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DONATO F. ALTOMARE
Coloproctological Unit
Department of Emergency and
Organ Transplantation
General Surgery and
Liver Transplantation Unit
University of Bari
Bari, Italy
SHAMIM ABSAR
Department of Colorectal Surgery
and Surgical Pathology
Stepping Hill Hospital
Trafford Healthcare Trust
Manchester, UK
L
UCIANO ALESSANDRONI
Department of Surgery
S. Camillo Hospital
Rome, Italy
GIAMPAOLO ANGELINI
Unit of Digestive Endoscopy
Policlinico “G.B. Rossi”
University of Verona
Verona, Italy
C
ORRADO R. ASTERIA
Department of Clinical Physiopathology
University of Florence
Florence, Italy
OMER AZIZ
Department of Biosurgery and
Surgical Technology
Imperial College London
St. Mary’s Hospital
London, UK
GORAN I. BARISIC
Institute for Digestive Diseases
Belgrade, Serbia-Montenegro
M
ICHELA BAROLLO
Department of General Surgery
University of Padua
Padua, Italy
D
AVID C.C. BARTOLO
Colorectal Unit
Western General Hospital
Edinburgh, Scotland, UK
P
IERO BAZZI
Unit of General Surgery
Policlinico S. Orsola-Malpighi
University of Bologna
Bologna, Italy
GABRIELE BAZZOCCHI
Unit of Visceral Disorder and
Autonomic Dysfunction
Montecatone Rehabilitation Institute
University of Bologna
Imola, Italy
L
UIGI BENINI
Department of Biomedical and
Surgical Sciences
Division of Gastroenterology
Policlinico G.B. Rossi
Verona, Italy
L
AURA BERNARDONI
Unit of Digestive Endoscopy
Policlinico “G.B. Rossi”
University of Verona
Verona, Italy
R
ICCARDO BERTOLINI
Department of Surgery
S. Camillo Hospital
Rome, Italy
FRANCESCO BIANCO
Department of Emergency Surgery
“S.G. Moscati” Hospital
Avellino, Italy
F
ABRIZIO BONFANTE
Department of Internal Medicine
Endoscopic Unit
Desenzano, Italy
Contributors
XIV
Contributors
FIORENZO BOTTI
2
nd
Unit of General Surgery
IRCCS Maggiore Hospital
Foundation, Mangiagalli e Regina Elena
Milan, Italy
M
ARIA LUISA B
RANDI
Departmentof Internal Medicine
University of Florence
Florence, Italy
P
IERO B
ROSOLO
Unit of Gastroenterology
Hospital “S. Bonifacio”
Verona, Italy
L
UCA CAMPANA
Section of Anal Physiology and
Ultrasound
Coloproctology Service
Department of Surgery
Regional Hospital
Treviso, Italy
M
ASSIMO CAMPIERI
Department of Internal Medicine and
Gastroenterology
University of Bologna
Bologna, Italy
ALBERTO CARRARA
2
nd
Unit of General Surgery
IRCCS Maggiore Hospital
Foundation Mangiagalli and Regina Elena
Milan, Italy
G
IUSEPPE CASULA
Department of General Surgery
University of Cagliari
Cagliari, Italy
GIANLUCA COLUCCI
Department of General Surgery
and Gastroenterology
University of Verona
Verona, Italy
M
ICHELE COMBERLATO
Gastroenterology Unit
Central Hospital
Bolzano Italy
E
TTORE CONTESSINI-AVESANI
2
nd
Unit of General Surgery
IRCCS Maggiore Hospital
Foundation Mangiagalli and Regina Elena
Milan, Italy
M
AURIZIO COSCIA
Unit of General Surgery
Policlinico S. Orsola-Malpighi
University of Bologna
Bologna, Italy
E
MANUELA
DAPUNT
Department of Surgery
Hospital of Brunico
Brunico, Italy
ANNIBALE D’ANNIBALE
Department of Surgery
Camposampiero Hospital
Padua, Italy
H
ANS DEJACO
Department of Surgery
Hospital of Brunico
Brunico, Italy
G
IAN GAETANO DELAINI
Department of General Surgery
and Gastroenterology
University of Verona
Verona, Italy
HERBERT M. DAL CORSO
Department of General Surgery
Santa Croce e Carle Hospital
Cuneo, Italy
F
OSCA DE IORIO
Department of Biomedical and
Surgical Sciences
Division of Gastroenterology
Policlinico G.B. Rossi
Verona, Italy
A
NNALISA DE LEONE
Unit of Gastroenterology and
Digestive Endoscopy
2
nd
University of Naples
Naples, Italy
RENATA D’INCÀ
