1:59

Um, but we will see plenty of, uh, great cases,

2:04

uh, of both Crohn's disease, ulcerative colitis.

2:06

Small and large bowel tumors.

2:08

All the indications, uh, CT and

2:11

MR, MR enterography are used for.

2:13

Um, and also we will spend a few minutes just

2:18

looking over the structured, standardized, uh,

2:20

reporting systems suggested for CTE's and MRE's.

2:25

And again, coming back to, let's start with CTE.

2:28

Um, of course, inflammatory bowel disease

2:31

remains the number one indication for CTE.

2:34

Uh, we also, um, suggest our, the

2:38

referring providers also request this for

2:40

evaluation of small bowel neoplasms and.

2:44

These are also wonderful for, uh, detecting

2:47

GI bleeding, and in fact, these are the, these

2:50

are the optimum imaging studies for detecting

2:53

GI bleeding and also for mesenteric ischemia with

2:56

just a slight modification in the protocol.

2:59

So.

3:00

Now for in general for CT enterography prep,

3:03

um, usually we advise fasting for six hours.

3:06

Some institutions use laxatives.

3:08

We don't use it in our institution, it's optional.

3:11

Um, in cases like this with large colonic stool

3:14

volumes, sometimes laxatives are very helpful.

3:17

Uh, these can compress on the

3:19

edges in small bowel loops.

3:20

Uh, also on MR, the large amount of

3:23

stool can sometimes cause artifacts.

3:25

So some laxatives can be useful.

3:28

Um, this is the protocol followed by our institution.

3:32

We don't do a pre-contrast image.

3:35

We are trying to reduce radiation as much as possible.

3:39

Uh, we have found that just the venous phase,

3:42

uh, done in axial and with reconstruction,

3:46

sagittal and coronal reconstruction suffice,

3:49

giving us all the information we need.

3:51

Uh, we also image from dome of liver to pubis.

3:58

Just a couple of minutes compared to MR

4:00

enterography, which takes much longer.

4:03

Uh, so we are able to cover large

4:04

areas in a short amount of time.

4:07

Now we do give PIC to the patients.

4:10

These may or may not be used in other institutions.

4:13

Um.

4:14

This was a policy in place before

4:16

I started here as a faculty.

4:18

Uh, I guess because of better

4:20

safety, renal safety profile of PIC.

4:22

It is slightly expensive, so may

4:24

not be feasible in all institutions.

4:26

Uh, contrast is given at a rate of four ccs.

4:29

The scan delay for, of 60 to 17.

4:32

Second, this is the typical

4:33

venous phase, oral contrast.

4:36

We give what is called, uh, the, uh, it's

4:39

called Bria, which is a flavored beverage.

4:42

Now let's take a step back and

4:43

talk about oral contrast agent.

4:45

Um, so the number one goal of oral

4:48

contrast agent is to identify bowel from

4:51

non-bowel structures in the abdomen.

4:54

Um.

4:54

This is also important for accurate assessment of

4:58

bowel wall thickness because, as you know, collapsed

5:00

bowel falsely gives us, um, increased thicken—thicken.

5:05

It gives the appearance of increased thickness,

5:07

and so we need to optimally distend it

5:09

before measuring the bowel thickness. And also,

5:13

especially with inflammatory bowel disease

5:16

and any enteritis as such, we absolutely need

5:19

to appreciate the mucosal, lip enhancement.

5:23

So, in general, there are like three types of

5:25

contrast: negative contrast, which is air—

5:27

It is

5:28

black. It outlines the wall.

5:31

Uh, positive contrast is the contrast which is used

5:34

in the normal outpatient, uh, inpatient settings.

5:37

It is bright. Contrast has barium or iodine

5:40

in it. And then we use neutral contrast.

5:43

So this is an image, is an example

5:45

of how positive contrast is

5:47

being—we are able to differentiate these

5:49

large lymph nodes, uh, in this patient with

5:52

non-Hodgkin's lymphoma from the actual bowel,

5:55

which are opacified with the contrast.

5:58

Again, this can be barium-based or iodine-based.

6:00

Um, if we are thinking of an, you know, in an ED

6:04

setting or, uh, where we—the patient may get

6:06

operated on, there is concern for perforation,

6:08

it's best to avoid barium to avoid the peritonitis.

6:12

Another example where these were actually the ovarian

6:16

in the pelvis in a patient with, uh,

6:18

ovarian hyperstimulation syndrome, you

6:20

can see some pleural effusion still.

6:22

Um, in this, we were able to effectively differentiate

6:25

these structures in the pelvis from the actual bowel.

6:30

Now, neutral contrast agent.

6:32

This is the contrast agent used

6:34

for CT and MR enterography.

6:36

We want the bowel to be not bright, so that we

6:41

can appre—appreciate this mucosal enhancement.

6:44

Um, and also the other goal for—to give

6:47

this large amount of fluid is to displace.

6:49

All the air in the bowel, uh, that

6:51

way it's kind of optimally distended,

6:53

doesn't create a lot of artifacts.

6:55

We typically give about 1,350 mL over 60 minutes.

6:58

Not all patients are able to drink this amount.

7:01

Uh, there are patients with large

7:03

bowel redundancy who may require more.

7:05

Um, the last 200 mL is given just 10

7:08

minutes before the study to—and the stomach

7:10

and di—di—the commercially available agents.

7:15

Um, Volumen—it's called Lumox now—and Bracco.

7:20

So Volumen has an extra component, which

7:23

is, um, uh, barium sulfate suspension,

7:26

but it is very, very low amount of barium.

7:29

The purpose—why barium is used for contrast agent is

7:33

it slightly increases the osmolality of the fluid,

7:37

and it keeps the bowel distended for several minutes,

7:41

giving us the time to image these

7:42

patients while the bowel is distended.

7:45

Now, Bracco does not have that component.

7:48

Um, it has other components which kind

7:50

of increase the slight thickness of

7:52

the, uh, fluid—like sorbitol, citric acid.

7:55

Um, but it is—theoretically it wouldn't

8:00

distend the bowel as much as Volumen does.

