Infectious, Inflammatory, and Ischemic Diseases of the Colon and Rectum

  • Richard M. Gore
  • Robert Silvers


Infectious, inflammatory, and ischemic diseases of the colon and rectum are very common causes of abdominal pain. Patients with these disorders often present with nonspecific signs and symptoms. As clinical and laboratory assessment cannot confidently identify a specific etiology in the majority of patients with acute abdominal pain, cross-sectional imaging is required. Computed tomography (CT) is the primary means of evaluating these patients because it nicely depicts pathologic changes in the colon wall, serosa, surrounding mesentery, and peritoneum. Ultrasound (US) is a readily available, real-time technique with reasonable accuracy that uses no ionizing radiation. CT provides fast assessment with high accuracy, optimal field of view, and good reproducibility. Magnetic resonance imaging (MRI) in patients with acute abdominal pain offers great clinical potential by virtue of providing a global imaging perspective, exquisite softtissue resolution, and high accuracy without using ionizing radiation.


Ulcerative Colitis Acute Appendicitis Ischemic Colitis Chronic Ulcerative Colitis Pseudomembranous Colitis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Bao J, Lopez JA, Huerta S (2013) Acute abdominal pain and abnormal CT findings. JAMA 310:848–849.PubMedCrossRefGoogle Scholar
  2. 2.
    Soyer P, Dohan A, Eveno C et al (2013) Pitfalls and mimickers at 64-section helical CT that cause negative appendectomy: an analysis from 1057 appendectomies. Clin Imaging 37:895–901.PubMedCrossRefGoogle Scholar
  3. 3.
    Sibileau E, Boulay-Coletta I, Jullès MC et al (2013) Appendicitis and diverticulitis of the colon: misleading forms. Diagn Interv Imaging 94:771–792.PubMedCrossRefGoogle Scholar
  4. 4.
    Shademan A, Tappouni RF (2013) Pitfalls in CT diagnosis of appendicitis: pictorial essay. J Med Imaging Radiat Oncol 57:329–336.PubMedCrossRefGoogle Scholar
  5. 5.
    Mariadason JG, Wang WN, Wallack MK et al (2012) Negative appendicectomy rate as a quality metric in the management of appendicitis: impact of computed tomography, Alvarado score and the definition of negative appendicectomy. Ann R Coll Surg Engl 94:395–401.PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Rosen MP, Ding A, Blake MA et al (2011) ACR Appropriateness Criteria® right lower quadrant pain—suspected appendicitis. J Am Coll Radio 8:749–755.CrossRefGoogle Scholar
  7. 7.
    Poletti PA, Platon A, De Perrot T et al (2011) Acute appendicitis: prospective evaluation of a diagnostic algorithm integrating ultrasound and low-dose CT to reduce the need of standard CT. Eur Radiol 21:2558–2566.PubMedCrossRefGoogle Scholar
  8. 8.
    van Randen A, Laméris W, van Es HW et al (2011) A comparison of the accuracy of ultrasound and computed tomography in common diagnoses causing acute abdominal pain. Eur Radiol 21:1535–1545.PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Kim HC, Yang DM, Kim SW et al (2012) Reassessment of CT images to improve diagnostic accuracy in patients with suspected acute appendicitis and an equivocal preoperative CT interpretation. Eur Radiol 22:1178–1185.PubMedCrossRefGoogle Scholar
  10. 10.
    Lai V, Chan WC, Lau HY et al (2012) Diagnostic power of various computed tomography signs in diagnosing acute appendicitis. Clin Imaging 36:29–34.PubMedCrossRefGoogle Scholar
  11. 11.
    Pooler BD, Lawrence EM, Pickhardt PJ (2012) Alternative diagnoses to suspected appendicitis at CT. Radiology 265:733–742.PubMedCrossRefGoogle Scholar
  12. 12.
    Nelson DW, Causey MW, Porta CR et al (2013) Examining the relevance of the physician’s clinical assessment and the reliance on computed tomography in diagnosing acute appendicitis. Am J Surg 205:452–456.PubMedCrossRefGoogle Scholar
  13. 13.
    Moteki T, Ohya N, Horikoshi H (2011) Evaluation of the maximum depth of intraluminal appendiceal fluid to diagnose appendicitis with a 64-detector row CT scanner. J Comput Assist Tomogr 35:703–710.PubMedCrossRefGoogle Scholar
  14. 14.
