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Fistula to Colon w/ Post Op Imaging

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0:01

Okay, so for this case, you can see a clear

0:03

abnormality in the terminal ileum here.

0:06

So here's the cecum here, here's the

0:08

ileocecal valve, and here's the terminal ileum.

0:09

And there's a long segment of clear wall thickening.

0:13

And so this is the patient with known Crohn's

0:15

disease and really fairly long-standing disease.

0:18

It's been getting regular disease monitoring.

0:21

And on this exam,

0:22

What we see is this long segment of narrowing.

0:26

Proximal to that, there's at least some dilation.

0:28

So this would definitely be characterized as a

0:31

stricture, and it's a fairly long segment stricture.

0:33

Note that the proximal dilation isn't too severe.

0:37

So on this T2 sequence, there's a

0:39

lot of bright signal in the wall.

0:41

So we think that maybe there is a good

0:43

amount of edema, but we want to verify

0:45

that with something with fat saturation.

0:48

In this case, we're looking at a true FISP

0:50

or a steady-state free precession image.

0:52

And we can see that some of that edema is certainly

0:55

real, that there are areas of that bowel wall that do

0:58

look brighter than the adjacent skeletal muscle.

1:01

However, there are also areas that are dropping

1:03

out on the fat-saturated sequence, so there's

1:05

also some chronic fat, so that's accounting

1:07

for some of that increased T2 signal.

1:09

But, importantly, there's not a lot of surrounding

1:13

inflammation or surrounding changes that we're seeing.

1:17

And we want to look at our post-contrast

1:20

images to help us further characterize this

1:22

and we see some patchy areas of enhancement.

1:25

So this suggests there are some acute and

1:27

some chronic changes with fat in the wall.

1:30

And then this patient with long-standing disease,

1:33

it's likely a mixture of acute and chronic changes.

1:36

But we also see, as I've been scrolling

1:38

through, you may have already noticed

1:39

that there's something going on here.

1:41

Or this loop of bowel does seem to

1:44

communicate with this adjacent loop of bowel.

1:46

And that is concerning, obviously, for a

1:50

fistula related to this long segment stricture.

1:52

So to further characterize that,

1:54

let's look at an axial plane.

1:56

And here you can clearly see this is that same area

1:58

of thickened fat and edematous containing bowel.

2:03

And as it comes down here, we see the sigmoid

2:06

colon coming towards that loop of bowel and we see

2:10

it communicating, and additionally, there's another

2:12

loop of small bowel. This is another loop of ileum

2:15

that's also communicating.

2:16

So there's a complex fistula with that asterisk

2:19

appearance, and you can confirm this is

2:22

the sigmoid colon by following it down from the

2:24

rectum up. So it's clearly a sigmoid colon. So this

2:27

was a new finding, and this patient has been on

2:30

multiple anti-inflammatory drugs for a long time.

2:33

And has never really fully gotten rid of that

2:36

inflammation, and eventually, this stricture formed.

2:40

So, at this point, the clinicians are stuck

2:44

with disease that just seems to be resistant

2:46

to the drugs that they're able to offer.

2:48

And they consulted the surgeon, and

2:50

the surgeon decided to do a resection.

2:52

Which makes sense because once you

2:53

have these fistulizing components,

2:55

it's very hard to improve that.

2:57

They may at times delay it if there's a lot

2:59

of inflammation, but there's not a lot of

3:01

surrounding inflammation around this loop of bowel.

3:03

So surgical resection appeared to

3:05

be a great option for management.

3:08

So that's what they did.

3:09

And we also have some postoperative

3:11

imaging for this case.

3:13

And following the surgery, what you see is they did

3:16

what they typically do, which is a right hemicolectomy.

3:19

Or at least removal of the cecum and removal of

3:23

the diseased distal ileum with creation of what

3:26

we call a neo terminal ileum, and it's a little

3:29

hard to follow, potentially, and these cases can

3:32

be a little more difficult because anatomy is

3:33

distorted and you no longer have an ileocecal

3:36

valve to help you find the terminal ileum.

3:38

But what we can see here is this is

3:40

the ascending colon. It comes down.

3:42

And it communicates with this loop of bowel here.

3:46

Here's where they put that anastomosis together.

3:48

We'll look at it again on a post-contrast image.

3:51

And you can see a little bit of artifact probably

3:53

from the surgical clips and anastomosis.

3:56

It can be really hard to see that

3:58

on MRI, but sometimes you see it.

4:00

And obviously on CT, it's

4:02

really quite obvious typically.

4:04

So for these post-surgical cases, we'll talk

4:06

about how to evaluate those in our next section.

Report

Faculty

Benjamin Spilseth, MD, MBA, FSAR

Associate Professor of Radiology, Division Director of Abdominal Radiology

University of Minnesota

Tags

Small Bowel

Non-infectious Inflammatory

MRI

Large Bowel-Colon

Idiopathic

Gastrointestinal (GI)

Crohn’s Disease

Body

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