Department of Gastroenterology
University of Padua
Padua, Italy
Contributors
XV
C
RESCENZO DI STAZIO
1
st
Division of General Surgery
2
nd
University of Naples
Naples, Italy
V
INCENZO D’ONOFRIO
Department of Gastroenterology
“S.G. Moscati” Hospital
Avellino, Italy
I
RIS DOTAN
Department of Gastroenterology and
Liver Diseases
Inflammatory Bowel Disease Service
Tel Aviv Sourasky Medical Center
Tel Aviv, Israel
ADAM DZIKI
Department of General and
Colorectal Surgery
Medical University
Lodz, Poland
ANDREA EDERLE
Unit of Gastroenterology
Hospital “S. Bonifacio”
Verona, Italy
I
LARIA
ESPOSITO
Unit of Gastroenterology and
Digestive Endoscopy
2
nd
University of Naples
Naples, Italy
ALBERTO FANTIN
Unit of Gastroenterology
Hospital “S. Bonifacio”
Verona, Italy
M
ONICA FONTANA
Department of General Surgery and
Gastroenterology
University of Verona
Verona, Italy
B
JØRN FORTLING
B-K Medical Engineer
Herlev, Denmark
ALESSANDRO FRANCHI
Department of Human Pathology
and Oncology
University of Florence
Florence, Italy
L
UCA FRULLONI
Department of Gastroenterology
Policlinico “G.B. Rossi”
University of Verona
Verona, Italy
S
USAN GALANDIUK
Section of Colon and Rectal Surgery
Department of Surgery
University of Louisville
School of Medicine
Louisville, USA
L
ORENZO GENTILINI
Unit of General Surgery
Policlinico S. Orsola-Malpighi
University of Bologna
Bologna, Italy
E
LISA GILARDONI
2
nd
Unit of General Surgery
IRCCS Maggiore Hospital
Foundation Mangiagalli and Regina Elena
Milan, Italy
PAOLO GIONCHETTI
Department of Internal Medicine and
Gastroenterology
University of Bologna
Bologna, Italy
V
ERONICA GIRARDI
Department of Radiology
Policlinico G.B. Rossi
Verona, Italy
M
ARIA C. GIUFFRIDA
Department of General Surgery
Santa Croce e Carle Hospital
Cuneo, Italy
ANTONIO GIULIANI
1
st
Division of Surgery
2
nd
University of Naples
Naples, Italy
I
LARIA GUADAGNI
1
st
Division of General Surgery
2
nd
University of Naples
Naples, Italy
ANKE GUTWENIGER
Department of Surgery
Hospital of Brunico
Brunico, Italy
XVI
Contributors
NAJIB HABOUBI
Department of Surgical Pathology
Trafford Healthcare Trust
Manchester, UK
Z
AMIR HALPERN
Department of Gastroenterology and
Liver Diseases
Tel Aviv Sourasky Medical Center
Tel Aviv, Israel
L
EIF H
ULTÉN
Department of Surgery
Colorectal Unit
Sahlgrenska University Hospital
Göteborg, Sweden
PAOLO INTURRI
Unit of Gastroenterology
Civil Hospital “S. Bonifacio”
Verona, Italy
S
IEGFRIED JESACHER
Department of Surgery
Hospital of Brunico
Brunico, Italy
Y
EHUDA KARIV
Unit of Colon and Rectal Surgery
Department of Surgery B
Tel Aviv Sourasky Medical Center
Tel Aviv, Israel
MIKE KEIGHLEY
Department of Surgery
Queen Elizabeth Hospital
Edgbaston, UK
A
NIL KESHAVA
Department of Colorectal Surgery
Western General Hospital
Edinburg, UK
ALFRED KÖNIGSRAINER
Department of General, Visceral and
Transplantation Surgery
Tübingen University Hospital
Tübingen, Germany
I
NGMAR KÖNIGSRAINER
Department of General, Visceral and
Transplantation Surgery
Tübingen University Hospital
Tübingen, Germany
Z
ORAN V. KRIVOKAPIC
Institute for Digestive Diseases
Belgrade, Serbia-Montenegro
M
ARINO LANDRA
Department of General Surgery
Santa Croce e Carle Hospital
Cuneo, Italy
RUTH LADURNER
Department of General, Visceral and
Transplantation Surgery
Tübingen University Hospital
Tübingen, Germany
SILVIO LAURETI
Unit of General Surgery
Policlinico S. Orsola-Malpighi
University of Bologna
Bologna, Italy
F
EDERICA LIPANJE
Department of Rehabilitation
Brunico Hospital
Brunico, Italy
B
ARBARA MAHLKNECHT
Department of Surgery
Hospital of Brunico
Brunico, Italy
MAURIZIO MAINENTE
