Answer
The findings on a barium enema examination vary with the stage and severity of disease (see the images below). The radiographic changes may involve the whole colon; when the disease is segmental, the left colon is usually involved. Rectal sparing is rare; it is thought to occur in 5% of cases. Skip lesions are unusual. The colon may appear narrow; such narrowing is often associated with incomplete filling caused by colonic spasm and irritability.
Double-contrast barium enema study shows changes of early disease. Note the granular mucosa.
Double-contrast barium enema studies show changes of early disease. Note the granular mucosa.
Double-contrast barium enema studies in a 44-year-old man known to have a long history of ulcerative colitis. Images show total colitis and extensive pseudopolyposis.
Double-contrast barium enema study shows pseudopolyposis of the descending colon.
Single-contrast enema study in a patient (same patient as in the previous image) with known ulcerative colitis in remission shows a benign stricture of the sigmoid colon.
Single-contrast enema study in a patient with total colitis shows mucosal ulcers with a variety of shapes, including collar-button ulcers, in which undermining of the ulcers occurs, and double-tracking ulcers, in which the ulcers are longitudinally orientated.
Double-contrast barium enema study shows total colitis. Note the granular mucosa in the cecum/ascending colon and multiple strictures in the transverse and descending colon in a patient with a more than a 20-year history of ulcerative colitis.
Postevacuation image obtained after a single-contrast barium enema study shows extensive mucosal ulceration resulting from Shigella colitis.
Double-contrast barium enema studies show granular mucosa associated with Campylobacter colitis.
The earliest mucosal changes are best depicted on a good-quality double-contrast barium enema study. Before ulcers appear, mucosal edema has a fine, granular appearance when the radiographs are seen en face. When ulcers first appear, the mucosa may have a fine, stippled appearance when seen en face. When mucosal ulcers become established and confluent, the mucosa is replaced by granulation tissue; on double-contrast enema examination, the characteristic appearance is coarsely granular.
In the acute and subacute phases of the disease, the ulcers may acquire a variety of shapes: collar-button ulcers occur with undermining of the ulcers; double-tracking ulcers are longitudinally orientated and are sometimes several centimeters long.
Symmetrical thickening of haustral folds may produce the appearance of thumbprinting. Pseudopolyps are a consequence of severe mucosal disease; they appear as multiple filling defects of varying sizes. These may develop rapidly, and they tend to persist, even when ulcerative colitis is quiescent. Occasionally, mucosal bridges are formed between pseudopolyps, which may be radiologically demonstrable.
With increased severity and duration of disease, the involved colon may become narrow, shortened, and loose in terms of its normal redundancy and haustral pattern. On lateral projections, rectal narrowing is easily recognizable as increased retrorectal space. When the entire colon is involved, changes in the terminal ileum may be seen (backwater ileitis); this involves 4-25 cm of the terminal ileum. The ileocecal valve appears patulous. The mucosa is granular and is usually associated with the absence of peristalsis.
Benign strictures occur in 1-11% of patients with long-standing disease. Such strictures are predominantly found in the left colon. Carcinomas that complicate ulcerative colitis are usually annular and may be difficult to differentiate from benign strictures. Often, however, malignant strictures are eccentric, with nodular narrowing and shouldered edges. Multiple carcinomas are not rare in the setting of ulcerative colitis. About 50% of these tumors are not detected on clinical or radiologic examination; instead, they are diagnosed at colectomy or autopsy.
The diagnostic signs of various colitides overlap considerably. Similar radiographic signs may be seen in cases of infective diarrhea, Crohn disease, ischemic colitis, drug-induced colitis, and amebic colitis. Infective diarrhea is occasionally the presenting feature of IBD.
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Double-contrast barium enema study shows changes of early disease. Note the granular mucosa.
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Double-contrast barium enema studies show changes of early disease. Note the granular mucosa.
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Double-contrast barium enema studies in a 44-year-old man known to have a long history of ulcerative colitis. Images show total colitis and extensive pseudopolyposis.
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Plain abdominal radiograph in a patient (same as in the previous image) who presented with an acute exacerbation of his symptoms. Image shows thumbprinting in the region of the splenic flexure of the colon.
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Plain abdominal radiograph obtained 2 days later in the same patient as in the previous image shows distention of the transverse colon associated with mucosal edema. The maximum transverse diameter of the transverse colon is 7.5 cm. The patient was treated for toxic megacolon.
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A 22-year-old man presented with abdominal pain, passage of blood and mucus per rectum, abdominal distention, fever, and disorientation. Findings from sigmoidoscopy confirmed ulcerative colitis. Abdominal radiographs obtained 2 days apart show mucosal edema and worsening of the distention in the transverse colon. The patient's clinical condition deteriorated over the next 36 hours despite steroid and antibiotic therapy, and the patient had to undergo total colectomy and ileostomy.
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Plain abdominal radiograph in a patient with known ulcerative colitis who presented with abdominal pain, peritonism, and leukocytosis. At surgery, a perforated toxic megacolon superimposed on ulcerative colitis was confirmed.
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Increased postrectal space is a known feature of ulcerative colitis.
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Plain abdominal radiograph on a patient with known ulcerative colitis who presented with an acute exacerbation of his symptoms. Image shows thumbprinting in the region of the splenic flexure of the colon.
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Double-contrast barium enema study shows pseudopolyposis of the descending colon.
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Single-contrast enema study in a patient (same patient as in the previous image) with known ulcerative colitis in remission shows a benign stricture of the sigmoid colon.
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Plain abdominal radiograph in a 26-year-old with a 10-year history of ulcerative colitis shows a long stricture/spasm of the ascending colon/cecum. Note the pseudopolyposis in the descending colon.
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Single-contrast enema study in a patient with total colitis shows mucosal ulcers with a variety of shapes, including collar-button ulcers, in which undermining of the ulcers occurs, and double-tracking ulcers, in which the ulcers are longitudinally orientated.
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Double-contrast barium enema study shows total colitis. Note the granular mucosa in the cecum/ascending colon and multiple strictures in the transverse and descending colon in a patient with a more than a 20-year history of ulcerative colitis.
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Single-contrast barium enema study shows burnt-out ulcerative colitis.
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Scan obtained with technetium-99m hexamethylpropylamine oxime (HMPAO)–labeled WBCs in a patient with active colitis involving the transverse and descending colon.
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Intravenous urogram shows features of ankylosing spondylitis.
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Lateral radiograph of the lumbar spine shows a bamboo spine.
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Single-contrast barium enema study in a patient with Shigella colitis.
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Postevacuation image obtained after a single-contrast barium enema study shows extensive mucosal ulceration resulting from Shigella colitis.
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Double-contrast barium enema studies show granular mucosa associated with Campylobacter colitis.