    Purysko AS, Remer EM, Filho HM et al (2011) Beyond appendicitis: common and uncommon gastrointestinal causes of right lower quadrant abdominal pain at multidetector CT. Radiographics 31:927–947.PubMedCrossRefGoogle Scholar
  15. 15.
    Garcia M, Taylor G, Babcock L et al (2013) Computed tomography with intravenous contrast alone: the role of intra-abdominal fat on the ability to visualize the normal appendix in children. Acad Emerg Med 20:795–800.PubMedCrossRefGoogle Scholar
  16. 16.
    Blumfield E, Nayak G, Srinivasan R et al (2013) Ultrasound for differentiation between perforated and nonperforated appendicitis in pediatric patients. AJR Am J Roentgenol 200:957–962.PubMedCrossRefGoogle Scholar
  17. 17.
    Herliczek TW, Swenson DW, Mayo-Smith WW (2013) Utility of MRI after inconclusive ultrasound in pediatric patients with suspected appendicitis: retrospective review of 60 consecutive patients. AJR Am J Roentgenol 200:969–973.PubMedCrossRefGoogle Scholar
  18. 18.
    Koo HS, Kim HC, Yang DM et al (2013) Does computed tomography have any additional value after sonography in patients with suspected acute appendicitis? J Ultrasound Med 32:1397–1403.PubMedCrossRefGoogle Scholar
  19. 19.
    Chiu YH, Chen JD, Wang SH et al (2013) Whether intravenous contrast is necessary for CT diagnosis of acute appendicitis in adult ED patients? Acad Radiol 20:73–78.PubMedCrossRefGoogle Scholar
  20. 20.
    Anderson SW, Soto JA, Lucey BC et al (2009) Abdominal 64-MDCT for suspected appendicitis: the use of oral and IV contrast material versus IV contrast material only. AJR Am J Roentgenol 193:1282–1288.PubMedCrossRefGoogle Scholar
  21. 21.
    Spalluto LB, Woodfield CA, DeBenedectis CM et al (2012) MR imaging evaluation of abdominal pain during pregnancy: appendicitis and other nonobstetric causes. Radiographics 32:317–334.PubMedCrossRefGoogle Scholar
  22. 22.
    Beddy P, Keogan MT, Sala E et al (2010) Magnetic resonance imaging for the evaluation of acute abdominal pain in pregnancy. Semin Ultrasound CT MR 31:433–441.PubMedCrossRefGoogle Scholar
  23. 23.
    Chabanova E, Balslev I, Achiam M et al (2011) Unenhanced MR imaging in adults with clinically suspected acute appendicitis. Eur J Radiol 79:206–210.PubMedCrossRefGoogle Scholar
  24. 24.
    Leeuwenburgh MM, Wiarda BM, Jensch S et al (2013) Accuracy and interobserver agreement between MR-non-expert radiologists and MR-experts in reading MRI for suspected appendicitis. Eur J Radiol Oct 8 [Epub ahead of print]Google Scholar
  25. 25.
    Humes DJ, Solyamani-Dodaran M, Fleming KM et al (2009) A population-based study of perforated diverticular disease incidence and associated mortality. Gastroenterology 136:1198–1205.PubMedCrossRefGoogle Scholar
  26. 26.
    Mora Lopez L, Serra Pla S, Serra-Aracil X et al (2013) Application of a modified Neff classification to patients with uncomplicated diverticulitis. Colorectal Dis 15:1442–1447.PubMedCrossRefGoogle Scholar
  27. 27.
    Kruis W, Morgenstern J, Schanz S (2013) Appendicitis/diverticulitis: diagnostics and conservative treatment. Dig Dis 31:69–75.PubMedCrossRefGoogle Scholar
  28. 28.
    Sibileau E, Boulay-Coletta I, Jullès MC et al (2013) Appendicitis and diverticulitis of the colon: misleading forms. Diagn Interv Imaging 94:771–792.PubMedCrossRefGoogle Scholar
  29. 29.
    Longstreth GF, Iyer RL, Chu LH et al (2012) Acute diverticulitis: demographic, clinical and laboratory features associated with computed tomography findings in 741 patients. Aliment Pharmacol Ther 36:886–894.PubMedGoogle Scholar
  30. 30.
    Hill BC, Johnson SC, Owens EK et al (2010) CT scan for suspected acute abdominal process: impact of combinations of IV, oral, and rectal contrast. World J Surg 34:699–703.PubMedCrossRefGoogle Scholar
  31. 31.