8:03

However, Bracco tastes like soda.

8:06

It has—

8:07

better, um, taste.

8:09

It has better, uh, flavor characteristics.

8:12

So it is, uh, kind of accepted by patients more.

8:15

In fact, there have been several

8:17

studies comparing these two agents.

8:19

Uh, there was one published in Radiology in

8:21

2018, which was a randomized control study of

8:24

66 pediatric patients, and they concluded

8:27

that the neutral oral contrast material,

8:30

uh, Bracco, uh, they provide similar small bowel

8:34

distension, and the patients tended—tended to

8:38

drink the entire volume of, uh, Bracco compared to

8:42

Volumen, where they were—Volumen—and where they were

8:45

not able to tolerate more than one or two bottles.

8:48

Now with imaging studies,

8:50

especially a long study such as MR

8:52

Enterography, patient cooperation

8:54

is extremely important.

8:56

So if you would ask me, I would rather

8:58

give the patient something which

9:00

they like, makes them comfortable.

9:03

And also, I would rather make them drink

9:06

a lot of fluid just than their bowel,

9:08

uh, than give something, uh, which, um.

9:12

Makes them, uh, creates discomfort.

9:14

There was another study in pediatric population,

9:17

uh, in which they said, uh, the Briza was more

9:20

palatable than Volin, and they also suggested

9:23

that, you know, you could try Volin. If the

9:25

patient doesn't like it, give them Briza.

9:28

So, use combination of both.

9:31

And so, what is a perfect, uh, CT Enterography?

9:35

Obviously, the bowel should be well distended.

9:38

Uh, most importantly, it should also have

9:40

an appropriate, uh, IV contrast phase.

9:44

And I have recently started loving

9:47

the multiplanar reconstructions.

9:49

These are really good to localize the mass or

9:53

inflammation, or they just exaggerate the abnormality.

9:57

Uh, they also show this, um, the prominent vasa

10:02

which you see in IBD really well.

10:05

And let's see, a few cases, uh.

10:10

Patient with, um, you know, really long

10:14

segment thickening of duodenum.

10:17

There is mucosal hyperenhancement.

10:20

Um, there is prominent vasa recta.

10:23

There were no fistulas or other abnormalities.

10:26

Um, in the cecal loops, you may have

10:28

noticed some enlarged lymph nodes.

10:30

And also, um, there was also a

10:35

perianal abscess as well.

10:37

All these findings were seen really well

10:39

on the enterography image in this patient

10:41

with active inflammatory bowel disease.

10:44

Another case, this case you could actually see

10:48

there is upstream, uh, dilatation of the bowel.

10:51

So, we could call this segment a stricture.

10:54

For you to call something stricture,

10:55

there should be a very obvious upstream dilatation.

10:59

Uh, also, the bowel was dilated

11:01

more than three or 3.5 centimeters.

11:03

This patient also had a perianal abscess.

11:07

All these features were seen on the CT Enterography.

11:10

Another example of, uh, a perianal abscess

11:13

as well as a fistula, um, which

11:17

was well visualized on this study.

11:20

And this is a case of a young woman with,

11:23

um, rectovaginal fistula, and you

11:29

can actually follow the tract pretty well.

11:32

Uh, this is coronal reconstruction.

11:34

You can see the fistula.

11:36

Um, so I do think that with experience and,

11:40

um, um, these can be picked up on CT as well.

11:44

Although MRI is considered the gold

11:46

standard for penetrating disease.

11:48

Um, very tiny fistulas are

11:51

kind of harder to see on CT.

11:54

Uh, this is the MR on the same patient.

11:57

Uh.

11:57

This was done a few months later and, uh, she's

12:00

pregnant on this MR. You can actually see.

12:02

And the non-contrast MRI was performed.

12:05

Um, you can actually see the fistula

12:07

tract pretty well on the MRI.

12:11

Again, the tract extending from ECT temp to...

12:16

So there are benefits to both techniques.

12:19

Um, another case, soft tissue mass in a

12:23

patient with biliary ductal dilatation

12:25

in the duodenum right at the ampulla.

12:28

So that was a case of ampullary

12:30

adenoma, um, again seen on enterography.

12:34

Um, so this would be a question slide.

12:39

So could we load question one?

12:42

Uh, for these images please?

12:46

Jaw, actually.

12:47

Oh yes, there it is.

12:49

Okay, so this — these windows can actually move to

12:52

the side if you still wanna look at the images.

12:55

These are the CT images of the pelvis.

12:58

What is your diagnosis?

13:00

Do you see a colon malignancy, colonic,

13:03

diverticulitis, aortitis, chronic

13:06

bleeding, or ulcerative colitis?

13:10

I love this combination of answers.

13:12

Thank you for participating.

13:14

So, looks like colonic

13:16

diverticulitis has the most words.

13:19

And to be honest, I'm from Missouri.

13:21

I see this like literally every day.

13:24

Uh, but in this case, there is diverticulosis,

13:27

there are tons of diverticula.

13:29

There is no inflammation around the colon.

13:32

There is no diverticulitis.

13:34

But you do see this.

13:36

So this is a non-contrast CT on the top and

13:39

then you start seeing the bright stuff inside

13:42

the colon, which tends to enlarge over time.

13:46

So this was a case of colonic bleeding,

13:50

and we were able to appreciate this bleeding

13:52

because of the enterography template.

13:54

Now, for GI—suspected GI bleeding,

13:57

we do get a non-contrast CT.

14:00

Uh, we also get an arterial and venous phase.

14:03

Um.

14:06

I am trying to get to the next slide.

14:08

Okay, there it is.

14:09

So this was, uh, the diagnosis

14:11

was actually colonic bleeding.

14:13

Um, and we ended up getting a

14:15

really delayed phase for the CT.

14:17

I don't know why, but then now the

14:19

colon's filled up with all the contrast.

14:22

You can see it in multiplanar reconstructions.

14:26

Case six.

14:27

So there's no question with this case, but I'll

14:29

give you guys a moment to spot that abnormality.

