0:01

So here's a case where there's pretty severe changes

0:04

from Crohn's disease that are pretty evident.

0:07

What we see is a lot of hyperenhancement

0:09

in this right lower quadrant, a lot of

0:12

distorted-appearing bowel. The bowel no longer

0:15

maintains its normal configuration at all.

0:17

There are some segments of bowel that have diffuse

0:20

enhancement, other segments where there's differential

0:23

enhancement with more mesenteric side enhancement.

0:26

Additionally, you see a lot of

0:27

enhancement beyond the wall of the bowel.

0:30

And so when you see that enhancement

0:32

that goes beyond the bowel wall.

0:34

That can just be an indication of acute inflammation,

0:38

or it can be an indication of a fistula or a sinus tract.

0:41

And so we need to try to find

0:43

if there is a fistula or sinus tract. We need to look

0:45

at some other sequences to see if that's the case.

0:48

And I think this is where the T2

0:49

images end up becoming very helpful.

0:52

As expected, a lot of these loops of bowel look like

0:55

they're bright on T2 relative to skeletal muscle,

0:57

and we confirm on our fat-saturated sequence that

1:00

that's true edema and not just fat in the wall.

1:02

And then we look and try to find if

1:05

there are any strictures or fistula tracts.

1:08

And what we see here, first of all, we see that

1:10

there's a dilated segment of bowel right here.

1:13

And that's upstream from this area of narrowing.

1:16

So that indicates that there's a stricture.

1:19

And oftentimes, when you have severe stricturing,

1:21

especially if it's combined with a severe transmural

1:24

inflammatory process, that's when you get fistulas.

1:27

Because the bowel lumen contents

1:30

need to go somewhere.

1:31

And if they can't get through the lumen

1:33

where they want to go, then they have to go

1:36

through the wall and start creating fistulas.

1:38

And so it's the stricture that really ends

1:40

up being a primary driver in these fistula

1:43

formations combined with acute inflammation.

1:45

So when we see all this inflammation

1:47

surrounding the bowel and we see a stricture,

1:49

then we need to decide what else is going on.

1:52

Is there a tract that we can identify?

1:52

47 00:01:54,560 --> 00:01:57,759 And in this case, after close scrutiny, we can see that

1:57

there's this T2-bright tract that comes through here

2:00

and there's a complex kind of sinus tract extending

2:04

from the bowel and connecting other loops of bowel.

2:08

And so in this case, there's this complex kind of sinus

2:11

tract and distorted appearance of the bowel indicating

2:15

a penetrating severe case of Crohn's disease.

2:18

And so the distal or terminal ileum and the

2:22

cecum are all intertwined in this complex fistula

2:26

communicating process with numerous sinus tracts.

2:30

And so communicating that's gonna be

2:31

important to our clinicians and colleagues.

2:35

And here you can see that this is not in the lumen.

2:37

This is a fistulous tract.

2:38

And so in this case, they may try to optimize

2:41

medical management, but if the symptoms

2:43

are too severe, at some point this

2:45

patient's gonna need surgery, most likely.