Level: MRCP, FRCS, ABR, EDiR, FRCR, Radiology Level Junior +
The initial image demonstrates a plain abdominal radiograph. Superficially the radiograph appears normal with no evidence of abnormal calcification projected over the kidneys, gallbladder or pelvis. There is no overt bowel dilatation to suggest obstruction. No free air is appreciated. Subtle abnormality is, however, demonstrable in the left flank where the descending colon extending into the sigmoid demonstrates thickening, characterised by indentations of the lateral and to a lesser degree the medial surface of the bowel. The properitoneal fat plane, the thin lateral lucency, which differentiates the descending colon from the left abdominal paracolic gutter is widened supporting bowel wall thickening in this region. These findings are suggestive of an early colitis.
The following radiograph performed 3 days later demonstrates that there is now dilatation of the distal descending colon and sigmoid. The thickening of the distal sigmoid and of the proximal aspect of the sigmoid can be noted overlapping over the left iliac wing. There is now more significant proximal small bowel dilatation which is likely due to ileus.
These appearances are suggestive of a colitis. Initial mural thickening, often termed "thumbprinting" as in this case, reflect bowel wall oedema. It is then followed by bowel atony and gaseous distended ileus. Many similar etiologies of colitis can result in similar appearance including inflammatory bowel disease (usually ulcerative colitis), but also pseudomembranous or other infectious colitis. In this case the disease process was due to ulcerative colitis and serial daily imaging was performed to assess the possibility of a toxic megacolon. Maximal dilatation was at the 3 day film. Toxic megacolon, typically affects the transverse colon which may develop pronounced lung printing, loss of haustration and formation of inflammatory polyps. As the colon distends to 6 cm in greater there is a perforation is significantly increased. Perforation clearly is associated with high morbidity and mortality.
The following radiograph performed 3 days later demonstrates that there is now dilatation of the distal descending colon and sigmoid. The thickening of the distal sigmoid and of the proximal aspect of the sigmoid can be noted overlapping over the left iliac wing. There is now more significant proximal small bowel dilatation which is likely due to ileus.
These appearances are suggestive of a colitis. Initial mural thickening, often termed "thumbprinting" as in this case, reflect bowel wall oedema. It is then followed by bowel atony and gaseous distended ileus. Many similar etiologies of colitis can result in similar appearance including inflammatory bowel disease (usually ulcerative colitis), but also pseudomembranous or other infectious colitis. In this case the disease process was due to ulcerative colitis and serial daily imaging was performed to assess the possibility of a toxic megacolon. Maximal dilatation was at the 3 day film. Toxic megacolon, typically affects the transverse colon which may develop pronounced lung printing, loss of haustration and formation of inflammatory polyps. As the colon distends to 6 cm in greater there is a perforation is significantly increased. Perforation clearly is associated with high morbidity and mortality.
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