0:01

All right, here's another case with post

0:03

operative changes following terminal

0:05

ileal resection and creation of a neoterminal ileum.

0:08

And in this case, we're again trying

0:11

to evaluate for any recurrent disease.

0:13

These cases can be challenging because of the

0:16

postoperative changes, and it's the difficulty

0:18

of finding and evaluating that anastomosis.

0:20

So this shows the importance of really looking

0:23

at it in all the different planes and trying

0:25

to understand the anatomy that way.

0:28

And so here we have the transverse colon coming

0:31

across and coming down into the ascending colon.

0:34

And there's not really a cecum here.

0:36

So the ascending colon ends prematurely.

0:39

And then somewhere in here, we're going to

0:40

find the neoterminal ileum, which is the place

0:43

we really need to scrutinize above all else.

0:46

Of course, we'll look everywhere else in the bowel,

0:48

and we don't see anything glaring or any clear

0:50

evidence of wall thickening or abnormality there.

0:53

Looking in the coronal plane, again, looking everywhere

0:57

for any bowel wall thickening or abnormality.

1:00

We don't really see anything striking,

1:01

which is a good sign for this patient that

1:03

there's not a lot of Crohn's disease.

1:05

Similarly, on the steady-state precession images,

1:07

there are similar findings.

1:11

But let's look at the axials as well.

1:13

And on the axials, I think it's a little

1:15

more clear to find the anastomosis.

1:16

So here's that ascending colon.

1:18

And as we come down, you can see right here,

1:21

this is where the terminal ileum comes in

1:23

here, and you can see the communication there.

1:26

That's postoperative and as expected.

1:29

You can also

1:30

subtly see dark areas where that anastomosis exists.

1:34

And so as we closely evaluate this, we do see

1:37

that there's a little bit more inflammation

1:38

right adjacent to that anastomosis,

1:41

but it doesn't extend much beyond that.

1:43

It doesn't extend into the

1:45

large or small bowel very far.

1:47

We need to, of course, look at our other sequences in

1:50

that region and we see that little bit of potentially

1:53

mild thickening in that area, although there's

1:54

some artifact from the postoperative change as well.

1:58

And also we want to look at

2:00

our diffusion images, which is

2:02

oftentimes the most sensitive

2:03

way to detect inflammation.

2:05

And we see it's maybe just a little bit of diffusion

2:07

restriction or bright signal on this high B-value

2:09

diffusion image right at the site of anastomosis.

2:13

So this is often seen, and it doesn't

2:16

necessarily mean recurrent Crohn's disease.

2:18

And the way we typically interpret it is that there's

2:21

a small amount of perianastomotic inflammation,

2:24

which is essentially a nonspecific finding.

2:27

If they do a colonoscopy, they may see some

2:31

changes to mucosa in that region, but it

2:33

doesn't, if they biopsy it, they're not going

2:35

to find typical changes of Crohn's disease.

2:37

And this is not of significant clinical concern,

2:42

and it's something that should be continued to

2:44

be monitored, but doesn't require any action,

2:47

doesn't require aggressive treatment,

2:49

and certainly doesn't require any repeat operation.

2:52

So this is mild perianastomotic

2:55

nonspecific inflammatory changes.