14:33

It's kind of an eye test.

14:35

I thought it was a cool case.

14:37

Okay, I think that moment's done.

14:40

Uh, so there is this fatty lesion in the ileal wall.

14:45

So this was a case of lipoma in the wall of the ileum.

14:51

This would be question two.

14:55

I could launch the poll.

15:00

I'll just move this to the side.

15:02

Uh, what is your diagnosis?

15:04

Is it small bowel lymphoma?

15:07

Small bowel hematoma? Crohn's disease?

15:10

I'm referring to the segment, uh, of proximal

15:13

small bowel—or small bowel adenocarcinoma.

15:19

That is great.

15:20

Yes, this is indeed small bowel lymphoma.

15:23

You all have very keen eyes.

15:26

Uh, so do you see this classic aneurysmal thickening

15:30

of the small bowel extending over a long segment?

15:34

So this came back as non-Hodgkin's

15:36

lymphoma of the small bowel.

15:41

Okay, so that was small bowel lymphoma.

15:44

I have a few example cases. I'll try

15:46

to get through as many as possible.

15:48

This was a case of small bowel to colonic fistula.

15:53

There were multiple tracts

15:56

in a patient with Crohn's disease.

15:58

Um, case nine, uh, there was—

16:03

uh, wait. Is this a question?

16:05

Yes.

16:06

So this is question number three.

16:09

What is the diagnosis?

16:12

Is this cecal adenocarcinoma?

16:15

Ccal angio ectasia, lower GI bleeding, or both B and

16:20

C. Which would be SL angio and lower GI bleeding.

16:26

Very well done.

16:28

So, yes.

16:29

So this was indeed.

16:31

So these hyper-enhancing dots, areas that you see

16:35

was actually a vascular abnormality in the SSL wall.

16:39

This is SL angioectasia, but you also see a blush.

16:45

Something which doesn't conform to the wall.

16:48

And it was confirmed on, um, angio.

16:51

So there was bleeding from this angio.

16:55

I have few more example cases.

16:58

Um, so this was both BMC, which is

17:00

SL angio with bleeding.

17:04

Uh, so there are abnormally dilated, uh, submucosal

17:08

veins, and right colon is the most common location.

17:13

Also, you can see there are exam—

17:15

These are the examples of arteriovenous

17:16

malformation where there are giant dilated

17:19

veins, uh, extending to the sigmoid colon.

17:23

Another case of a, uh, AV malformation in the jejunum.

17:31

This is, um, let me try to pronounce this.

17:37

Dieulafoy, sorry, I, I am, uh, not even gonna try it.

17:41

It's like, I think it's called like the Dieulafoy lesion.

17:44

Uh, I may be wrong.

17:45

So this is actually rare.

17:47

Um, it is seen, it's a large caliber arterial

17:51

in the bowel wall, and that sometimes erodes

17:54

and bleeds and can lead to GI bleeding.

17:58

A few other cases.

18:00

Uh, this is a case of, uh, mesenteric hematoma.

18:05

And these bright stuff, which you see

18:08

was actually just blood products, as there

18:10

was no active bleeding seen on, um, uh,

18:14

subtraction images, a case of adrenal hematoma.

18:19

And this was a case of, um, ileal adenocarcinoma,

18:25

again, seen on— okay, this would be a question four.

18:36

I would say this is the highlight of today's doc.

18:40

What is your diagnosis?

18:43

Is this a small bowel obstruction secondary

18:46

to adhesions, small bowel obstruction,

18:48

secondary to closed loop, uh, obstruction,

18:52

or a small bowel obstruction from internal

18:54

hernia, or a small bowel obstruction from B.

18:59

Yes, this indeed was a small bowel obstruction

19:04

secondary to— this was a giant hairball.

19:09

This was a baby hairball in the kind of—

19:13

Well, the report said distal jejunum, proximal

19:17

ileal region causing upstream dilatation.

19:21

And I have to apologize in advance.

19:26

I will be showing you some unpleasant images.

19:29

So this was actually endoscopy images.

19:31

You can see gastric rugae.

19:33

This was the hairball in the stomach.

19:36

Hairball in the jejunum.

19:37

You can see all mucosal part there.

19:40

Uh, so that was also spotted on enterography.

19:45

Um, I think this is the last case for CT enterography.

19:48

This was a case of obstruction secondary to adhesions.

19:52

Oh, and this was a case from last week.

19:55

I couldn't stop myself from, uh, posting this.

19:57

This was a case of small bowel wall, and because there

20:01

was no oral contrast present, uh, to create confusion,

20:06

you can actually see the segments which are

20:09

enhancing and the segments that were not enhancing.

20:12

There was extensive ischemia in

20:13

this patient from twisting cent.

20:16

At this point, you can see the beak there.

20:21

And, uh, this is a case of colon to duodenal

20:24

fistula, a small—this case shows how

20:29

important it is for the small bowel to be distended.

20:32

Okay, let's talk about MR enterography.

20:35

MR enterography, it's becoming the preferred

20:37

imaging modality to assess disease activity.

20:41

The GI docs are like more familiar with

20:44

this technique, and they've been requesting

20:46

more and more of MR enterography.

20:48

Uh, the advantages are there is no radiation

20:51

exposure, so this is extremely helpful, especially in

20:55

pediatric population, in children with inflammatory

20:57

bowel disease, who will get follow-up studies

20:59

all their life. Uh, because these radiation doses can

21:03

accumulate over time to cancer-forming doses, it's

21:06

important that we image wisely in this population.

21:10

And also, this is extreme.

21:12

This gives us high diagnostic confidence in evaluating

21:15

inflammatory, stricturing, and penetrating disease.

21:18

Um, prep, again, similar to CT—fast for six hours.

21:22

Laxative optional. Oral contrast is

21:25

given one hour before the procedure.

21:26

Again, Breather versus Volumen, things still stay.

21:29

Okay.

21:30

Just one point about Volumen: although it has barium

21:32

sulfate, which technically, uh, should

21:36

make, uh, this, um, the bowel dark, uh, because of

21:40

barium, but it's such minimal amount of barium

21:43

that this really doesn't signal intensity.