    Ben Yaacoub I, Boulay-Coletta I, Jullès MC et al (2011) CT findings of misleading features of colonic diverticulitis. Insights Imaging 2:69–84.PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    Elmi A, Hedgire SS, Pargaonkar V et al (2013) Is early colonoscopy beneficial in patients with CT-diagnosed diverticulitis? AJR Am J Roentgenol 200:1269–1274.PubMedCrossRefGoogle Scholar
  33. 33.
    Wilkins T, Embry K, George R (2013) Diagnosis and management of acute diverticulitis. Am Fam Physician 87:612–620.PubMedGoogle Scholar
  34. 34.
    Öistämö E, Hjern F, Blomqvist L et al (2013) Cancer and diverticulitis of the sigmoid colon. Differentiation with computed tomography versus magnetic resonance imaging: preliminary experiences. Acta Radiol 54:237–241.PubMedCrossRefGoogle Scholar
  35. 35.
    Mutter D, Marescaux J (2013) Appendicitis/diverticulitis: minimally invasive surgery. Dig Dis 31:76–82.PubMedCrossRefGoogle Scholar
  36. 36.
    Mazzei MA, Cioffi Squitieri N, Guerrini S et al (2013) Sigmoid diverticulitis: US findings. Crit Ultrasound J 5(Suppl1):S5. doi: 10.1186/2036-7902-5-S1-S5Google Scholar
  37. 37.
    Puylaert JB (2012) Ultrasound of colon diverticulitis. Dig Dis 30:56–59.PubMedCrossRefGoogle Scholar
  38. 38.
    Hwang JA, Kim SM, Song HJ et al (2013) Differential diagnosis of left-sided abdominal pain: primary epiploic appendagitis vs colonic diverticulitis. World J Gastroenterol 19:6842–6848.PubMedCentralPubMedCrossRefGoogle Scholar
  39. 39.
    Mollà E, Ripollés T, Martínez MJ et al (1998) Primary epiploic appendagitis: US and CT findings. Eur Radiol 8:435–440.PubMedCrossRefGoogle Scholar
  40. 40.
    Bunni J, Corrigan A, Jacob K et al (2010) Epiploic appendagitis: a case report highlighting correlation between clinical features, computed tomography images and laparoscopic findings. Int J Surg 8:401–403.PubMedCrossRefGoogle Scholar
  41. 41.
    Singh AK, Gervais DA, Hahn PF et al (2005) Acute epiploic appendagitis and its mimics. Radiographics 25:1521–1534.PubMedCrossRefGoogle Scholar
  42. 42.
    Schnedl WJ, Krause R, Wallner-Liebmann SJ et al (2012) Primary epiploic appendagitis and successful outpatient management. Med Sci Monit 18:CS48–51.PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Chen JH, Wu CC, Wu PH (2011) Epiploic appendagitis: an uncommon and easily misdiagnosed disease. J Dig Dis 12:448–452.PubMedCrossRefGoogle Scholar
  44. 44.
    Sasmal PK, Tantia O, Patle N et al (2010) Omental torsion and infarction: a diagnostic dilemma and its laparoscopic management. J Laparoendosc Adv Surg Tech A 20:225–229.PubMedCrossRefGoogle Scholar
  45. 45.
    Wertheimer J, Galloy MA, Régent D et al (2013) Radiological, clinical and histological correlations in a right segmental omental infarction due to primary torsion in a child. Diagn Interv Imaging doi:pii: S2211-5684(13)00198-8. 10.1016/j.diii. 2013.05.009 [Epub ahead of print]Google Scholar
  46. 46.
    Lubner MG, Simard ML, Peterson CM et al (2013) Emergent and nonemergent nonbowel torsion: spectrum of imaging and clinical findings. Radiographics 33:155–173.PubMedCrossRefGoogle Scholar
  47. 47.
    McClure MJ, Khalili K, Sarrazin J et al (2001) Radiological features of epiploic appendagitis and segmental omental infarction. Clin Radiol 56:819–827.PubMedCrossRefGoogle Scholar
  48. 48.
    Kim J, Kim Y, Cho OK et al (2004) Omental torsion: CT features. Abdom Imaging 29:502–504.PubMedGoogle Scholar
  49. 49.
    Singh AK, Gervais DA, Lee P et al (2006) Omental infarct: CT imaging features. Abdom Imaging 31:549–554.PubMedCrossRefGoogle Scholar
  50. 50.
