Eosinophilic enteritis presenting as acute abdomen: US features of two cases

Eosinophilic enteritis is a rare disease which may mimic acute abdominal emergency. Two sonographically documented cases are presented, which were subsequently proven at operation. Although the sonographic features of severe echolucent bowel wall thickening were not specific, combination with clinical and laboratory data may suggest the correct diagnosis.

[99mTc-HMPAO leukocyte scintigraphy in inflammatory intestinal disease]

Eighteen patients, suspected of active inflammatory bowel disease, were investigated. The 99mTc-HMPAO-leucocyte scintigraphy was evaluated using the results of the simultaneous clinical examinations, which included clinical and biochemical parameters, small intestinal series, colonoscopy and, in two patients, operation, as reference. In agreement with the clinical examinations, the leucocyte scintigraphy indicated active inflammatory bowel disease in 14 of the 18 patients. The leucocyte scintigraphy disclosed inflammation in all of the 19 bowel segments, in which the clinical examinations indicated active inflammation. In three patients with Crohn's disease the scintigraphy indicated more extensive inflammation. A correlation between the scintigraphic activity and the Crohn's Disease Activity Index was found. However, the leucocyte scintigraphy did not seem useful as a disease activity index. The 99mTc-HMPAO-leucocyte scintigraphy seemed especially useful in severely ill patients and in patients suspected of relapse.

Tc-99m albumin scintigraphy in the localization of protein loss in the gut

Scintigraphic localization of gastrointestinal protein loss has been recently reported. A noninvasive method for the localization of protein loss in the gut using Tc-99m labeled albumin seems encouraging and is described here. In six patients studied for protein-losing enteropathy, scintigraphic results of four were positive.

Three-dimensional transrectal ultrasound: preliminary patient evaluation

Transrectal ultrasound is uniquely useful in diagnosing and localizing the extent of lower colon and rectal disease. This paper reports the preliminary evaluation of three-dimensional intraluminal ultrasound imaging of normal and diseased rectal segments. The three-dimensional reconstructions were produced using a computerized PC based image analysis system which aligns ultrasound images to produce the three-dimensional images. A unique perspective for displaying both normal and pathologic anatomy is achieved using this new technology and the method has promising diagnostic and therapeutic potentials.

The use of indium 111 leukocyte scans in children with inflammatory bowel disease

Indium 111 leukocyte (WBC) scans have been used in the investigation of inflammatory bowel disease in recent years, but their use in children is not well described. We reviewed our experience with 281 indium 111 scans over an 8-year period in a total of 109 children with inflammatory bowel disease (Crohn's disease 70, ulcerative colitis 39). One hundred twenty-eight indium 111 scans done within 2 weeks of a radiographic contrast study, endoscopic examination, or surgical procedure were evaluated for diagnostic accuracy. Analysis showed that indium 111 scans were accurate when compared with conventional diagnostic tests and operative findings. This noninvasive imaging technique can play a useful role in the management of children with inflammatory bowel disease.

[Digitization of conventional x-ray films]

The diagnostic value of a digitization system for analogue films based on a charge-coupled-device (CCD) scanner with adjustable resolution of 2.5 or 5 lp/mm was assessed. Some 110 skeletal radiographs, 50 contrast studies, including 25 of patients with Crohn's disease, and 70 abdominal plain films before and after successful lithotripsy for renal stones were digitized. Receiver operating characteristic (ROC) studies showed improved detection of cortical and trabecular defects with contrast-optimized digitized films. Edge enhancement algorithms yielded no additional information. Inflammatory lesions of Crohn's disease were detected equally well by conventional films and digitized images. A statistically significant improvement (p less than 0.05) in the recognition of disintegration after lithotripsy was found for the processed digitized images. On the basis of this initial investigation, the digitization system tested appears to be useful for diagnostic purposes, especially when contrast resolution plays an important part, as with stone fragmentation or cortical defects.

