0:01

So not all cases are pretty,

0:02

and this is an especially ugly one.

0:04

This patient has really severe disease, and this

0:07

is what things can look like in that setting.

0:10

So this is a patient with a lot of edema;

0:12

you can see all throughout the pelvis.

0:14

I think probably on the coronal images,

0:16

you can see really well.

0:17

that there's a lot of thickened bowel throughout

0:20

this patient's pelvis, really thickened loops,

0:23

and a lot of this looks quite edematous.

0:25

When we look at our fat-saturated sequence,

0:27

it's a little bit of an older case, so it's

0:29

a little messy on the fat saturation,

0:31

but you can see a lot of things that are bright.

0:33

There's a lot of fluid, a lot of edema, a lot

0:35

of issues throughout this person's pelvis.

0:38

So when we see that degree of inflammation, we need

0:40

to really look hard and figure out why it is so bad.

0:43

Is there some fistulization going on?

0:45

What is going on because of that?

0:47

On our axial sequences, we can see

0:49

there's some free fluid in the pelvis.

0:51

We can also see a lot of inflamed bowel loops.

0:55

And right here, we have that, again, that kind of

0:59

confluence of numerous bowel loops coming together

1:01

and kind of having that asterisk appearance.

1:05

And this is a site where there's a complex fistula

1:08

involving multiple loops of bowel.

1:10

And it's all conglomerating right there

1:11

in the central abdomen.

1:13

It almost has this kind of flagrant mass

1:15

type appearance in the center of the abdomen.

1:18

And we see this much degree of inflammation, this much

1:21

wall thickening, and inflammation throughout the pelvis,

1:23

we also need to look and make sure there's not

1:26

abscesses associated with a case like this.

1:29

And in this case, as we come up,

1:32

we see a few concerning things.

1:36

For one thing, this area here kind

1:38

of has this intermediate signal, and

1:40

it doesn't really look like bowel.

1:42

As we come up a little higher, you can see it has this

1:44

kind of thin rim of enhancement, and it turns out all

1:47

of this is an extraluminal complex fluid and debris.

1:52

So this is a large abscess.

1:54

I find that oftentimes when the abscesses are

1:56

really big, they can be embarrassingly hard to see,

2:00

and so I've seen lots of residents and fellows

2:03

miss cases where there are huge abscesses in the

2:06

pelvis, and it's because things look so ugly

2:09

that you have a hard time differentiating

2:11

what's bowel from what's abscess.

2:13

And so this is all extraluminal fluid and abscess.

2:16

You can also see here in the right lower quadrant,

2:19

we see that kind of same abnormal, kind of heterogeneous

2:23

signal on T2, and then peripherally, it's not enhancing.

2:27

So one of the hallmarks of abscesses

2:29

is that the periphery enhances,

2:31

but the center of it doesn't enhance.

2:33

So this is a small abscess over here.

2:35

This is an abscess here in the central abdomen with

2:39

the periphery enhancing, the center non-enhancing.

2:42

And I think on the coronal images, you can see

2:44

perhaps better where these abscesses are located.

2:47

So here's one here in this right lower quadrant with

2:49

that peripheral enhancement, central non-enhancement.

2:52

Here's that large area in the mid abdomen

2:55

that has that peripheral enhancement and

2:56

central non-enhancement, and you can see it

2:58

kind of expands all throughout this region.

3:01

And then another small one is

3:03

seen in the deep pelvis here.

3:05

And so when you have these severe complex

3:08

fistulas, you can see abscesses, and they're often

3:10

adjacent to the fistula tract, but they can

3:12

span throughout other locations in the abdomen.

3:14

So keep your eye out for those.

3:17

Those are things that everybody needs and wants

3:19

to know about because it really alters management

3:21

when you have big collections like this.