0:01

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

0:02

strictures in Crohn's disease and how to identify

0:06

them and what we need to talk about when we see them.

0:08

And so this is a patient who has multiple

0:12

segments of bowel that are hyperenhancing.

0:14

If you look at this area here, this

0:16

is a proximal jejunal segment.

0:18

So when we compare it to other proximal jejunal

0:20

segments, we see it's clearly more enhancing than

0:24

the surrounding bowel, but it extends for quite

0:27

a long period here up into the upper abdomen.

0:31

As we come into the upper abdomen, we see this kind

0:33

of transition where it goes from, you know, fairly

0:36

normal or slightly smaller caliber to a larger caliber.

0:40

I mean, whenever we see that transition, when

0:42

we see a larger caliber segment, we need to

0:45

decide, is there a stricture there?

0:47

And if so, how do we describe that?

0:50

And so when we look on our axial plane, we see that

0:52

that area really is quite narrowed as it comes into

0:56

this more proximal segment that's quite distended.

1:00

And so this is a slam dunk case where there's

1:03

clearly a stricture in the segment of bowel.

1:06

And so anytime you see upstream dilation that's

1:09

greater than three centimeters, and you see

1:11

narrowing downstream from that, you should call

1:15

a stricture, and you should call it confidently.

1:17

Sometimes you'll have cases where there's

1:19

a persistent narrowing, but you don't

1:21

really see that upstream dilation.

1:24

And for those cases, you should raise the

1:26

possibility of stricture, but it's not as much of a

1:28

clear slam dunk case, and it may not be as clinically significant

1:32

as these cases where we clearly see upstream dilation.

1:36

So you can call it a probable stricture if there's

1:39

a fixed narrowing, but when we see the upstream

1:41

dilation as we do in this case, along with the

1:44

area of narrowing, we call it a clear stricture.

1:47

Now these happen as a mix of acute and

1:50

chronic processes from the Crohn's disease.

1:53

However, oftentimes it's a marker of

1:55

a more chronic fibrotic process.

1:58

And so in addition to the degree of

2:00

stricturing, we need to talk about the degree

2:02

of inflammation that's associated with that,

2:04

and we'll talk a little bit more about that

2:06

in subsequent cases.

2:07

But in this case, we have a pretty

2:10

substantial upstream narrowing and we have

2:13

upstream dilation and downstream narrowing.

2:16

It's a slam dunk Crohn's stricture.

2:18

There are other causes of strictures,

2:20

of course, in the small ball, including

2:22

NSAID use and radiation enteropathy.

2:24

So strictures aren't specific for Crohn's disease,

2:27

but there are common...an important finding on imaging

2:32

studies and the surgeons and

2:34

gastroenterologists really need to know when they're present.