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This is Pediatrics week 5 case number five. The

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diagnosis under consideration is inflammatory bowel disease

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and we have Mr. Enterography, which

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is the gold standard for evaluation on Imaging. Of

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course as a corollary, the gastroenterologist will

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perform colonoscopy or maybe even EGD and

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do direct visualization and

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biopsy sampling of the mucosa.

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On Mr. Imaging what we expect to see

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if inflammatory bowel disease is indeed present is

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free fluid indicating inflammation in

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the abdomen. We expect to see bowel wall thickening whether

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it be spot lesions and the ilium and colon

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or even the rectum.

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or continuous involvement

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and then in severe cases, we might see fistulization

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of the bowel to other structures even to

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the skin and abscess in a late

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complication and then there's also the possibility

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of perianal disease which is typically evaluated separately

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on an MR pelvis. We're going to focus on the bowel here

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on this case. I've got T2 weighted.

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Coronal Imaging and you can see there is fluid in the bowel. This

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patient has ingested positive contrast in addition to

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us giving IV contrast on later Imaging sequences. And

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as we scroll through we can see the majority of

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the loops of small bowel have a normal appearance of the bow wall.

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This isn't asymmetrically thickened. It doesn't

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look abnormally collapsed. This is pretty typical. We're not

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too worried about this Bell.

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First I want to go over and look at these Loops, but

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then I want to look at the colon and cecum.

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And here's the cecum here. And this looks like a little mild wall

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thickening. Here's the iliocecal valve.

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Don't be confused by the leaflets of

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the valve appearing in large. That's typical. What we're

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more interested in is what does the terminal ileum? Just prior to

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that ileocal valve look like and it looks a little thickened and

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as we scroll backwards we can see some abnormal

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thickening of this terminal ilium, so I'm going to magnify this.

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Just so that we can drive this point home. So we're very much

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looking carefully at the right lower quadrant. Look

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at the thickness of the bowel wall. So this is

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normal colonic bowel wall.

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Look at the sharp thin lines.

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That's appropriate. However

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If you look over here, this wall is

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quite thickened on both sides.

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And this is focal inflammation of

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the terminal ileum. And if I were to

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scroll over over by the cecum, you would see the same appearance.

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So we've got asymmetric partial involvement

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of the terminal ileum. We've got thickening you

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can even see the diameter of the Lumen his tapered

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dramatically from here down to here and

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then of course at the level of the insertion

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on the CM, there's a little bit of thickening of the

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proximal colon.

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Let's go ahead and look at a post contrast Imaging sequence.

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just to see if there is

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Any enhancement?

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And here we can see.

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There's pretty uniform enhancement of the bow

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wall.

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and the

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colon is very full of stool which could indicate

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some level of dysmotility, but you can

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see that the bow wall here.

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Over in the left Hemi abdomen is roughly enhancing as

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much as it is here at this thickened area of the terminal ilium. So

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what that suggests if you see thickening of

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the wall, but not particularly hyper enhancement is

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this maybe chronic inflammatory bowel

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changes without acute exacerbation.

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So once that thickening occurs, it'll be

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there even in between a cute episodes that are

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so called flares of the inflammatory bowel disease.

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This patient turned out to have Crohn's disease but enhancement

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can help you to distinguish between the acute

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and a chronic appearance of the disease. That's

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the end of the case.