the terminal ileum to the right psoas muscle (Fig 7). The third patients.
tient
Volume
One
had
patient
an
179
Number
Penianal on Penirectal Inflammation Inflammatory changes in the penanal on peninectal area were noted in 10 patients, ranging from a single focal area of linearly increased attenuation to ill-defined bilaterally increased attenuation of penianal on perirectal fat. We reserved the diagnosis of penirectal or penianal fistuba to visualization of air on barium within a well-defined tract and included these with fistulas described in the previous section.
had
enterocutaneous
a
to the anterior abdominal wall along with a penirectal fistula. The fourth patient had multiple penianah fistulas to the skin and a fistula to the right internal obturator muscle (Fig 9).
fistula
2
DISCUSSION Information patients with and a changing symptoms
obtained with CT in known Crohn disease pattern of clinical has been shown to have a
significant
ment
effect
of adult
on
patients.
clinical
manage-
In a series
of
80 patients, Fishman et al showed that CT findings altered management decisions in nearly 30% of adult patients (2). These findings enabled detection of unsuspected abscesses or fistulas, exclusion of suspected abscesses, as well as detection of unsuspected skeletal abnormalities (aseptic necrosis, osteomyelitis) and unsuspected femonal vein thrombosis that were the cause of the patients’ symptoms. CT has been shown to be excellent in enabling detection of small bowel disease and the complications of Crohn disease (1-13). The latter are typically extraluminal components of disease such as abscesses, phlegmon, and lymphadenopathy, which are at best inferred from findings on barium studies and are directly seen on CT scans. Focal fatty proliferation can be discovered as a palpable mass and can cause mass effect on barium studies. With CT, focal fatty proliferation can be identified and differentiated from previously mentioned complications that have similar findings at physical examination and on barium studies (3,7).
The usefulness of CT in the pediatnc patient with Cnohn disease has not been extensively evaluated. To our knowledge, there are only two available studies involving pediatric patients with Crohn disease. In a senies of 22 pediatric patients with small bowel disease and 110 control patients, Siegel et al found that identification and classification of small bowel disease were possible from analysis of bowel wall thickening, mesentenic masses, and penitoneah fat attenuation (14). Only seven patients
Radiology
a
497
with Cmohn disease were included in that series. In a second series reported by Riddlesberger, various examples of extraluminal complications were demonstrated in 10 patients with Crohn disease, but the abnormalities were not systematically meviewed (15). As in the adult patient, we found CT to be extremely useful in depicting complications of Crohn disease including abscesses, phlegmon, and focal fatty proliferation of the mesentemy in children. The presence and extension of fistulas were all well documented on these studies. The presence of mural disease is well seen, and, in agreement with the findings of Siegel et al (14), small bowel thickness in all our patients was 1 cm or less. Evaluation of the penianal disease, which is especially common in the pediatric group, is also clearly defined. We conclude that CT should be the initial study performed in the patient with known Cmohn disease with a changing pattern of clinical symptoms (eg, in-
creasing optimize
a
Radiology
pain or fever) management.
to
8.
Gore
RM,
for
We
secretarial
thank
Margaret
Stun-
9.
support.
Gore man
AJR RM, HL,
1.
tions
Onel SC, Rubesin SE, Bayless TM, Siegelman
Jones 55.
mognaphy
studies
vs barium
ly symptomatic
patient
ease. J Comput 11:1009-1016. 2.
Fishman
EK,
Siegelman disease:
AJR 3.
with
Assist
EK, to-
in the
acute-
Crohn
dis-
Tomogn
EJ, Jones
B, Bayless
CT evaluation
effect
on
patient
Fragen
DH,
Menine
Goldman
TM,
of Crohn’s
tions
Fishman
Beneventano
TC.
in Crohn disease. 1983; 7:819-824.
EK,
Kuhlman
JE,
Yousem
DM,
Cnohn
disease:
Fishman
at CT.
EK,
penirectal Radiology
Jones
and
D, Sottile
L, Redmond V. Computed
Cnohn’s
disease.
Am
P. Purow E, Megna tomography in
J Gastnoenterol
JM. of local
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1984;
CS, Kelley Crohn’s manifesta-
complications.
Castro-
77:914-920.
Rabinowitz
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Granulomatous
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149:253-259. R, Dumoulin
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1985;
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extraintestinal 1979;
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Rubin
HD, Melnyk Cooperative
perianal
HC,
1983; 13.
B.
1988;
Yeh
Sci
evaluation
Gastrointest
Study:
enterocolitis: and computed
Jones
334. Berliner
12.
M,
Dis
complications
GB, Watts National and
of complicaDig
Greenberg
enterology M,
detection
disease.
extraintestinal
Rankin ML Jr.
in ulcerindeterminate
Vogelzang RL, NeiValue of computed
tomography
Disease
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