21:47

The sequence we perform are—

21:51

A regular T2-weighted sequence

21:53

in coronal and axial planes.

21:55

This gives us, the purpose of this is for anatomy,

21:58

to localize the lesion where it is present.

22:00

And this sequence is pretty robust for motion.

22:04

So even if there is peristalsis, kind of, it's, it

22:07

doesn't appear as, um, uh, you know, with peristalsis,

22:12

the, the motion is not reflected on the images.

22:15

Um, T2 fat saturation.

22:16

This is extremely important.

22:19

And also imaging,

22:20

the perianal region is really

22:21

important in all IBD patients.

22:23

That's part of our protocol, whether

22:25

the providers request it or not.

22:27

And with these T2 fat sat images,

22:29

the abscesses and fistulas just become

22:32

more conspicuous, and they stand out.

22:34

Um, another sequence, which is my

22:36

favorite is, um, the steady-state fast

22:40

precision sequence, which is slightly T

22:42

2-weighted so that the wa— the lumen,

22:44

the fluid within the lumen appears bright.

22:46

Uh, this kind of, uh, marks the bowel segment

22:50

and also this is pretty robust to motion.

22:52

Uh, so if you wanna evaluate, um, any

22:55

narrowing, uh, this, this is a good

22:58

sequence for thick wall thickening and—

23:01

Actually, this is my favorite sequence.

23:03

It's the cine, uh, steady-

23:05

state fast precision sequence.

23:07

Unfortunately, because we are trying

23:08

to make our MR shorter and shorter, uh,

23:12

we don't do this, um, sequence anymore.

23:16

Uh, but this gives us such a good idea about

23:19

the motility of the bowel, um, kind of,

23:23

um, is able to point us or lead us towards—

23:27

the actual segments which are narrow or strictured.

23:32

And, uh, of course, the— I say my, um,

23:36

my mentor used to call this the money shot,

23:38

which is the post-contrast sequences.

23:41

Um, these— it's so important to have as

23:45

less motion because these are gradient

23:48

sequences, and they are susceptible to motion

23:51

artifacts and to— wide or decrease the—

23:56

Glucagon is usually given, uh, just before

23:59

imaging, getting the post-contrast images. Now,

24:04

there are several different

24:05

protocols suggested for glucagon.

24:07

Uh, it can be given both IM or IV.

24:10

IM has a more unpredictable, uh, response.

24:13

IV has a more predictable response, but it causes

24:16

nausea, so it has to be injected very slowly, and it

24:20

has given— uh, some institutions recommend giving

24:23

it both before the pre-contrast sequences and also

24:27

just before administering contrast administration.

24:31

Um, unfortunately, because of the

24:32

nausea and the patient discomfort, we

24:35

don't give this in our institution.

24:37

Um, but, uh, this definitely

24:41

increases, um, that it, it stops the

24:44

peristalsis of the bowel and really helps, uh.

24:48

Decrease the amount of artifacts.

24:51

Uh, this is contraindicated in patients with

24:53

insulinoma, pheochromocytoma, glucagon.

24:56

Now, glucagon and imaging, again, this

24:59

is a little controversial, just like,

25:01

uh, volume and Brisac, um, controversy.

25:04

So there is—the evidence for its efficacy is lacking.

25:08

Um.

25:08

So there was this article in 1999, uh,

25:12

by EJ and group. Uh, they did not find

25:15

any improvement in colonic distension.

25:18

They—and then there was a publication by Dhan,

25:21

uh, which, uh—the publication said the IV

25:24

glucagon improved bowel visualization in pediatric MR

25:28

enterography, decreases examination length,

25:31

but however, it causes nausea, uh, commonly.

25:35

And, uh, in my experience,

25:39

patients have tolerated this.

25:40

Okay?

25:41

And some patients have crawled out of the scanner

25:44

because this just makes them extremely uncomfortable.

25:48

Uh, so there is wide variation in

25:50

how people react to glucagon and, uh.

25:53

There is this article in which, uh, Dhan concluded

25:57

that they tolerated hyoscine butylbromide—

26:00

it's also called Buscopan—better.

26:03

This could be a good alternative, um,

26:05

especially in developing countries where,

26:07

because hyoscine is, uh, cheaper than glucagon.

26:10

Uh, and this—but however, in this article, they

26:13

said that the distension with glucagon was better.

26:15

So there are two options.

26:17

Glucagon now.

26:19

Diffusion-weighted images.

26:21

These—

26:22

I feel are critical for diagnosis

26:25

of, um, especially in IBD.

26:27

Also, if there are any small and large bowel

26:30

tumors, these sequences make them more conspicuous.

26:34

Diffusion-weighted images are

26:35

also helpful, uh, to look for

26:38

any extraintestinal manifestations, for example.

26:42

Um, if there is cholangitis associated

26:44

with primary sclerosing cholangitis or if

26:47

there are metastases in the liver, um, we,

26:49

these sequences make it more conspicuous.

26:53

Um, now interpretation.

26:56

I would strongly recommend to refer to these articles.

26:59

I have referred to them and I continue

27:02

to refer to them while reporting.

27:04

Um, I think it's important for us to follow

27:06

the consensus recommendations and kind of

27:09

have, we do have structured reporting for CT

27:11

Enterography, and the structured reporting is

27:14

really helpful just to consistently communicate

27:17

the findings, uh, with the referring providers.

27:20

Uh, all the next few slides are

27:22

heavily based on these articles.

27:24

Let's start with this case.

27:26

This was an example of, um, you know, routine MR

27:30

uh, in which you could see in a patient with IBD.

27:33

There is a long segment inflammation.

27:36

Um, it's highlighted well on this steady

27:39

state free precession, uh, sequence.

27:42

Seen well on T2 and the diffusion-weighted image

27:46

is especially being able to highlight that portion

27:50

of mucosal, uh, enhancement or mucosal, uh, activity,

27:54

disease activity, which is shown as restriction.

