Crohn's: Mucosal Features

Left: Normal ileum.

Right: Mucosal inflammation causes redness,
friability (ease of bleeding) and edema
(swelling), giving rise to a granular appearance.
As inflammation extends deeper into the bowel
wall, edema results in a cobblestone appearance.

As inflammation progresses, ulcers appear, and

may be punctate (left), linear, or more extensive
(right). Repeated ulceration causes destruction of
mucosa, giving the swollen surviving mucosa a
raised, polypoid appearance (pseudopolyps), seen
in distance on left and foreground on right. 

Pseudopolyps.

Gastroduodenal
Crohn's

Crohn's disease involving the gastric outlet and

proximal duodenum, resulting in gastric outlet
obstruction. Image on the right shows a view of the
stricture as seen through a translucent dilating
balloon, which has been inflated in the
stricture. 

48 year-old man with new-onset Crohn's disease involving the stomach,

duodenum and colon. Shown here is the largest of several gastric ulcers. 
 72
year
old
man
with

abdominal pain and known Crohn's colitis. Endoscopy revealed antral gastritis with
erosions (left) and duodenal erythema with mucosal granularity (center and right). Biopsies
revealed chronic active gastritis negative for H. pylori, and chronic active duodenitis with
granulomas. 

Left: 23 year old man with abdominal pain and known Crohn's colitis, and Right: 32 year old
woman with nausea, vomiting, abdominal pain and known severe Crohn's ileocolitis. In both
patients, upper endoscopy was grossly normal, however in both patients biopsies obtained from
gastric antrum revealed microscopic chronic active inflammation with granulomas, consistent with
gastric Crohn's. Images are included here to illustrate that active disease may not be grossly visible.

Crohn's Ileitis

20 year-old woman with Crohn's involving the

distal ileum (left), with no visible involvement
of the colon (right).
 55 year-old man undergoing colonoscopy for evaluation of occult
bleeding. No colonic pathology was seen, but cannulation of the
ileocecal valve revealed distal ileitis with ulceration.

Inactive Crohn's -- Fibrosis

Fibrosis in a patchy
distribution in the colon of a
53 year old woman with
quiescent Crohn's colitis. 

Crohn's Enteritis

Mucosal edema and erythema. 

Aphthous ulcerations.
 LEFT and RIGHT: Villous edema and mucosal
erosion. Patchy exudates/punctate ulcerations.

LEFT and RIGHT: Inflammatory strictures with

surrounding musocal ulceration.

Crohn's Colitis

33 year-old man with Crohn's involving the

proximal colon, with severe inflammation, edema

and ulcers. 

Same patient as above. The ileum appears normal (left). As commonly seen in Crohn's colitis, there
is minimal involvement of the rectum (right). 

Mucosal erythema, granularity and friability in a 51 year old woman with

Crohn's colitis symptomatically in remission. 

60 year-old woman with

longstanding Crohn's
colitis. Colonoscopic
findings included
extensive, severe
inflammation with
edema and multiple deep ulcers. 

45 year-old woman with

longstanding Crohn's
ileocolitis. Surveillance
colonoscopy revealed
edema, granularity,
superficial ulceration
and pseudopolyp formation. 

32 year-old man with a

one year history of
abdominal pain, bloody
diarrhea and 10-15 lb.

weight loss. Colonoscopy demonstrated inflammation to varying degrees throughout the colon,
with ulceration and occasional pseudopolyp formation. 
Same patient as above. Biopsies were consistent with inflammatory bowel disease; no granulomas
were seen. Diagnostically, Crohn's colitis was favored over ulcerative colitis because of the
variable severity of inflammation, although this could be also have been designated as
indeterminate colitis. 

63 year
old man
with
Crohn's
colitis.

Colonoscopy revealed mucosal erythema, granularity, nodularity, friability and mucosal ulceration,
as well as a few pseudopolyps in the sigmoid colon. 

30 year
old man
with
Crohn's
colitis.

Colonoscopy revealed ulceration of the ileocecal valve (left), segmental inflammation with linear
ulcers (center) and a pseudopolyp in the sigmoid colon(right). 

Crohn's Ileocolitis

54 year-old man with severe inflammation

involving the ileum and colon. Shown at left is
ileitis with edema, granularity, cobblestoning and
punctate ulcers.
 Colitis with granularity and ulcers.

Pseudopolyps in the colon.

Anastomotic Crohn's
Recurrent inflammation on the ileal (small bowel) side of the ileocolic
anastomosis (left side of photograph), without apparent extension to the
colonic side (right side of photograph).

Crohn's -- Rectovaginal Fistula

57 year-old woman with longstanding Crohn's
disease, with recurrent fistulas, having undergone
surgical repair approximately 18 months earlier.

Crohn's -- Colonic Fistula

Colonic view of the site of a jejunal-colic fistula in a 39 year-old woman with longstanding Crohn's
disease. 
Crohn's Disease -- Inflammatory Polyp

50 year old man previously diagnosed with ulcerative

colitis. Current exam revealed multiple segments of grossly
inflamed mucosa, with intervening "skip" areas which
appeared grossly normal and which were normal on
biopsy, consistent with Crohn's colitis. This inflamed
pedunculated polyp, resembling an adenoma, was located
at the transition point between inflamed and non-inflamed
segments of colon. The lesion contained no adenomatous elements.

Ulcerative Colitis: Mucosal Granularity

Left: normal.
Right: Mild colitis produces redness and swelling
of the mucosa, resulting in a loss of the normal
vascular pattern, an overall granular appearance,
and friability (fragility with ease of bleeding).

Mucosal granularity, exudate and superficial

ulceration. There is often an abrupt transition to
relatively normal-appearing mucosa (right).

With increasing severity, petechiae (points of

bleeding), exudate (pus) and small, discrete ulcers
appear.
Ulcerative Colitis: Ulcerations
Moderate colitis is characterized by
granularity, friability, exudate, spontaneous
bleeding and increasingly larger areas of
ulceration.

With increasing severity, ulcers may appear as

punctate (see above), linear (left) or larger
(right).

Ulcerative Colitis:
Pseudopolyps

The repeated cycle of

ulceration, alternating with
the deposition of
granulation tissue during
the healing phase, results in
the development of raised areas of inflamed tissue that resemble polyps.

However, these lesions are not neoplastic (i.e., true polyps), but inflammatory tissue, and are called
pseudopolyps. They have no malignant potential.
DALM (Dysplasia Associated Lesion or Mass)

Three
sessile
polypoid
lesions,
one
readily
visible and
the other two smaller and more subtle, found in the sigmoid colon of a 43 year old man with
longstanding ulcerative colitis who was undergoing colonoscopy for routine dysplasia screening.
Histology revealed low-grade dysplasia in all three lesions with a background of chronic colitis.