Department of Surgery and
Gastroenterology
University of Verona
Verona, Italy
R
OBERTO MALAGÒ
Department of Radiology
Policlinico G.B. Rossi
Verona, Italy
R
ICCARDO MANFREDI
Department of Radiology
Policlinico G.B. Rossi
Verona, Italy
R
AIMUND MARGREITER
Department of General and
Transplantation Surgery
Medical University Innsbruck
Innsbruck, Austria
Contributors
XVII
H
ANSJORG MARSONER
Department of Surgery
Hospital of Brunico
Brunico, Italy
F
EDERICO MARTIN
Surgery Unit
Central Hospital
Bolzano, Italy
E
MILIO MORPURGO
Department of Surgery
Camposampiero Hospital
Padua, Italy
C
LAUDIA MORSELLI
Department of Internal Medicine and
Gastroenterology
University of Bologna
Bologna, Italy
G
ABRIELLA NESI
Department of Human Pathology and
Oncology
University of Florence
Florence, Italy
M
ONIKA NIEDERKOFLER
Department of Surgery
Hospital of Brunico
Brunico, Italy
F
ILIPPO NIFOSÌ
Department of General Surgery and
Gastroenterology
University of Verona
Verona, Italy
P
ATRICK O’CONNOLLY
Department of Surgical Pathology and
Gastrointestinal Surgery
Hope Hospital
Manchester, UK
BARBARA OREGGIA
II Unit of General Surgery
IRCCS Maggiore Hospital
Foundation, Mangiagalli e Regina Elena
Milan, Italy
T
OM ÖRESLAND
Department of Surgery
Colorectal Unit
Sahlgrenska University Hospital
Göteborg, Sweden
D
ANIELE ORTOLANI
Department of Surgery and
Gastroenterology
University of Verona
Verona, Italy
U
MBERTO PANDINI
Department of Surgery
Hospital of Brunico
Brunico, Italy
M
ARIO P
ESCATORI
Coloproctology Unit
Villa Flaminia Hospital
Rome, Italy
L
UCIA PICARIELLO
Department of Internal Medicine
University of Florence
Florence, Italy
FILIPPO PIERANGELI
Unit of General Surgery
Policlinico S. Orsola-Malpighi
University of Bologna
Bologna, Italy
W
ALTER PIUBELLO
Department of Internal Medicine
Endoscopic Unit
Desenzano, Italy
G
ILBERTO POGGIOLI
Unit of General Surgery
Policlinico S. Orsola-Malpighi
University of Bologna
Bologna, Italy
R
OBERTO POZZI MUCELLI
Department of Radiology
Policlinico “G.B. Rossi”
Verona, Italy
MONICA PRETO
Unit of Gastroenterology
Hospital “S. Bonifacio”
Verona, Italy
M
ICHA RABAU
Unit of Colon and Rectal Surgery
Department of Surgery B
Tel Aviv Sourasky Medical Center
Tel Aviv, Israel
XVIII
Contributors
GABRIELE RIEGLER
Unit of Gastroenterology and
Digestive Endoscopy
2
nd
University of Naples
Naples, Italy
F
ERNANDO RIZZELLO
Department of Internal Medicine and
Gastroenterology
University of Bologna
Bologna, Italy
J
OAN
ROBERT-YAP
Unit of Proctology
Department of Surgery
University Hospital of Geneva
Geneva, Switzerland
C
HIARA ROCHA
2
nd
Unit of General Surgery
IRCCS Maggiore Hospital
Foundation Mangiagalli and Regina Elena
Milan, Italy
B
RUNO ROCHE
Unit of Proctology
Department of Surgery
University Hospital of Geneva
Geneva, Switzerland
GIOVANNI ROMANO
Department of Emergency Surgery
“S.G. Moscati” Hospital
Avellino, Italy
EMIL SALMO
Department of Surgical Pathology
Trafford Healthcare Trust
Manchester, UK
BEATRICE SALVIOLI
Department of Internal Medicine and
Gastroenterology
S. Orsola-Malpighi Hospital
University of Bologna
Bologna, Italy
G
IULIO A. SANTORO
Section of Anal Physiology and
Ultrasound
Coloproctology Service
Department of Surgery
Regional Hospital
Treviso, Italy
M
ARCO SCAGLIA
Department of Surgery
S. Luigi Gonzaga Hospital
Orbassano, Turin, Italy
C
HIARA SCATTOLINI
Department of Gastroenterology
Policlinico “G.B. Rossi”
University of Verona
Verona, Italy
C
LAUDIA S
CHULZ
Department of General, Visceral and
Transplantation Surgery
Tübingen University Hospital
Tübingen, Germany
GUIDO SCIAUDONE
1
st