27:59

So the important, uh, description and why MRI is

28:03

also useful and consistently shows these features

28:06

is, uh, segmental mural hyperenhancement.

28:09

Uh, this is increased signal

28:11

on contrast-enhanced, uh, MRI.

28:14

This could be asymmetric, it

28:17

could be bi- or tri-laminar.

28:19

For example, the mucosa and muscularis

28:22

propria enhanced, uh, with mucosa in between.

28:25

Or they could be homogeneous.

28:29

So this brings us to question number five.

28:33

Don't have image with this.

28:35

Which one of the following is considered a

28:38

highly specific feature of Crohn's disease?

28:42

Is it asymmetric bowel wall thickening?

28:44

Is it intramural edema, stricturing, or ulceration?

28:52

Yes, I am.

28:53

I'm glad it's kind of, uh, divided between asymmetric

28:57

bowel wall thickening and stricturing actually until,

29:01

um, the recent publications by Braining et al.

29:05

I was under the impression too that

29:07

stricturing is highly specific.

29:10

Um, so I think I should have, like,

29:12

reworded this a little bit better.

29:14

Structuring can be seen in several etiology.

29:17

We have to remember that it is

29:18

seen with radiation enteritis.

29:20

It is actually commonly seen

29:22

with NSAIDs intake for pain.

29:26

So that having said, asymmetric bowel wall thickening

29:29

is actually considered a highly specific feature.

29:33

Um, especially in active Crohn's disease and,

29:38

uh, this asymmetric thickening, um, is actually,

29:41

once this information came out, or I have been

29:44

like seeing this in a lot of, um, enterography,

29:48

a lot of active disease cases where the mucosal

29:52

border seems to be more affected than the—

29:57

It is thickened.

29:58

Uh, and what, what is meant

30:00

by this asymmetric thickening?

30:01

And they described in that article, uh, by Broering

30:05

that it could be asymmetric pattern of hyper

30:09

enhancement, or it could be asymmetric wall

30:12

thickening, or it could be asymmetric stratification.

30:15

Any of these three constitutes as

30:18

asymmetric thickening as seen in this case.

30:22

And wall thickening should only be measured in

30:25

the bowel that is well distended by, uh,

30:28

contrast, and it can be graded as mild, moderate,

30:31

and severe based on the amount of thickness.

30:33

Mild would be 3 to 5 millimeter thickness,

30:36

moderate would be 5 to 9 millimeter thickness,

30:39

and if it's more than 10 millimeter

30:40

thickness, it's considered severe disease.

30:44

And if it is way more than one centimeter—

30:48

if it's like almost 1.5 centimeters—then you

30:50

should start getting concerned about malignancy.

30:53

And also another point, uh, if there is

30:57

concern for malignancy, like in that, um,

31:00

uh, small bowel carcinoma case that we

31:03

saw today, the wall was really thickened.

31:06

Uh, mass and malignancy can also grow into—

31:09

organs. They kind of start growing

31:11

outside their serosal border.

31:13

So that could be another tip too.

31:15

So if there is significant thickening,

31:17

don't ignore that as just IBD.

31:20

Um, also, you should be concerned for malignancy.

31:23

Next point: we'll discuss intramural edema.

31:26

This is really well seen on the

31:27

T2 fat images, and if you see—

31:32

uh, hyperintense signal on fat-sat images,

31:35

as well as restriction on diffusion-weighted

31:37

images—that confirms, uh, severe inflammation.

31:43

Now, um, luminal stricture.

31:46

So I actually, I know we are speaking about the MR

31:48

portion, but I brought up the CT image because this

31:50

shows the definition of stricture really, really well.

31:54

Uh, for you to call something a

31:55

stricture, there should be unequivocal

31:58

upstream dilatation and the lumen.

32:00

Upstream dilatation should be

32:02

at least three centimeters.

32:04

And, uh, we should describe

32:06

the length of the stricture.

32:07

This will be helpful for

32:08

surgical endoscopic evaluation.

32:10

And also, as I was mentioning, strictures can

32:13

also be seen with NSAIDs and radiation pathy.

32:16

Um, so this, these are few other examples

32:19

of strictures with, like, upstream dilatation.

32:22

This is a long segment stricture.

32:25

And ulcerations, we actually see them,

32:27

especially if the study is done really well.

32:29

Um, these are, uh, kind of small focal

32:33

breaks in the surface of the bowel wall.

32:36

We can also see them on these T2 FSE images,

32:39

and in the article, um, they, uh, suggest that

32:44

avoid the term penetrating ulcer so that it is not

32:47

confused with penetrating disease such as fistula.

32:52

We can also sometimes see micro

32:54

abscesses in the wall, and also there

32:58

is a terminology called pseudopolyps. The border

33:03

shows asymmetric thickening and strictures.

33:06

The wall can also stricture asymmetrically.

33:09

So sometimes you see these

33:10

projections along the mesenteric border.

33:13

This is the mesenteric border.

33:14

It's just that the baby is flipped.

33:16

Um, these are called pseudosacculations.

33:19

They indicate more, uh, chronic, uh, disease and

33:23

there is diminished motility, which you see as well.

33:26

In this case, there is, um...

33:29

Fistula, and these few segments are moving

33:33

less than the other non-affected segments.

33:36

Now let's talk about penetrating

33:38

disease, uh, because the highlight of MR

33:40

enterography is the ability to

33:44

identify and describe these lesions. So,

33:47

fistulas can be defined as simple.

33:49

So penetrating disease can be

33:51

fistulas, abscesses, sinus tracts.

33:54

So, simple fistula.

33:56

Again, the definition is from the article.

33:58

Again, I cannot emphasize how often this article is.

34:01

Um, so simple fistula can arise from a

34:04

segment of active inflammation or stricture.

34:07

It can connect.

34:08

Bowel to bowel when it is tract,

34:10

fistula to adjacent organs.

34:12

Uh, for example, vagina or bladder, or

34:15

to the skin when it's called a cutaneous.

