Learning Radiology xray montage

Ulcerative Colitis



    • Predominantly mucosal disease, possible auto-immune producing crypt abscesses
    • Usual age at onset is 20-40; another peak at 60-70
    • Equal male:female ratio 


    • Recurrent episodes of bloody diarrhea
    • Electrolyte depletion
    • Abdominal pain
    • Fever
    • Periods of exacerbation and remission
    • Iritis, erythema nodosum, pyoderma gangrenosum
    • Pericholangitis, chronic active hepatitis, sclerosing cholangitis, fatty liver
    • Spondylitis, peripheral arthritis, RA (10-20%)
    • Thrombotic complications 


    • Begins in rectum with retrograde progression
    • Rectosigmoid involved 95%; continuous involvement of left colon
    • Terminal ileum in 5-10% with backwash ileitis 

Imaging Manifestations 

  • Acute inflammatory stage
    • Spasm and irritability
    • Fine mucosal granularity=earliest finding on air-contrast BE
    • Spiculated, serrated bowel margins from tiny, multiple ulcerations
    • Collar button ulcers-from undermining (not specific for UC)
    • Double-tracking=long, longitudinal ulcers in submucosa    
    • Thumbprinting=from edema of wall
    • Pseudopolyps=scattered islands of edematous mucosa in a sea of ulcerated mucosa
    • Widening of the presacral space 
  • Subacute stage
    • Coarser, more granular mucosa
    • Inflammatory polyps= frondlike lesions of inflamed mucosa 
  • Chronic stage
    • Shortening of the colon=may be from spasm of longitudinal muscles or from irreversible fibrosis (lead-pipe colon)
    • Loss of haustrations on left side of colon
    • Postinflammatory polyps=filiform polyps=long worm-like lesions
    • Backwash ileitis (5-10%)=wide open ileocecal valve and dilated terminal ileum                                                                                      

Differential Diagnosis

    • Crohn’s disease–skip lesions: R colon; TI abnormal
    • Cathartic colon-loss of haustrations on Right side of colon; rectum spared
    • Familial polyposis–multiple polyps but no inflammatory changes
    • Radiation ileitis–should have other loops involved and appropriate hx
    • Lymphoma–should have tumor masses, less spasm
    • Amebiasis–cone-shaped cecum 

Extra-intestinal Manifestations

    • Fatty infiltration of the liver
    • Gallstones (28-34%)
    • Sclerosing cholangitis
    • Bile duct carcinoma
    • Amyloidosis
    • Urolithiasis:oxalate/uric acid stones
    • Migratory arthritis
    • Sacroiliitis and ankylosing spondylitis
    • Erythema nodosum and uveitis 


    • Toxic megacolon
    • Adenocarcinoma of the colon (1-16%)
        • Increased risk of developing ca of colon with long-standing (usually more than 25 years) ulcerative colitis
    • Higher incidence of multiple carcinomas
    • Usually involve distal transverse colon, descending colon and rectum
    • May present with smooth, tapering edges and resemble a benign stricture or may be annular constricting lesions
    • Colonic strictures (10%)
    • Smoothly tapering edges, usually single, commonly in sigmoid; must be differentiated from ca

 ulcerative colitis

Ulcerative Colitis: Barium enema examination demonstrates loss of haustral folds in the entire descending colon with small ulcerations suggested. The colon has a "lead-pipe" appearance. The distribution and appearance are suggestive of ulcerative colitis.