Crohn disease

Case contributed by Dr Bruno Di Muzio


Abdominal pain. Previous ileectomy/bowel obstruction.

Patient Data

Age: 30 years
Gender: Female

Abdominal radiographs

Supine and erect projections. Dilated small loops with air-fluid levels within the central portion of the abdomen are suggestive of bowel obstruction. Moderate fecal loading within the rectum is noted. There are no signs of pneumoperitoneum. The pleural bases are clear. 


CT Abdomen and pelvis

Transmural thickening and enhancement of the distal ileum. Hyperemia in the supplying mesentery and minor stranding in the surrounding fat. Marked dilatation of proximal small bowel, caliber up to 4.2 cm, with multiple air-fluid levels. Small bowel feces sign distally and dilated segment. Transition point at the right iliac fossa, at the abnormally thickened segment of distal ileum. Small amount of free fluid in the peritoneal cavity, but no free gas. Multiple prominent lymph nodes in the small bowel mesentery. The large bowel has unremarkable imaging appearances. The liver, gallbladder, pancreas, adrenal glands, spleen, and kidneys have normal appearances. The lungs and pleural bases are clear. No suspicious bone lesions.

Conclusion: Distal ileitis consistent with Crohn's disease. Mechanical small bowel obstruction with transition point in the distal ileum at the right iliac fossa. Morphological abnormality of small bowel loop in this location favor inflammatory stricture over adhesion as the cause of obstruction.


MRI Enterography

Extending to the ileocecal junction, there is a 2.5 cm segment of mildly thickened and moderately hyperenhancing terminal ileal disease. No upstream dilatation. The preceding 7 cm of terminal ileum is mildly involved. Proximal to this, there is a second focal 2.5 cm segment which is moderately thickened and moderately hyperenhancing. No upstream dilatation. No small bowel obstruction, fistula or mesenteric collection. Tiny liver cysts. The background liver parenchyma appears unremarkable. Normal gallbladder, spleen, pancreas and adrenals. No suspicious osseous lesion.

Conclusion: Two focal segments of moderate active inflammation in the distal ileum, at the ileocecal junction and distal terminal ileum at 10 cm. No Crohns related complications. Appearances have mildly improved compared to recent CT.


US small bowel

Colon: There was no evidence of active inflammation in the proximal colon with a maximal wall thickness of 1.6mm and no hyperemia on Doppler US.

Small bowel: There was evidence of widespread inflammatory and stricturing Crohn's disease - at the ICV and distal terminal ileum, there was evidence of mild to moderate-severity inflammation (maximal wall thickness 4.7mm, positive SMI detection). A further segment of stricturing small bowel was seen in the terminal ileum over a 4-5cm segment with active inflammation and pre-stenotic dilatation (luminal diameter of 2.9cm). Active inflammation in the jejunum was seen with absent peristalsis and active inflammation (wall thickness 2.8mm).

Other: There were widespread mesenteric hyperechogenicity and lymphadenopathy.

CONCLUSION: Stricturing (ileal) disease present with active inflammation in both the ileum and jejunum. 

Case Discussion

This case illustrates a patient with known Crohn disease with a multimodality approach including MRI and US. 

This patient was managed with step-up therapy with biologic therapy and close monitoring.

Special thanks to Professor Robert Gibson for the help with the ultrasound images. 

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Case information

rID: 57225
Published: 22nd Feb 2018
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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