34:17

Complex fistula is kind of, you cannot

34:21

really, uh, have a start and endpoint to it.

34:24

Multiple bowel just come and they converge, uh,

34:27

usually around an abscess or an inflammatory centric

34:30

mass, and they form what is called a star sign.

34:34

Sinus tract is kind of a blind-ended tract.

34:37

It extends outside the, but

34:39

it doesn't really extend to

34:42

organ, soft skin.

34:44

And then, yes, we always image the perianal

34:47

region and, uh, uh, so there could be many

34:52

patients who present at the time of initial

34:54

diagnosis with the penetrating disease.

34:56

Uh, so this unfortunately brings me to this case,

35:00

uh, of a young man with Crohn's disease who had

35:04

all types of fistulas, sinuses,

35:06

and all, and abscesses.

35:08

Um, there were several perianal

35:12

draining, uh, fistulas extending to the skin.

35:15

In fact, the fistulas were crossing over.

35:18

There were a few transsphincteric, uh, fistulas.

35:23

And this is, uh, an enterocutaneous fistula,

35:27

draining both posteriorly and anteriorly.

35:31

This is the star sign, where all the bowel kind

35:34

of confluence around this, uh, area of scarring.

35:41

And this patient, the ureter also got caught up

35:44

in the clover sign or the star sign, a complex

35:47

fistula tract, and there was debris within

35:49

the ureter, which end upstream dilatation.

35:53

The patient also had myositis, uh, the inflammation

35:56

extended to the muscle, and also, it's not included

35:59

in the image, but the coccyx was inflamed, uh, coccyx,

36:02

and the patient also had osteomyelitis.

36:07

So, last question for the day.

36:10

Identify the structure indicated by the arrow.

36:14

It's the same patient.

36:18

All right, so.

36:21

This was actually this patient's undescended testicle.

36:27

And I will be honest, it took me a few minutes

36:30

to figure this out, and that's why I have

36:33

this companion image of the left groin, where

36:36

you kind of see this on the left side too.

36:38

It was undescended.

36:40

Um.

36:41

But it was not completely

36:43

descended into the scrotal sac.

36:44

It was kind of in the inguinal canal, but on the

36:47

right side it was actually along the pelvic sidewall

36:51

and it was caught up in all this inflammation.

36:55

And, uh, so there was no testicle present

36:57

in the right groin or right scrotal sac.

37:01

And it has, the appearance of it has, it's T

37:03

2 intermediate, uh, does not hyperenhance.

37:07

Uh, so, um.

37:10

So for those of you unstatistical,

37:12

that, that's the right answer.

37:18

Okay.

37:20

This is another case of trans

37:22

fistula, different patient.

37:24

Uh, it starts from a small abscess, but

37:27

then you can see, um, let me control this.

37:31

So it kind of extends.

37:34

Along, uh, the external and internal sphincters.

37:39

Uh, it's also shown based on the coronal

37:42

images, uh, the dark signal with the

37:46

fistula because of the presence of air.

37:50

And, uh, this extraordinarily good resolution,

37:54

um, is seen on T2 fat-saturated images.

37:58

Um.

37:59

Also the other entities we should know with.

38:02

Um, uh.

38:04

Inflammatory bowel disease is, um, the inflammatory

38:07

mass, which we can see shows restriction

38:10

of diffusion and heterogeneous enhancement.

38:12

There is fibro-fatty proliferation, which

38:15

is, which we have seen in all these examples.

38:17

Uh, some of the sequelae of IBD could also be centric

38:21

vein thrombosis, and we almost always see adenopathy.

38:25

Um.

38:26

With MR enterography, we can

38:27

also see extraintestinal findings.

38:30

For example, in this patient with ulcerative

38:32

colitis who also had primary sclerosing

38:35

cholangitis, and we were able to see

38:38

multiple areas of strictures in the liver.

38:43

So reporting-wise to kind of, um, we

38:47

did see all the interpretation portions.

38:49

Uh, so what do the GI docs want?

38:51

They want to know if there is Crohn's.

38:53

First of all, they wanna know if there is IBD or not.

38:56

And then we should, uh, report the number of

38:59

involved bowel segments, approximate location,

39:02

length, and degree of upstream dilatation, and, um.

39:06

When describing the bowel loops, having

39:08

Crohn's stricture, it's important for us

39:11

to say if there is active disease or not,

39:14

because you can still see strictures, fistulas,

39:17

in patients who do not have active disease.

39:21

Uh, so the, uh, the article in Radiology

39:24

has given us, um, suggestions on how we can

39:27

structure our imaging findings and impression.

39:30

Uh, for example, if there is just

39:32

segment hyperenhancement, um.

39:35

Or, uh, you know, if there is no

39:38

known diagnosis of Crohn's disease.

39:40

You can call the impression of non-specific small

39:43

bowel inflammation until it is diagnosed, um,

39:47

by colonoscopy or other tests, and if there is

39:51

asymmetric wall thickening, hyperenhancement, edema.

39:55

Um.

39:56

You could say, uh, and if in a patient with high

39:59

suspicion for Crohn's disease in the impression,

40:01

you could include it as active inflammatory,

40:03

small bowel Crohn's disease, and, uh, whether

40:06

you can also include in the impression without

40:08

luminal narrowing or with luminal narrowing.

40:11

Um, and then in a patient with known Crohn's disease,

40:16

uh, if there are no imaging findings of inflammation.

40:20

You could include in your impression as

40:22

Crohn's disease with no imaging signs of

40:25

active inflammation, and if there is persistent

40:29

luminal narrowing with upstream dilatation,

40:32

that's when you're gonna call it a stricture.

40:34

And if there is, uh, there is upstream dilatation.

40:38

You can also call it a small bowel obstruction.

40:40

And you need to see active inflammation—

40:42

that is, mucosal hyperenhancement—

40:45

uh, to call this, um, stricture with

40:48

imaging findings of active inflammation.

40:51

If there is fistula, sinus tract, or abscesses,

40:55

you could include penetrating Crohn's disease in

40:57

your, uh, disease, and depending on the location,

40:59

you can call it perianal Crohn's disease.

