Differential Diagnosis of the Colitides

The differentiation of granulomatous colitis and ulcera-tive colitis is important in terms of medical management, surgical options, and prognosis. This distinction can usually be made on the basis of colonoscopy with biopsy histology, double-contrast barium enema, disease distribution, and clinical course. CT can occasionally help distinguish these disorders by demonstrating differences in mural thickness, wall density and distribution of colonic involvement, as well as the presence or absence of small bowel disease, abscess, fistula, and fibrofatty mesenteric proliferation.

Idiopathic inflammatory bowel disease must also be differentiated from infectious colitides. Although there is considerable overlap in the CT findings of these disorders, there are certain differentiating features. The presence of ascites is more suggestive of an acute, rather than chronic, cause of colonic inflammation. Peritoneal fluid is commonly found in the acute colitides, particularly pseudomembranous, infectious, and ischemic colitis, and not in chronic inflammatory bowel disease. Ascites is only infrequently seen in patients with acute inflammatory bowel disease. Submucosal fat deposition detected by CT is primarily found in subacute and chronic colitides, usually ulcerative colitis, and not in acute disease.

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