    Paterno F, McGillicuddy EA, Schuster KM et al (2010) Ischemic colitis: risk factors for eventual surgery. Am J Surg 200:646–650.PubMedCrossRefGoogle Scholar
  51. 51.
    Gore RM, Thakrar KH, Mehta UK et al (2008) Imaging in intestinal ischemic disorders. Clin Gastroenterol Hepatol 6:849–858.PubMedCrossRefGoogle Scholar
  52. 52.
    Gore RM, Yaghmai V, Thakrar KH et al (2008) Imaging in intestinal ischemic disorders. Radiol Clin North Am 46:845–875.PubMedCrossRefGoogle Scholar
  53. 53.
    Romano S, Romano L, Grassi R (2007) Multidetector row computed tomography findings from ischemia to infarction of the large bowel. Eur J Radiol 61:433–441.PubMedCrossRefGoogle Scholar
  54. 54.
    Moszkowicz D, Mariani A, Trésallet C et al (2013) Ischemic colitis: the ABCs of diagnosis and surgical management. J Visc Surg 150:19–28.PubMedCrossRefGoogle Scholar
  55. 55.
    Mazzei MA, Guerrini S, Cioffi Squitieri N et al (2013) Magnetic resonance imaging: is there a role in clinical management for acute ischemic colitis? World J Gastroenterol 19:1256–1263.PubMedCentralPubMedCrossRefGoogle Scholar
  56. 56.
    Reginelli A, Genovese E, Cappabianca S et al (2013) Intestinal Ischemia: US-CT findings correlations. Crit Ultrasound J 5(Suppl 1):S7.CrossRefGoogle Scholar
  57. 57.
    Gore RM, Laufer I, Berlin JW (2008) Ulcerative and granulomatous colitis: idiopathic inflammatory bowel disease. In: Gore RM, Levine MS (Eds) Textbook of Gastrointestinal Radiology, 3rd ed. Elsevier, Philadelphia, pp 1071–1108.CrossRefGoogle Scholar
  58. 58.
    Norsa AH, Tonolini M, Ippolito S et al (2013) Water enema multidetector CT technique and imaging of diverticulitis and chronic inflammatory bowel diseases. Insights Imaging 4:309–320.PubMedCentralPubMedCrossRefGoogle Scholar
  59. 59.
    Strobel D, Goertz RS, Bernatik T (2011) Diagnostics in inflammatory bowel disease: ultrasound. World J Gastroenterol 17:3192–3197.PubMedCentralPubMedGoogle Scholar
  60. 60.
    Patel B, Mottola J, Sahni VA et al (2012) MDCT assessment of ulcerative colitis: radiologic analysis with clinical, endoscopic, and pathologic correlation. Abdom Imaging 37:61–69.PubMedCrossRefGoogle Scholar
  61. 61.
    da Luz Moreira A, Vogel JD, Baker M et al (2009) Does CT influence the decision to perform colectomy in patients with severe ulcerative colitis? J Gastrointest Surg 13:504–507.PubMedCrossRefGoogle Scholar
  62. 62.
    Thoeni RF, Cello JP (2006) CT imaging of colitis. Radiology 240:623–638.PubMedCrossRefGoogle Scholar
  63. 63.
    Horsthuis K, Bipat S, Bennink R, Stoker J (2008) Inflammatory bowel disease diagnosed with US, MR, scintigraphy, and CT: meta analysis of prospective studies. Radiology 247:64–79.PubMedCrossRefGoogle Scholar
  64. 64.
    Ordas I, Rimola J, Rodriguez S et al (2012) Imaging of the colon in inflammatory bowel disease: ready for prime time? Curr Drug Targets 13:1252–1260.PubMedCrossRefGoogle Scholar
  65. 65.
    Perlman SB, Hall BS, Reichelderfer M (2013) PET/CT imaging of inflammatory bowel disease. Semin Nucl Med 43:420–426.PubMedCrossRefGoogle Scholar
  66. 66.
    Hristova L, Soyer P, Hoeffel C et al (2013) Colorectal cancer in inflammatory bowel diseases: CT features with pathological correlation. Abdom Imaging 38:421–435.PubMedCrossRefGoogle Scholar
  67. 67.
    Horton KM, Corl FM, Fishman EK (2000) CT evaluation of the colon: inflammatory disease. Radiographics 20:399–418.PubMedCrossRefGoogle Scholar
  68. 68.
