Perianal Region

0 12.6 Aphthous erosions in early phase of Crohn disease

0 12.6 Aphthous erosions in early phase of Crohn disease

Cecum Crohn Disease

Typical aphthous erosions in an otherwise normal surrounding (cecum).

b Aphthous erosion in ascending colon.

Typical aphthous erosions in an otherwise normal surrounding (cecum).

b Aphthous erosion in ascending colon.

c Aphthae in the sigmoid colon. Other lesions were also nearby.

Hiperplasia Linfoide Reto Sigm Ide

CT C

t5 c

|T| 12.7 Ulcers in Crohn disease

|T| 12.7 Ulcers in Crohn disease

Sigmoid Colon

c Oval ulcer at hepatic flexure.

Elongated ulcer in otherwise normal area of sigmoid colon.

Serpiginous ulcer, surrounding area quite normal (ascending colon).

c Oval ulcer at hepatic flexure.

Serpiginous Ulcer

d Appendix involvement: appendix edges e Long, vaguely serpiginous, parallel f Typical elongated ulcer in descending are completely swollen, two small ulcerations in descending colon; colon, extending toward upper sigmoid ulcers inside. typical CD finding. colon.

What Causes Lesions Segmoid Colon

g, h Recent diagnosis. g Recent ulcer, pitlike appearance (ascending colon). h Longitudinal ulcers and jagged mucosa; the totality of these changes enables diagnosis.

Solitary mini-ulcers in Crohn disease in ascending colon.

Analattack

Fig. 12.19 CD in terminal ileum with a "skip lesion," i. e., an eccentric ulcer, a relatively wide ileal segment and low or moderate inflammation of the rest of the ileal wall.

Fig. 12.19 CD in terminal ileum with a "skip lesion," i. e., an eccentric ulcer, a relatively wide ileal segment and low or moderate inflammation of the rest of the ileal wall.

Fig. 12.20 Scarring and discrete inflammatory change (vaguely aphthous), eccentric, i. e., "skip lesion" at the splenic flexure.

Fig. 12.21 Cobblestoning beginning to form in CD in the ascending colon.

Pseudopolyp Anus

Fig. 12.24 Relative stenosis and pseudopolyp bouquet in sigmoid colon. There is also a fistulous tract ending here, originating in the neoterminal ileum (diagnosed at resection, not endoscopically identifiable).

Fig. 12.22 Mixture of cobblestoning, pseudopolyp formation, and relative stenosis in the sigmoid colon related to CD. Several typical findings can appear simultaneously at varying locations in the intestine.

Fig. 12.23 Pancolitis Crohn with varied appearance: aphthous erythema, pseudopo-lyps, and small ulcers at the same time in ascending colon.

Fig. 12.24 Relative stenosis and pseudopolyp bouquet in sigmoid colon. There is also a fistulous tract ending here, originating in the neoterminal ileum (diagnosed at resection, not endoscopically identifiable).

Pseudopolypen

Fig. 12.25 Pronounced pseudopolyps and chronic inflammatory stenosis in sigmoid colon. Adjacent are aphthae and patchy inflammation focals typical of CD.

H|

X

• *

1.

#

• .

V

Fig. 12.27 View into terminal ileum with pronounced ulcerations (finding largely unchanged one year later).

Fig. 12.25 Pronounced pseudopolyps and chronic inflammatory stenosis in sigmoid colon. Adjacent are aphthae and patchy inflammation focals typical of CD.

Fig. 12.26 Pronounced mucosal scarring after intense immune suppression

(steroids, azathioprine).

Fig. 12.27 View into terminal ileum with pronounced ulcerations (finding largely unchanged one year later).

CT C

t5 c

TO U

CT O

Perianal Region

Fig. 12.29 Inspection of perianal region revealing extreme thickening of skin folds (chronic inflammation infiltration), an outward early warning sign of a massive CD attack in the anal canal.

Fig. 12.28 Invasion of anal canal and lower rectum with vaguely cobblestone appearance and fissurizing ulcerations as well as relative narrowing of anal canal (retro-flexed instrument).

Fig. 12.29 Inspection of perianal region revealing extreme thickening of skin folds (chronic inflammation infiltration), an outward early warning sign of a massive CD attack in the anal canal.

Fig. 12.30 View into the anal canal, tinged with blood, immediately after bougienage in anal canal attack with severe stenosis.

Examining the terminal ileum

An attack involving the ileocecal valve frequently results in stenosis caused by ulceration and scarring, which in turn often prevents passage of the colonoscope into the terminal ileum (012.8). If passage is possible, aphthous erosions or ulcers of various sizes (sometimes stenosing) are typically seen in the ileum. In the distal terminal ileum, changes can affect the entire circumference; in the proximal ileal segment, changes can also be focal (Fig. 12.27). Especially among younger patients, differential diagnosis should exclude lymphoid hyperplasia in its polypoid form.

Examination in patients of prior ileocecal resection

CD typically recurs in the anastomosed region with erosions, ulcerations, and increasing stenosis (012.9). It is usually found very close to the anastomosis in the neoterminal ileum. Deep ulcerations near the anastomosis can be precursors of a high-grade stricture. If the strictured area is less than 5-8 cm long, it is probably passable using balloon dilation (see Chapter 21). Rutgeerts et al. (6) have proposed that clinical relapse can be predicted by severity of inflammation as evaluated endoscopically. This view has not found wide acceptance since a postoperative routine evaluation of the anastomosis is not considered necessarily indicated, but instead is decided on a case-to-case basis, in particular, if there is doubt concerning indications for remission-maintaining drugs.

Examining the anal canal

The anal canal is sometimes affected by inflammatory infiltrates, ulcerations, and ultimately abscesses and scarring which can cause strictures (Figs. 12.28,12.29). The use of a small-caliber endoscope or even bougienage—either digitally or using an endoscope—is sometimes necessary (Fig. 12.30), under appropriate sedation, in order to enable examination of rectal segments. Attack in the rectum does not necessarily accompany anal attack, but is often present.

- [F] 12.8 Inflammatory atrophy and stenosis in the ileocecal region in CD

- [F] 12.8 Inflammatory atrophy and stenosis in the ileocecal region in CD

Sigmoid Colon

a and b Inflammatory atrophy of the cecum. a With wide, irregular ulcerations. b Atrophy of the cecum, viewed from ascending colon.

c Narrow, inflammatory atrophied ileocecal valve, cannot be intubated, initial flat ulcerations.

Images Sigmoid Colon

d and e Rigid ileocecal valve. d View into the valve. e Further in the terminal ileum: narrowing with semicircular ulcer, no longer readily passable, behind it again a broader segment partly with "colonlike" mucosa and vessels.

f Ileocecal valve with inflammation and atrophy, bleeding after unsuccessful intubation attempt.

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Responses

  • celendine bunce
    What is segmental cobblestoning, erosions in anal canal?
    3 years ago

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