Division of General Surgery
2
nd
University of Naples
Naples, Italy
D
IEGO SEGRE
Department of General Surgery
Santa Croce e Carle Hospital
Cuneo, Italy
F
RANCESCO SELVAGGI
1
st
Division of General Surgery
2
nd
University of Naples
Naples, Italy
T
OMÁŠ
S
KŘIC
ˇ
KA
Bakeš Memorial Hospital
Brno, Czech Republic
M
ARIANNE STARCK
Department of Surgery
Malmö University Hospital
Malmö, Sweden
WOLFGANG STEURER
Department of General, Visceral and
Transplantation Surgery
Tübingen University Hospital
Tübingen, Germany
G
IACOMO C. STURNIOLO
Department of Gastroenterology
University of Padua
Padua, Italy
Contributors
XIX
N
AIKA TACCHELLA
Department of Biomedical and
Surgical Sciences
Division of Gastroenterology
Policlinico “G.B. Rossi”
Verona, Italy
ROSY TAMBASCO
Department of Internal Medicine and
Gastroenterology
University of Bologna
Bologna, Italy
MORENA TEBALDI
Department of Internal Medicine
Endoscopic Unit
Desenzano, Italy
ROBERTO TERSIGNI
Department of Surgery
S. Camillo Hospital
Rome, Italy
MARCO TESTONI
Department of Radiology
Policlinico “G.B. Rossi”
Verona, Italy
P
ARIS
TEKKIS
Department of Biosurgery and
Surgical Technology
Imperial College London
St. Mary’s Hospital
London, UK
WALTER THALER
Department of Surgery
Hospital of Brunico
Brunico, Italy
F
RANCESCO TONELLI
Department of Clinical Physiopathology
University of Florence
Florence, Italy
H
AGIT TULCHINSKY
Unit of Colon and Rectal Surgery
Department of Surgery B
Tel Aviv Sourasky Medical Center
Tel Aviv, Israel
F
EDERICA U
GOLINI
Unit of General Surgery
S. Orsola-Malpighi Hospital
University of Bologna
Bologna, Italy
ROSA VALANZANO
Department of Clinical Physiopathology
University of Florence
Florence, Italy
I
TALO VANTINI
Department of Biomedical and
Surgical Sciences
Division of Gastroenterology
Policlinico “G.B. Rossi”
Verona, Italy
A
LEX WIEGELE
Department of Surgery
Hospital of Brunico
Brunico, Italy
LUIGI ZORCOLO
Department of General Surgery
University of Cagliari
Cagliari, Italy
SECTION I
General Approach
Introduction
In clinical practice, imaging techniques are used at
the initial presentation to establish a diagnosis and to
assess the exact location, extent, and severity of dis-
ease [1]. These modalities are also used as follow-up,
during and after treatment, to determine the optimal
choice and dose of medication (e.g., systemically or
topically active) [2, 3]. With the advent of new med-
ication such as infliximab, an immunomodulatory
drug with considerable side effects, follow-up to
determine if medication is becoming increasingly
important.
In Crohn’s disease, formation of perianal fistulas
and/or abscesses can be seen in a large percentage of
patients. Nowadays, there is a tendency towards
imaging of these fistulae, given that in Crohn’s disease
fistulae can be very extensive and complex, rendering
the conventional gold standard (i.e., examination
under anesthesia) not wholly accurate [4]. As misclas-
sification of fistulae can lead to severe, irreversible
complications (e.g., fecal incontinence) or recurrent
disease, the American Gastroenterology Association
(AGA) has recently stated the importance of preoper-
ative imaging. Another reason for performing imag-
ing studies is the increasing use of infliximab, which
has been associated not only with external closure of
perianal fistulae but also with the persistence of tracks
as can be visualized with MRI [5, 6].
The earliest change caused by the disease occurs in
the submucosa and consists of lymphoid hyperplasia
and lymphedema. Radiologic findings at this (early)
stage include subtle elevations and aphthoid ulcers.