[Diagnosis of activity in Crohn's disease and ulcerative colitis: scintigraphy with TC-99m glucoheptonate labelled leukocytes]

We evaluated a pre-tinning leukocyte labeling technique using Glucoheptonate-Sn lyophilized kit, in the detection of activity in 15 patients with clinical and laboratory signs of active inflammatory bowel disease (IBD). 25 patients, without gastrointestinal disease were the control group. In 7/8 patients with Crohn's disease and in 7/7 with Ulcerative Colitis the study was positive. The negative study corresponded to a patient who has only involvement of the duodenum, an area of difficult evaluation due to the high liver uptake. 3/25 patients of the control group had activity in the intestine at 4 hour images. In spite of the small group evaluated, we believe that this labeling technique is a promising procedure for evaluation of activity in patients with IBD (Sensitivity 93.3%, Specificity 88.0%).

[New trends in the diagnosis of Crohn's disease]

The Authors in reviewing the diagnostic techniques commonly used in Crohn's disease, focus their attention on Indium-111 scanning. The method seems useful, not only to point out the complications of the disease (stenosis, abscess, fistula) but especially for the follow up of patients after surgery with early diagnosis of a possible relapse.

Case report: tuberculous colitis mimicking Crohn's disease

Although intestinal tuberculosis is rare in this country, increasing numbers of patients are now being seen, particularly in the immigrant population. We present the history of a lady who had acute diarrhoea and in whom the radiological and endoscopic findings looked very similar to those seen in Crohn's disease. The radiological presentation included widespread aphthous ulceration, a feature that has rarely been reported in tuberculous colitis.

[Sonographic findings in Crohn's disease]

In 59 subjects (25 men and 34 women) with confirmed Crohn's disease 91 sonographic examinations were made, using dynamic records by means of a sector probe with a frequency of 3.5 and 5 MHz. The disease had persisted on average for 7.1 years. A positive sonographic finding was recorded in 68% of the examined subjects, incl. 42% where the finding on palpation of the abdominal cavity was negative. During examination the following typical findings were recorded: the symptom of a tubular structure with a thickened intestinal wall (frequency 77.5%), cockade symptom (65%), convolution of the loops (62.5%), congestion in the intestinal loops (10%) and abscess in the abdominal cavity (7.5%). Ultrasonography is a significant diagnostic method which can help in the differential diagnosis of resistance on palpation and in the follow up of the disease and the effect of therapy in patients with Crohn's disease.

Air enema revisited in assessment of colitis

Plain radiographs and air enema were performed in 37 patients with ulcerative colitis, 7 patients with proctitis, and 8 patients with Crohn's disease. The air enema was superior to plain radiographs for diagnosing colitis, and for delineating the extent of disease and the degree of mucosal involvement. The air enema is simple to perform and easy to evaluate as shown by an almost complete agreement between 2 observers.

Leucocyte scintigraphy to localize inflammatory activity in ulcerative colitis and Crohn's disease

The validity of using autologous leucocytes labelled with technetium -99m hexamethyl-propyleneamine-oxine (Tc-HMPAO) for scintigraphy in inflammatory bowel disease was evaluated in 12 patients with clinically active ulcerative colitis (UC) and 10 with Crohn's disease (CD). Colonoscopy and biopsy were used as reference. Scintigrams taken 1 h and 3 h after leucocyte reinjection were evaluated blindly by two independent observer groups. Full agreement was found in 11 of 12 UC patients when compared with colonoscopy but in only 3 of 10 CD patients. Segments with agreement in CD patients often showed neutrophilic granulocyte infiltration at biopsy. The judgements of clinicians and physiologists differed for only 2 of totally 70 UC segments but for 13 of 59 CD segments (kappa, 0.94 and 0.52). It is concluded that Tc-HMPAO scintigraphy might be an alternative to colonoscopy in the control of disease extent in UC. In CD patients the technique might warn about infections complications.

[Endoscopic sonography of the anorectum in inflammatory rectal diseases]

213 patients, classified in 3 groups, were examined in a prospective trial using endorectal ultrasound. 80 patients (group A) had no anorectal disease, the endorectal ultrasound showed normal structures of the anorectum and the perirectal tissue. 80 patients (group B) suffered from Crohn's disease, 30 of them had no clinical signs, the rest of this group (50 patients) felt pain in the anal/perianal region. 83 patients (group C) had perianal abscesses or fistulas, Crohn's disease could be excluded. In all 64 perianal fistulas and 66 perianal abscesses were diagnosed. The results of the rectal-proctological examination were compared with endorectal ultrasound. 100% of the perianal abscesses could be recognized using endosonography. The digital-proctological examination revealed only 57% of perianal abscesses and 48% of perianal fistulas; the supralevatory abscesses couldn't be detected proctologically at all. By endorectal ultrasonography we obtained useful informations about localization and extension of the inflammatory process. From a therapeutic and prognostic view the endorectal ultrasound is a simple, practicable and useful method to investigate perianal and anorectal diseases.