41:02

Now, creeping fat, you know, this is—

41:06

no longer an entity, entity, which is

41:08

ignored, uh, because, um, it is, it is becoming—

41:12

they're becoming more and more aware of the

41:14

fact that visceral and mesenteric fat can become,

41:17

is to become a therapeutic target in IBD.

41:20

And, uh, people are coming up with various imaging,

41:23

uh, techniques to actually assess the changes

41:26

in, um, fat around the inflamed segment or the

41:29

creeping fat to assist the response to treatment.

41:32

Um.

41:34

Few examples of MR enterography.

41:36

Uh, this is a patient with ulcerative colitis.

41:39

You see a long segment of descending colon, which

41:43

is, uh, starting from rectum, then sigmoid colon,

41:49

and then you see descending colon, splenic flexure,

41:54

portion of transverse colon are all a RA.

41:57

It's interesting how you can actually

41:59

see the transition to normal RA and

42:02

the transverse level of transverse colon

42:07

right over here.

42:10

Uh, this is T2-weighted images, which also shows

42:14

that haustral nature of the colon pretty well.

42:18

Uh, so this mainly affects the mucosa, submucosa.

42:21

So stricture is really rare.

42:23

If you do see a stricture in the colon in

42:26

a patient with ulcerative colitis, there, you

42:28

should start getting concerned about cancer.

42:31

You can also see pseudopolyps.

42:33

Um, this, because of the stricture, because of

42:36

the inflammation, it can shorten the colon.

42:39

Now, CT versus MR. There’s always this debate—

42:44

Which one's best?

42:45

There are several articles which said both

42:47

have similar sensitivity in detecting the—

42:50

uh, active disease or chronic changes.

42:53

I think for inpatient and ER settings, CT

42:57

enterography, which can be done rapidly, is optimal.

43:01

I'm yet to see a single, uh, inpatient MR

43:04

enterography which has come out perfectly.

43:06

These patients cannot hold— like,

43:08

they cannot really cooperate.

43:09

They cannot hold the breath.

43:10

They have other comorbidities.

43:12

So I think doing a rapid test,

43:14

such as CT, is better with them.

43:16

Enterography needs more, uh, patients

43:19

who can cooperate a little better.

43:21

Um, CT—

43:22

Great for initial diagnosis and then for

43:25

follow-up studies to assess response to treatment.

43:27

MR enterography would be—

43:29

optimal in pediatric patients.

43:31

I strongly recommend MR enterography

43:34

because there is no radiation risk.

43:36

MR enterography can also be utilized in

43:38

pregnancy or in incidences, uh, in and other

43:41

examples where you want to do a non-contrast

43:44

MRI, um.

43:46

But if there are contraindications to MRI,

43:49

uh, pacemaker or other contraindications, CT

43:52

Enterography would be the default technique to do.

43:55

Again, if there's iodine dye

43:57

allergy, we can consider MR

43:59

Enterography for penetrating Crohn's disease.

44:02

MR Enterography is optimal at the end of all this.

44:06

I think, um, the.

44:08

It completely depends on local

44:10

image access and expertise.

44:12

Um, and also the preferences of

44:14

referring providers sometimes.

44:15

And also we should follow the ACR and

44:18

other, um, GI guidelines while, uh,

44:21

performing and ordering these studies.

44:24

A couple more examples.

44:26

Um, so this was a patient who had a

44:29

centric mass, also had a mass in the cecum.

44:33

Right at the level of ileocecal junction, there

44:36

were some calcifications seen within the mass.

44:40

An octreotide scan — it lit up.

44:43

In addition, there were two lesions

44:45

also seen in the right liver.

44:47

So this was a neuroendocrine tumor,

44:50

um, for carcinoid tumor possibly.

44:53

And, um, so.

44:55

We did do an MR Enterography on this patient in

44:58

which you can see the mass, which is lobulated,

45:02

and on MRI you will not be able to appreciate

45:04

the calcifications, and we were able to see

45:08

really well the liver lesions. The, it, it has

45:12

T2 intermediate intensity, enhances as well.

45:16

Uh, restrict and diffusion in addition, but we

45:19

saw numerous spots of restriction of diffusion.

45:22

So these were all neuroendocrine

45:24

metastases, which were not seen on the CT.

45:27

So with this case, I would like to say

45:29

that sometimes CT and MR Enterography

45:31

are complementary to each other, so we

45:33

may not have to decide one over the other.

45:36

Um, you know, if you don't see penetrating

45:38

diseases well, or if you want to work

45:40

up, the metastases can come in handy.

45:45

This is another case, uh, which was

45:46

actually seen initially on CT and

45:48

then an Enterography was performed.

45:51

There is a mass in the duodenum, restrict on

45:55

diffusion, and, uh, you can actually see it on

45:59

T2, seen well on, uh, coronal images as well.

46:03

And that was an adenoma.

46:05

And this is another case of, um, really this

46:09

is a T2-bright lesion in the colon, which.

46:13

Shows nodular enhancement with gradual fill-in.

46:17

Does it ring a bell?

46:18

This is how hemangiomas enhance, right?

46:20

In liver or in the colon.

46:22

So this was a great example of hemangioma.

46:26

So to summarize, CT Enterography and MRI

46:30

are both excellent imaging options, uh, for

46:33

evaluation of IBD and other bowel tumors.

46:36

Uh, CT is excellent for initial diagnosis.

46:38

MRE could be used for follow-up and for evaluation

46:41

of the penetrating disease, and it's important for

46:44

us to use a consistent, standardized terminology.

46:47

Again, going back to the article by Brainey,

46:50

I would recommend that, um, to accurately

46:53

describe radiology findings, and also

46:57

this ensures the comprehensive evaluation

47:01

and facilitates the compatibility of the reports.

47:05

Thank you.

47:05

Um, you can email me with any questions,

47:07

but I guess we have a few minutes

47:09

to discuss your question as well.

47:15

If you, uh, look in the bottom right-hand

47:17

corner, or actually it should be at the

47:18

top because you're sharing your screen.