    Langhorst J, Kühle CA, Ajaj W et al (2007) MR colonography without bowel purgation for the assessment of inflammatory bowel diseases: diagnostic accuracy and patient acceptance. Inflamm Bowel Dis 13:1001–1008.PubMedCrossRefGoogle Scholar
  69. 69.
    Ajaj WM, Lauenstein TC, Pelster G et al (2005) Magnetic resonance colonography for the detection of inflammatory diseases of the large bowel: quantifying the inflammatory activity. Gut 54:257–263.PubMedCentralPubMedCrossRefGoogle Scholar
  70. 70.
    Horsthuis K, Bipat S, Stokkers PC, Stoker J (2009) Magnetic resonance imaging for evaluation of disease activity in Crohn’s disease: a systematic review. Eur Radiol 19:1450–1460.PubMedCrossRefGoogle Scholar
  71. 71.
    Furukawa A, Saotome T, Yamasaki M et al (2004) Cross-sectional imaging in Crohn disease. Radiographics 24:689–702.PubMedCrossRefGoogle Scholar
  72. 72.
    Rimola J, Rodríguez S, García Bosch O et al (2009) Magnetic resonance for assessment of disease activity and severity in Crohn disease. Gut 58:1113–1120.PubMedCrossRefGoogle Scholar
  73. 73.
    Hammer MR, Podberesky DJ, Dillman JR (2013) Multidetector computed tomographic and magnetic resonance enterography in children: state of the art. Radiol Clin North Am 51:615–636.PubMedCrossRefGoogle Scholar
  74. 74.
    Gee MS, Harisinghani MG (2011) MRI in patients with inflammatory bowel disease. J Magn Reson Imaging 33:527–534.PubMedCentralPubMedCrossRefGoogle Scholar
  75. 75.
    Zijta F, Stoker J (2010) Magnetic resonance imaging of the colon (colonography): results. In: Stoker J (Ed) Magnetic resonance imaging of the gastrointestinal tract. Springer Verlag, Berlin, Heidelberg, pp 185–204.Google Scholar
  76. 76.
    Rimola J, Rodriguez S, Gracia-Bosch O et al (2009) Role of 3.0-T colonography in the evaluation of inflammatory bowel disease. Radiographics 29:701–719.PubMedCrossRefGoogle Scholar
  77. 77.
    Röttgen R, Herzog H, Lopez-Häninnen E, Felix R (2006) Bowel wall enhancement in magnetic resonance colonography for assessing activity in Crohn’s disease. Clin Imaging 30:27–31.PubMedCrossRefGoogle Scholar
  78. 78.
    Hammer MR, Podberesky DJ, Dillman JR (2013) Multidetector computed tomographic and magnetic resonance enterography in children: state of the art. Radiol Clin North Am 51:615–636.PubMedCrossRefGoogle Scholar
  79. 79.
    Al-Hawary MM, Kaza RK, Platt JF (2013) CT enterography: concepts and advances in Crohn’s disease imaging. Radiol Clin North Am 51:1–16.PubMedCrossRefGoogle Scholar
  80. 80.
    Gee MS, Harisinghani MG (2011) MRI in patients with inflammatory bowel disease. J Magn Reson Imaging 33:527–534.PubMedCentralPubMedCrossRefGoogle Scholar
  81. 81.
    Regge D, Neri E, Turini F et al (2009) Role of CT colonography in inflammatory bowel disease. Eur J Radiol 69:404–408.PubMedCrossRefGoogle Scholar
  82. 82.
    Eaton SR, Mazuski JE (2013) Overview of severe Clostridium difficile infection. Crit Care Clin 29:827–839.PubMedCrossRefGoogle Scholar
  83. 83.
    Lee JH, Lim GY, Im SA et al (2008) Gastrointestinal complications following hematopoietic stem cell transplantation in children. Korean J Radiol 9:449–457.PubMedCentralPubMedCrossRefGoogle Scholar
  84. 84.
    Gluecker TM, Williamson EE, Fletcher JG et al (2003) Diseases of the cecum: a CT pictorial review. Eur Radiol 13(Suppl4):L51–61.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2014

Authors and Affiliations

  • Richard M. Gore
    • 1
  • Robert Silvers
    • 1
  1. 1.Department of RadiologyUniversity of Chicago, North Shore University Health SystemEvanstonUSA

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