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The Reversed Question Mark Sign and the Dragon Sign of Ulcerative Colitis

Akira Hokama, Shuichi Maruwaka, Kunikazu Hoshino, Kazuto Kishimoto, Fukunori Kinjo, Jiro Fujita

Akira Hokama, Shuichi Maruwaka, Kunikazu Hoshino, Kazuto Kishimoto, Jiro Fujita, Department of Infectious, Respiratory, and Digestive Medicine, University of the Ryukyus, Okinawa 903-0215, Japan
Fukunori Kinjo, Department of Endoscopy, University Hospital of the Ryukyus, Okinawa 903-0215, Japan

Correspondence to: Akira Hokama, Department of Infectious, Respiratory, and Digestive Medicine, University of the Ryukyus, Okinawa 903-0215, Japan.
hokama-a@med.u-ryukyu.ac.jp
Telephone: +081-98-8951144
Fax: +081-98-8951414
Received: September 22, 2012
Revised: October 21, 2012
Accepted: October 25, 2012
Published online: February 21, 2013

ABSTRACT

In gastroenterology, a sign is usually a marker or indicator of the presence of a particular disease and many signs are related to findings on clinical examination. In relation to ulcerative colitis (UC), only a few signs have been described that may assist with the interpretation of imaging studies. The well-known sign of UC is tubular appearance. We highlight other radiological findings in UC that we have called “the reversed question mark sign” and “the dragon sign”.

Key words: Ulcerative colitis; Computed tomography

© 2013 The Authors. Published by ACT Publishing Group Ltd.

Hokama A, Maruwaka S, Hoshino K, Kishimoto K, Kinjo F, Fujita J. The Reversed Question Mark Sign and the Dragon Sign of Ulcerative Colitis. Journal of Gastroenterology and Hepatology Research 2013; 2(2): 429-430 Available from: URL: http://www.ghrnet.org/index./joghr/

TO THE EDITOR

We report impressive pictures from two patients with ulcerative colitis (UC). A 36-year-old man with 1-year history of UC presented with hematochezia and lower abdominal pain. Physical examination showed tenderness in the left lower quadrant without rebound. Computed tomography (CT) scan revealed circumferential and symmetric wall thickening of the sigmoid colon and the rectum (Figure 1). Together with the target appearance of the rectum, this CT feature resembles a reversed question mark. Hyperemic pericolonic stranding, increased presacral space and enlarged lymph nodes are also presented. Sigmoidoscopy confirmed the exacerbation of UC. The patient improved with the administration of mesalazine and prednisolone. Another picture is from a 16-year-old woman with a 3-year history of UC presented with hematochezia and lower abdominal pain. CT scan revealed diffuse wall thickening and luminal narrowing of the rectum and the sigmoid colon and hyperemic mesenteric vessels (Figure 2), which resembles a dragon. Sigmoidoscopy confirmed the diffuse exacerbation of UC. She improved with the administration of mesalazine and prednisolone. In gastroenterology, a sign is usually a marker or indicator of the presence of a particular disease and many signs are related to findings on clinical examination. In relation to UC, only a few signs have been described that may assist with the interpretation of imaging studies. The well-known sign of UC is tubular appearance[1], which refers to a loss of haustration that typically extends to the left colon, indicating active or quiescent inflammation. Another sign is target sign[2], which indicates edematous layer of submucosa of lower attenuation is paralleled by external layer of muscularis propria and internal layer of hypertrophied mucosa, both of which show higher attenuation[3,4]. In Figure 1, the rectum has the target appearance on axial scan and the longitudinal slice of the sigmoid colon present several layers of wall thickening, resembling the reversed question mark. In figure 2, CT shows wall thickening with uniform increased enhancement and hypervascularity of the involved mesentery, manifesting as vascular dilatation, tortuosity, and prominence. As a result, the rectum and the sigmoid colon present wall thickening and pericolonic stranding, resembling the dragon. All above features reflect the hyperemic state seen typically with active inflammation. Although the target appearance also occurs in Crohn’s colitis, it usually display eccentric and discrete. In conclusion, we highlight other radiological findings in UC that we have called “the reversed question mark sign” and “the dragon sign”. Although the final diagnosis of the type of colitis is based on clinical and laboratory data and colonoscopic and biopsy findings, specific CT features help narrow the differential diagnosis. We plan to perform a larger study comparing CT imaging with clinical and endoscopic findings in patients with UC, in order to address a relationship between above radiologic signs and progression of the diseases.

REFERENCES

1 Hokama A, Ihama Y, Chinen H, Kishimoto K, Kinjo F, Fujita J. The sigmoid colon of ulcerative colitis. Dig Dis Sci 2010; 55: 538

2 Ahualli J. The target sign: bowel wall. Radiology 2005; 234: 549-550

3 Gore RM, Balthazar EJ, Ghahremani GG, Miller FH. CT features of ulcerative colitis and Crohn's disease. AJR Am J Roentgenol 1996; 167: 3-15

4 Wittenberg J, Harisinghani MG, Jhaveri K, Varghese J, Mueller PR. Algorithmic approach to CT diagnosis of the abnormal bowel wall. Radiographics 2002; 22: 1093-1097

Peer reviewer: Diego Sánchez Muñoz, Gastroenterologist, Usp Clínica Sagrado Corazón, C/ Rafael Salgado , 3, 41003, Sevilla, Spain.

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