0:01

So I feel like I'm beating a dead horse to some

0:03

extent showing all these fistula cases, but I

0:05

think it's really important that everybody sees

0:07

a lot of these because in my practice, one of

0:10

the things that I see missed frequently and the

0:13

drastically alters management is people don't

0:15

see these fistulas because they just haven't been

0:18

looking for them and haven't seen enough of them.

0:20

And so they get referred to the university and they've

0:23

had images with fistulas on them, and nobody's talked

0:26

about it, and the patient just never gets better

0:28

and it's because they have this chronic fistula.

0:30

So I really want to show you several kinds of patterns

0:33

where you can see what these fistulas look like because

0:36

once you've seen a few, then they start to be like, oh

0:38

look at that, that's that architectural

0:40

distortion and that asterisk appearance, that’s

0:43

what fistulas in Crohn's disease look like.

0:45

So here's a case where there's a lot of

0:47

inflammation in the right lower quadrant.

0:50

You may think that that's just kind of bowel, but when

0:53

you look at it, all the bowel is really distorted.

0:55

Here's your ascending colon, the cecum, and it's kind

0:58

of distorted as it approaches this kind of nidus here.

1:02

You can see the central nidus that's non-enhancing.

1:04

It's also involving other loops of bowel.

1:07

So here's a loop of bowel coming from the left

1:09

and then this distal ileum is involved and

1:12

it's all sucked in towards this area, and really

1:15

burn this image into your head because it's

1:17

got this really nice asterisk shape in it.

1:19

There's a central nidus in it and all

1:21

the bowel kind of emanates from that.

1:24

Additionally, you can see it's got a branching sinus

1:27

tract that comes down through here, and so this is

1:30

another complex kind of classic Crohn's-type fistula.

1:35

Once you've seen a few of these, you're

1:37

not going to miss them in the future

1:38

as long as you keep looking for them.

1:40

But keep your eye out for that architectural

1:42

distortion, that central nidus, and that

1:44

asterisk shape, because that's the fistula

1:46

that everybody needs and wants to know about.