0:01

So for this case, we're going to talk again

0:02

about putting together a report, but this time

0:04

for a patient with multiple segments of disease.

0:07

And again, the first stage is detection.

0:10

And so we're going to go through our sequences and

0:12

try to use the ones that we think are most critical

0:14

for detecting any areas of small bowel disease.

0:18

I like to start with the coronal oftentimes,

0:21

and in the coronal, we clearly see a segment

0:25

of abnormal bowel here with some narrowing.

0:28

It looks a little bit hyperenhancing when

0:30

you compare it to some adjacent segments.

0:32

And also, there are some sacculations there, which

0:34

indicate disease, probably of a chronic nature.

0:37

We also see a similar segment here.

0:39

So this is the true terminal ileum here.

0:42

You can see communicating with the

0:43

ileocecal valve and the ascending colon.

0:46

And in this disease segment, we know that there's

0:49

some creeping fat and hyperproliferation of fat, which

0:52

indicates a significant involvement of Crohn's disease.

0:56

Also, as we look for detection, we look at the

1:00

remaining small bowel, and the jejunum

1:03

folds look fairly similar to each other,

1:05

and they all have a typical, normal-looking

1:07

pattern, so I don't see much disease there.

1:10

We look in the colon, and as I look through the

1:12

colon, I see maybe a little bit of brightness

1:14

through here, so we're going to want to pay

1:16

attention to that on our other sequences, but

1:18

the remaining colon, I don't see too much.

1:21

So now we're going to look at our other sequences

1:23

because we've so far detected at least two adjacent

1:27

segments of bowel and potentially the sigmoid.

1:28

So let's look at our other sequences

1:30

to see if we can see the same stuff.

1:32

So here's that one disease of terminal ileum and

1:35

here's another more proximal ileal disease

1:39

segment on this T2 sequence without fat saturation.

1:42

I'm not seeing a ton of other stuff that looks

1:45

too concerning. That area of sigmoid colon doesn't

1:48

look super inflamed here, and it doesn't look like

1:51

there's a lot of wall thickening at that site.

1:53

But we do want to look at our other sequences.

1:55

I think looking at the axial sequence is going to

1:57

help us to just see things in a different projection.

2:00

And so as we look at that sequence, here's our disease

2:03

terminal ileum, and here's the other disease segment.

2:05

And we're done.

2:06

We also see this segment over here that really

2:08

does look like it's enhancing quite a bit.

2:10

And I don't think we picked that up as easily

2:12

on the other sequences, but as I look here,

2:14

it looks like there's another skipped lesion

2:16

that we need to really closely scrutinize.

2:19

Are there other disease segments here in

2:20

the right abdomen, more proximal, that we

2:23

weren't seeing with those early sequences?

2:25

And so if we look a little more closely at that,

2:28

we do see other areas that don't look normal.

2:32

If you compare this bowel here to this and

2:34

you look at it closely, you see that it does

2:36

look like there's some type of enhancement.

2:37

So there's more than just the two disease segments.

2:40

There's going to be three or four disease segments.

2:42

Lastly, we're going to look at the diffusion sequence.

2:46

So this is a high b-value diffusion,

2:48

and this can at times help us more

2:51

sensitively detect the areas of disease.

2:53

And so when we look through this, we see this area

2:56

of disease that corresponds to the terminal ileum.

2:59

When we see the more proximal loop here, we

3:02

also see a little bit of increased signal at

3:04

that site where we thought there was probably

3:06

some inflammation in the right upper quadrant.

3:09

But when we look in the left abdomen, we see

3:11

loops of jejunum that all look fairly similar.

3:13

One of the things about diffusion is the

3:15

jejunum can be a little brighter because

3:17

the wall is thicker and segments that are

3:20

decompressed can also be a little brighter.

3:22

And so I think this is normal because it looks

3:25

similar to the adjacent bowel and in our other

3:28

sequences we noted that the fold patterns

3:30

look normal without evidence of disease.

3:34

So that's the first step is detection.

3:37

The next step is to measure the lengths of all the

3:39

disease segments to include that to help our

3:42

gastroenterologist and then move on to other features

3:45

such as the potential for strictures or fistulas.