Case of the Week: October 10-October 17, 2002

11 year old with 2 year history of vague abdominal pain,

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Case Details




A transmural granulomatous inflammatory disease that may affect any part of the GI tract from mouth to anus. 


  • incidence: 5-11/100,000 

  • age of onset: 

    • peak age of onset in 2nd and 3rd decades 

    • less than 5% present before 5 years of age : 

  • M = F 

  • whites > blacks 


1. Etiology

  • the exact etiology is unknown, infection or an autoimmune process has been suggested. Up to 10% of patients with Crohn's Disease have a family history of Irritable Bowel Disease. 

2. Anatomic Involvement

  • terminal ileum + variable segments of the colon (particularly the ascending colon) - 50-60% 

  • small bowel involvement only (most in terminal ileum) - 30-35% 

  • large bowel only - 10-15% 

  • the esophagus, stomach, or duodenum is involved in 30-40% of patients 


1. Gastrointestinal Manifestations

  • abdominal pain (75%) 

  • diarrhea (65%) 

  • weight loss (65%) 

  • fever (50%) 

  • growth retardation (25%) 

  • nausea/vomiting (25%) 

  • rectal bleeding (20%) 

  • perirectal disease (15%) 

  • extraintestinal manifestations (25%) 

2. Gastrointestinal Complications

1. Hemorrhage

2. Obstruction

3. Perforation

4. Abscess

5. Fistula Formation

6. Others

  • toxic megacolon (3.7%) - increases to 11% if disease confined to colon 

  • carcinoma - 20x greater risk than in general population

Imaging Studies:

1. Barium Enema

A. Single Contrast

  • to identify colonic fissures 

  • contraindicated in suspected cases of severe colitis 

B. Double Contrast (Air-Barium)

  • to define mucosal defects - narrowing, stenotic areas, cobblestoning, filling defects 

2. Upper GI Series with Small Bowel Follow-through

  • particularly to visualize the terminal ileum: 

  • cobblestone appearance 

  • deep ulcers 

  • fistula 

  • nodularity 

  • stenotic areas (string sign) 

  • thickened bowel wall 

3. Abdominal Ultrasound/CT

  • bowel wall thickening 

  • abscesses 

  • fistula

  • focal fat proliferation


1. Macroscopic

  • focal or segmental inflammation with skip areas of normal mucosa 

  • complications of inflammation: 

  • cobblestone pattern (ulceration with regeneration and hyperplasia) 

  • wall thickening with stricture formation 

  • fissures, sinuses, ulcerations, fistulas, phlegmon (inflammatory masses) 

  • matted adjacent loops of bowel 

2. Microscopic

A. Early Changes

  • superfical aphtoid lesions of mucosa overlying lymphoid follicles; granulomas 

B. Later changes

1. Transmural Enterocolitis

  • diagnostic with histopathology of intestinal lesions showing extensive infiltration with inflammatory cells 

  • lymphocytes, histiocytes, plasma cells found throughout the bowel wall but extensively in the submucosa 

  • collagen deposition within the submucosa leading to strictures +/- obstruction 

  • deep fissuring ulceration into the muscularis propria 

  • crypt abscesses and goblet cell depletion 

2. Granulomas

  • may be absent in 60-70% of biopsies 

Goals of Therapy:

  • therapy (pharmacolgic, nutritional, or surgery) is not curative 

  • no prophylactic role of therapy 

  • goal is to control symptoms, prevent complications, improve growth, and to induce remission during an acute episode by either pharmacologic, nutritional and/or surgical strategies 


  • Crohn's Disease at this time is a chronic incurable disease of the bowel marked by periods of exacerbation and remission (99% suffer at least one relapse) 

  • triggers of acute exacerbations are unknown but viral illnesses (EBV, adenovirus) may play a role 

  • unable to predict the extent and severity of the disease over time (except those with ileocolitis have greater morbidity) thus while morbidity is very high, mortality is essentially zero 

Correct answers by users

VCU Resident
Radiology Pediatrics
VCU Department of Pediatric Radiology Virginia Commonwealth University VCU Medical Center