As the disease progresses, it extends transmurally to
the serosa (transmural stage) and beyond to the
mesentery and adjacent organs (extramural stage).
Aphthoid ulcers develop into linear ulcers and fis-
sures to produce an ulcero-nodular or “cobblestone”
appearance. The bowel wall is thickened by a combi-
nation of fibrosis and inflammatory infiltrates. Bowel
obstruction, strictures, abscesses or phlegmon, fistu-
lae, and sinus tracts are common complications of
advanced disease [1, 2].
Abdominal MRI
The diagnosis of Crohn’s disease should include
assessment of the presence, severity, and extent of
disease, inflammatory lesion activity, and the pres-
ence of extra-intestinal complications to aid in treat-
ment planning, which largely depends on imaging
findings, particularly those of cross-sectional imag-
ing. Endoscopy and barium studies are the principal
tools for diagnosis and evaluation of Crohn’s disease;
however, they are limited in their capability to
demonstrate the transmural or extramural extent of
disease or extra-intestinal complications.
With MRI, both inflammatory changes of the
bowel wall and the extramural complications of
Crohn’s disease can be assessed. The non-invasive-
ness of this technique, as well as its lack of ionizing
radiation, has prompted many groups to perform
systematic studies of MRI for evaluation of Crohn’s
disease.
Computed tomography (CT) is currently the
cross-sectional imaging modality of choice at most
institutions; however, magnetic resonance (MR)
imaging has also proved highly effective in this set-
ting. The role of cross-sectional imaging in the diag-
nosis of Crohn’s disease has expanded with recent
advances in CT and MR imaging technology, which
allow rapid acquisition of high-resolution images of
the intestines during a breath-hold examination.
Both imaging modalities provide information that is
crucial in the diagnosis of Crohn’s disease and in
treatment planning [7–16].
Intraluminal Contrast Media
Adequate distension of the bowel lumen is mandato-
ry in MRI, as it facilitates demonstration of morpho-
logical changes caused by Crohn’s disease and allows
identification of subtle abnormalities. Collapsed
bowel loops can hide lesions or mimic disease by
mimicking pathologically thickened bowel wall in
MRI in Inflammatory Small-Bowel Diseases
Riccardo Manfredi, Roberto Malagò, Marco Testoni,Veronica Girardi, Roberto Pozzi Mucelli
4 R. Manfredi, R. Malagò, M. Testoni, V. Girardi, R. Pozzi Mucelli
collapsed segments [17]. Moreover, collapsed normal
bowel loops can exhibit enhancement that is similar
to diseased segments, after administration of an
intravenous contrast medium [18].
Various kinds of intraluminal contrast agents
have been proposed for MR imaging [7, 18–26] and
are classified as positive, negative, or biphasic. Posi-
tive agents produce high intraluminal signal, and
negative agents produce little or no intraluminal sig-
nal regardless of the applied pulse sequence. Biphasic
contrast agents may produce either a high or low sig-
nal depending on the pulse sequence used, usually
demonstrating low signal intensity on T1-weighted
MR images and high signal intensity on T2-weighted
images. Negative or biphasic contrast agents seem to
be more suitable for assessing the small bowel [7, 19].
Polyethylene glycol has been proposed by several
authors as a suitable biphasic contrast medium; it is
not absorbable, remains unmodified in the small
bowel, is easily prepared and administered, and pro-
vides adequate bowel distension. Furthermore, tran-
sit time is fast, allowing for small-bowel distension
within 30 min. However, undesirable side effects
(e.g., motion artifacts or severe diarrhea) can occur
due to the prokinetic action of the solution. Theoret-
ically, water would be a perfect biphasic contrast
medium, but in many patients, the water is reab-
sorbed before it has reached the terminal ileum.
Moreover, it does not optimally distend the bowel
(Fig. 1).
An anti-peristaltic agent is injected to minimize
potential artifacts caused by bowel movement or
contraction. Although many authors reporting on
MR enteroclysis administer anti-peristaltic drugs to
reduce motion artifacts, reflex atony is induced by
high flow rates, theoretically allowing images
(almost) to be free of motion artifacts.
Sequences
Technological advances, including the use of respira-
tion-suspended sequences, improved coils, fat sup-
pressions, and intravenous gadolinium, have extend-
a
d
e
bc
Fig. 1. Coronal T2W Hal Fourier RARE image (a) and fat-suppressed true-FISP images along the coronal (b), sagittal (c),
and axial (d, e) planes show good distension of bowel loops after oral administration of biphasic contrast media (PEG),
thus permitting the distinguishing of the jejunal and ileal loops
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