0:01

So here's another case of a patient with

0:03

long-standing Crohn's disease involving the

0:05

terminal ileum, and the question is how much

0:07

acute inflammation, if any, is still present.

0:10

And as we look at our coronal images,

0:15

we can see that there's a kind of abnormal

0:17

appearance of the terminal ileum.

0:21

A couple of things to notice about this case.

0:23

One is that you can see the terminal ileum

0:25

and there's not a lot of other bowel around it.

0:29

And that's because it has that kind

0:30

of creeping fat type appearance.

0:33

So one of the things that happens with longstanding

0:35

Crohn's disease is you get vascular engorgement

0:37

and the fat becomes a lot more predominant.

0:40

And so you see a lot of fat around a diseased segment

0:44

of bowel that's been there for a very long time.

0:46

But the question before us today is,

0:49

is this patient have acute or chronic

0:52

disease, and which one is predominating?

0:54

And this is an exam where we

0:56

don't have seven-minute images.

0:58

And I know a lot of you are going to

0:59

be working without seven-minute images.

1:01

It does cause some problems with

1:03

workflow to add that to your sequence.

1:06

If you want to get seven-minute images, one thing

1:08

we do is to do our timing a little bit differently.

1:11

And so if you do your early images

1:14

first, so do your up to two minutes, you know,

1:17

your, your three consecutive dynamic images.

1:20

Then we do our diffusion after that, because

1:22

you can do that with gadolinium on board.

1:24

And then we do seven-minute images after that.

1:26

And so then you don't have to sit with the

1:27

patient on the stand or doing nothing for that

1:29

four-minute gap you get.

1:31

So I would advocate you do that.

1:33

But a lot of practices still aren't gonna

1:36

have seven-minute images in their protocol.

1:39

And so you need to look at other factors to try to

1:41

help you decide if this is acute, chronic, or both.

1:44

And so for this case, let's look at our T2 sequences.

1:47

And what we see on non-fat T2 sequences,

1:51

and we see a lot of this looks quite dark,

1:53

which would suggest fibrosis.

1:54

But we also see areas that look pretty bright in here.

1:58

And so we're questioning,

1:59

you know, why is it so bright in there?

2:01

Is that a marker of acute inflammation

2:03

that we need to be concerned about?

2:05

Or what's going on?

2:06

As we look at our fat-saturated sequence,

2:09

we lose a little fat saturation here,

2:10

but you can still get the picture.

2:12

And up through here, all we see

2:13

is T2 bright signal in the lumen.

2:15

We don't even see the wall hardly at all.

2:17

And that's because it's predominantly fibrotic.

2:20

If it were brighter, it would suggest there's

2:23

an acute component going on and some edema.

2:25

And for the most part, it's not bright at all.

2:27

And through here, we also see that it's really

2:30

similar to the adjacent fibers, not very bright at all.

2:33

And so, in the end, what we conclude is that

2:36

this T2 brightness is actually fat in the wall,

2:39

which we lose with the fat-saturated

2:42

sequence, and there's not a lot of edema, and if

2:47

there's no edema in a segment of bowel, that means

2:49

that there's also not acute inflammation.

2:52

And so we can say this is

2:54

a chronic process at this point.

2:56

They've got the creeping pattern indicating,

2:57

you know, Crohn's disease with a pretty high specificity.

3:00

There's even some pseudo-sacculations here.

3:03

So this patient does have Crohn's

3:05

disease, but it looks chronic here,

3:08

it's a chronic stricture.

3:09

So if they're symptomatic, they need a surgical

3:12

intervention and not a gastroenterologist.

3:17

Lastly, just to confirm that it really is

3:20

fat, we happen to have a CT on this patient.

3:22

And as you look through that diseased segment of the

3:24

bowel, you can see the really dark fat in the wall.

3:28

So, with chronic changes like this, in addition

3:31

to the creeping fat that you see in the mesentery,

3:34

you can see fat in the wall of the bowel as well.

3:37

That's not unexpected in a patient with

3:40

long-standing Crohn's disease, such as.

3:42

In conclusion, this patient, if they're having

3:44

symptoms, they need to see a surgeon and see about

3:47

getting that long segment stricture resected.