Interactive Transcript
0:01
Okay, so for this case, you can see a clear
0:03
abnormality in the terminal ileum here.
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So here's the cecum here, here's the
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ileocecal valve, and here's the terminal ileum.
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And there's a long segment of clear wall thickening.
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And so this is the patient with known Crohn's
0:15
disease and really fairly long-standing disease.
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It's been getting regular disease monitoring.
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And on this exam,
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What we see is this long segment of narrowing.
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Proximal to that, there's at least some dilation.
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So this would definitely be characterized as a
0:31
stricture, and it's a fairly long segment stricture.
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Note that the proximal dilation isn't too severe.
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So on this T2 sequence, there's a
0:39
lot of bright signal in the wall.
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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.
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In this case, we're looking at a true FISP
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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.
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But, importantly, there's not a lot of surrounding
1:13
inflammation or surrounding changes that we're seeing.
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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.
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And that is concerning, obviously, for a
1:50
fistula related to this long segment stricture.
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So to further characterize that,
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let's look at an axial plane.
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And here you can clearly see this is that same area
1:58
of thickened fat and edematous containing bowel.
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And as it comes down here, we see the sigmoid
2:06
colon coming towards that loop of bowel and we see
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it communicating, and additionally, there's another
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loop of small bowel. This is another loop of ileum
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that's also communicating.
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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.
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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.
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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.
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So surgical resection appeared to
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be a great option for management.
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So that's what they did.
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And we also have some postoperative
3:11
imaging for this case.
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And following the surgery, what you see is they did
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what they typically do, which is a right hemicolectomy.
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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.
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But what we can see here is this is
3:40
the ascending colon. It comes down.
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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.
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So for these post-surgical cases, we'll talk
4:06
about how to evaluate those in our next section.
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