[Intestinal tuberculosis. The radiologic aspects of a disease not to be overlooked]

Intestinal tuberculosis still exists in the Western world, where it is usually underestimated and often mistaken for Crohn's ileo-colitis or cancer. The authors report the results of 4 cases of intestinal tuberculosis observed between 1983 and 1988. The cases are discussed in the light of the epidemiological data emerging from a review of recent medical literature. The danger is that the disease, which is endemic in Asian and African regions, may spread again in the Western world fostered by intensifying migrations of people and by the spreading of AIDS. According to recent experience, a negative chest film and Mantoux skin-test no longer have a negative predictive value for intestinal tuberculosis. In the radiological differentiation from Crohn's disease it is useful to keep in mind some topographic features of TBC: the systemic non-discontinuous involvement of both sides of ileocecal junctions; the unusual presence of ileal lesions, with no cecal lesions, and localizations below the transverse colon. Useful differential morphological criteria can be: star-like or transverse ring-shaped profile of isolated ulcerations, tubular ileocolic junction with retracted cecum and open valve, and uniformity of lesion in the comprehensive picture of the clinical case.

Evaluation of the small intestine by enteroclysis for Crohn's disease

We reviewed the records of 100 consecutive patients referred for enteroclysis by gastroenterologists because of suspected Crohn's disease of the small bowel to assess the clinical utility of the information obtained by this method. More than one-third of the patients in the study group had subtle lesions of early Crohn's disease, all patients who required surgery had severe disease by radiologic criteria, and none of the 34 patients clinically suspected of having Crohn's disease of the small bowel in whom the enteroclysis was normal developed Crohn's disease in two or more years of clinical follow-up. Enteroclysis provides gastroenterologists with accurate and detailed structural information relevant to the appropriate management of the disease and in our hands is a reliable test for excluding Crohn's disease of the small bowel.

Changes in splanchnic hemodynamics in inflammatory bowel disease. Non-invasive assessment by Doppler ultrasound flowmetry

An increase in splanchnic blood flow in both arterial and venous beds has been demonstrated in inflammatory bowel disease (IBD) by means of angiographic and scintigraphic studies. Doppler ultrasound (US) enables a non-invasive evaluation of splanchnic arterial inflow in the superior mesenteric artery (SMA) and of venous outflow in the portal vein. The aim of this study was to assess the role of Doppler US in detecting changes in the hemodynamic variables measured in patients with IBD. Forty-five patients with IBD were studied, including 22 with Crohn's disease (CD) and 23 with ulcerative colitis (UC), and compared with 45 matched normal subjects. The mean velocity of portal flow (Vmean) and the resistance index (RI) of the SMA were evaluated by Doppler US. In CD the Vmean of portal flow was significantly higher in patients with active disease than in controls (p less than 0.001) and patients with inactive disease (p less than 0.001). The RI of the SMA was significantly lower in active disease than in controls (p less than 0.005), but no significant difference was noted between active and inactive CD. Also in UC, the Vmean of portal flow was significantly higher in patients with active disease than in controls (p less than 0.01) and patients with inactive disease (p less than 0.05). The RI of the SMA was significantly lower in active disease than in controls (p less than 0.005) and in patients with inactive disease (p less than 0.005). Doppler follow-up studies were carried out in 10 patients after initiation of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Crohn's disease of the proximal small intestine: radiologic findings in 55 patients

