Inflammatory Bowel Disease

Crohn's disease may affect any part of the gastrointestinal tract, being the commonest site in the ileo-cecal region. In children, 20% of cases of Crohn's disease present with acute abdominal pain mimicking acute appendicitis (Hayes 2004). In fact, Crohn's disease may cause, though rarely, appendicitis. Parietal involvement is often discontinuous in Crohn's disease with intervals of apparently normal bowel, producing "skip lesions." Another specificity of the disease is the transmural inflammation extending through all layers of the intestinal wall and involving the mesentery (Valette et al. 2001). Imaging shows stratified transmural thickening of the bowel wall usually involving distal ileum, proximal colon, as well and mesentery. The transmural pattern of the disease is often associated with an irregular thickening of the submucosa and muscular layers. The involved segment appears rigid and shows no peristalsis on US (Fig. 1.73) (Hayes 2004). Differential diagnosis with an infectious ileocolitis may be more difficult than with acute appendici a b

Fig. 1.72a-d. Ileocecitis due to Yersinia enterocolitica infection. US images at the right iliac fossa show thick-walled bowel representing the ascending colon, terminal ileum and ileocecal valve. a Transverse US scan. There is mural stratification with a predominant bright submucosa in the colonic wall (arrows) and lymphoid hyperplasia of the mucosa in the terminal ileum (M). b Longitudinal US scan showing the "accordion" sign in the ascending colon. c Longitudinal US scan of the ileocecal valve shows a thickened valve (arrows). d Barium examination shows irregularity and nodularity of the terminal ileum

Fig. 1.72a-d. Ileocecitis due to Yersinia enterocolitica infection. US images at the right iliac fossa show thick-walled bowel representing the ascending colon, terminal ileum and ileocecal valve. a Transverse US scan. There is mural stratification with a predominant bright submucosa in the colonic wall (arrows) and lymphoid hyperplasia of the mucosa in the terminal ileum (M). b Longitudinal US scan showing the "accordion" sign in the ascending colon. c Longitudinal US scan of the ileocecal valve shows a thickened valve (arrows). d Barium examination shows irregularity and nodularity of the terminal ileum a c b d tis. Wall thickening is usually - though not always - transmural, with inflammation of the surrounding fatty tissue, which makes distinction from infectious ileocecitis easy (Puylaert 2001). Characteristic CT findings include terminal ileal thickening with or without a target sign enhancement pattern on contrast-enhanced CT, fibrofatty proliferation of the ileal mesentery, reactive adenopathy and perien-teric sinus tracts and mesentery abscesses in cases of severe extramural inflammation (Birnbaum and Jeffrey 1998). Crohn's disease may involve the appendix as distinct from acute obstructive or suppurative appendicitis. The appendix appears collapsed with transmural thickening of the wall, usually maintaining the stratification (three-ring pattern). Recommended treatment is conservative if the appropriate diagnosis can be established with noninvasive techniques.

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