Radiographs of the upper gastrointestinal tract and the small bowel of 55 patients were reviewed to identify changes associated with proximal enteric Crohn's disease. Five patients had gastroduodenitis, 18 duodenitis, 14 jejunitis and 18 jejunoileitis. Nineteen had previously undergone ileocecal resection. The terminal ileum was spared in 11 of the 36 patients who had not undergone ileocecal resection; of these, 9 had jejunoileitis, 1 jejunitis and 1 jejunitis secondary to colitis with colojejunal fistulas. In just over 80% of the patients with jejunal disease and all the patients with primary jejunal disease in whom the terminal ileum was spared, the condition developed before the patients reached 30 years of age. Duodenal disease was not associated with any particular age group, and duodenitis was invariably a "skip" lesion in patients with disease of the terminal ileum. The diagnosis of proximal enteric Crohn's disease depended on the presence of one or more characteristic lesions in the jejunum or terminal ileitis associated with a duodenal or jejunal abnormality. Ulceration occurred in 88% of the patients with a diseased terminal ileum but was less common in patients with a diseased duodenum (occurring in 43%), jejunum (in 53%) or proximal ileum (in 57%). Fistulas in the terminal ileum complicate ulceration in 10% to 26% of patients, and sinuses complicate ulceration slightly more often, but proximal enteric fistulas or sinuses occurred in only four (7%) of the patients described here.(ABSTRACT TRUNCATED AT 250 WORDS)

Monoclonal antigranulocyte antibody imaging in inflammatory bowel disease: a preliminary report

The 99Tcm-labelled antigranulocyte antibody BW250/183 has been used in the detection of intestinal inflammation in patients with active ulcerative colitis and Crohn's disease. Planar images were obtained up to 24 h after intravenous injection of the antibody. Eight out of nine patients with ulcerative colitis and six out of seven patients with Crohn's disease gave positive images. In 11 patients distribution of the inflammation was confirmed by barium studies, colonoscopy or surgery, whilst in two the antibody scan suggested more extensive disease than barium enema. None of the patients had any adverse reactions. Imaging with BW250/183 appears to give an accurate indication of the extent of inflammation in inflammatory bowel disease.

Tc HMPAO-labelled white cell scintigraphy in Cröhn's disease of the small bowel

99mTechnetium-hexamethyl propylene amine oxime (99mTc HMPAO) white cell scintigraphy is increasingly used in the investigation of inflammatory bowel disease. It is now an accepted technique in the assessment of patients with colitis, although its role in small bowel is less clear. A retrospective study was performed on patients with jejunal and ileal Cröhn's disease to assess the sensitivity, reliability and usefulness of this technique in small bowel disease. Tc HMPAO scintigraphy was compared with barium studies, clinical outcome and, where available, subsequent histology. Good correlation between this technique and barium studies was found in 14 out of 18 patients and additional information was provided in two patients. A single false positive scan highlights the importance of early scanning in avoiding errors of interpretation due to the normal hepatobiliary excretion of activity that occurs with this pharmaceutical.

99Tcm-labelled IgG scanning does not predict the distribution of intestinal inflammation in patients with inflammatory bowel disease

In order to assess the value of 99Tcm-labelled-immunoglobulin G(99Tcm-IgG) in the assessment of the activity and distribution of intestinal inflammation in patients with inflammatory bowel disease (IBD), 99Tcm-IgG scans were performed in 18 patients. Patients were divided clinically into two groups, those with (ten patients) and those without (eight patients), intestinal inflammation. Disease activity and distribution were assessed by 111In-oxine granulocyte scanning and/or histological extent of inflammation at endoscopy or surgery in all patients with IBD and most of those without intestinal inflammation. In the assessment of the presence or absence of inflammation, a sensitivity of 80% and specificity of 87% were achieved. However, when the localization of intestinal inflammation was evaluated, only five of eight true positive scans were concordant with the distribution of intestinal inflammation as determined by other methods. Thus, significant areas of inflammation were missed in five of ten patients with IBD (two false negative, three incorrect localization of inflammation). Although 99Tcm-IgG scanning appears to have moderate sensitivity and acceptable specificity in the detection of intestinal inflammation, it performs poorly in assessing the distribution of inflammation and is, therefore, of little value in the assessment of patients with suspected or proven IBD.

Value of endoscopic ultrasonography in the assessment of inflammatory bowel diseases

The value of EUS in the assessment of inflammatory bowel diseases was determined. EUS was useful for estimation of the histological changes of inflammatory bowel diseases. In ulcerative colitis, EUS findings were classified into five types, which correlated with the colonoscopic and histological findings. Studies in surgical cases and further prospective investigations are necessary, however, to determine whether EUS can contribute to the management of inflammatory bowel diseases.