47:20

Oh yeah.

47:21

There should be a Q&A section you can click

47:23

on, and you'll be able to see all the questions.

47:25

Yeah, I think I was able to pull it up,

47:27

but just let me know if I missed any questions.

47:30

So the first question I see is,

47:32

can water act as neutral agent?

47:35

Absolutely.

47:36

Water is a neutral agent.

47:38

Uh, the only issue with

47:40

using water for CT and MR Enterography is they—it

47:44

gets absorbed really fast, which is kind of okay for

47:49

CT Enterography too, but you know, it's more rapid.

47:53

You need something which has slightly higher osmolality

47:56

and distends the bowel, at least for a few minutes.

47:59

Uh, water absolutely doesn't

48:01

work for MR Enterography.

48:03

You need the bowel to be distended,

48:04

at least for 20 to 30 minutes.

48:06

So you need to use other agents which have sorbitol,

48:09

gum, and you know, barium sulfate in volume, and

48:13

other agents which can kind of increase the

48:16

osmolality of the water to keep the bowel extended.

48:19

Um, next question is, can we give neutral

48:23

contrast in case of subacute obstruction?

48:26

You know what?

48:27

I, at the, for obstruction, any contrast is great.

48:32

Any contrast which is safe is great because you

48:36

want to extend the, to find a transition point.

48:40

For subacute obstruction, I would personally give a,

48:43

um, bright contrast agent or a positive contrast agent,

48:47

just so that I can definitively say if the contrast

48:51

has transitioned beyond the transition point. I will

48:55

not be able to say that with neutral contrast agent.

48:58

So for subacute obstruction, my personal

49:00

preference would be a positive contrast agent.

49:03

The next question is, do you give

49:04

medications for bowel paresis?

49:07

You know what? I, personally, I think giving

49:11

medications for bowel paresis is very helpful.

49:14

Um, glucagon and Buscopan are both

49:17

agents, which I discussed in this—

49:19

Um.

49:19

—presentation. We don't give them at our

49:22

institutions because it was just

49:25

really hard to kind of, um, coordinate.

49:28

And then, um, it's just, many

49:31

patients—we have only used glucagon.

49:34

We have not used Buscopan, so I cannot, um,

49:37

really speak about our experience with

49:39

that medication, but with glucagon,

49:41

many patients were uncomfortable.

49:43

So the nurses have to be trained, or the

49:45

technologist, to inject this really, really slowly.

49:49

And we, as a fellow—I, um, I actually injected

49:53

it myself really slowly, but you know, the

49:56

workflow—things have become so much busier.

49:58

So it's kind of harder for us to get involved.

50:01

Yes.

50:02

So if you are able to do it, then

50:04

I think medications really help.

50:06

Uh, we don't do it in our institutions.

50:10

So are these videos available for watching later?

50:12

I think this is a question for Joe.

50:14

They, they are available as replays, right?

50:17

Yes.

50:18

It'll be available on the website later this evening.

50:21

Okay.

50:24

Yes.

50:25

And, uh, thank you, Joe.

50:27

And they said, can we have structured

50:29

reporting format available?

50:32

You know what, um, I will be

50:33

happy to share it with you.

50:35

Uh, we have a very well-functioning, uh,

50:37

structured, structured reporting format.

50:40

I can send it to Ashley and Joe, or you could

50:42

like email me, uh, on this email on the

50:45

screen, and I'll be happy to share it with you.

50:49

Um.

50:50

For underdeveloped countries, what

50:51

alternative preparation we can use if we

50:53

don't have Briza and Volumen really available?

50:56

You know what, that's a very good question.

50:59

I have been thinking about this, and I, I have

51:04

tasted Briza, so you know what, I, I don't, I'm

51:07

sure, like the companies have better reasoning.

51:10

These are safer, well-tested on people.

51:13

Um, so.

51:16

I would just give water or soda or other

51:19

preparations, which, um, could, uh, so

51:22

fizzy water, basically, um, soda, can they

51:26

say, um, can, uh, keep the bowel distended?

51:31

I don't have personal experience with this,

51:33

so I'm not really endorsing the technique.

51:35

But, um, that is something I've thought of.

51:37

And, uh, I would, I would like to know if any of you

51:41

have used anything other than this, which is, um.

51:45

Kind of less expensive alternatives, but I would,

51:48

I would think soda or, uh, you know, just sparkling

51:51

water should do that, you know, should help.

51:54

Although I have no experience with this.

51:56

Um, can patients with difficult bowel prep

51:59

for endoscopy can be, uh, so can people

52:06

with difficult bowel prep for endoscopy

52:08

can be an indication for CT enteroscopy?

52:13

You know what, I don't think so, because

52:16

large amount of stool in the colon

52:20

really creates a lot of artifacts.

52:23

So I think a good, uh, that is not really

52:26

an indication, but if the patient cannot

52:29

get an endoscopy for any reason, we

52:31

could definitely try CT enterography.

52:33

I think it'll still give you information,

52:36

but you shouldn't be referring the patient

52:38

just because the bowel prep is not good.

52:41

Maybe repeat endoscopy with the stronger

52:43

regimen would be a good option, uh, because.

52:47

Excessive amount of stool just

52:49

does, just degrades the images.

52:51

But if there are no other choices,

52:53

definitely CT enterography.

52:56

Now, 1.5 was the 3T magnet for abdominal MRIs.

53:00

I think a lot of, um, they, they're, you

53:04

know, it's improving now, right?

53:06

They're bringing in all these newer

53:09

sequences which are more robust to motion.

53:12

I personally do like 1.5 Tesla, especially

53:16

uh, imaging structures which have, you know,

53:21

techniques or imaging studies which are

53:23

prone to artifact, which is the best example,

53:26

is the post-contrast images of, uh, MR

53:28

enterography.

53:30

The bowel is peristalsing.

53:31

So if you have not given glucagon, if there

53:33

is no adequate, uh, distension, I think

53:36

1.5 would be more robust for the artifacts.

53:40

But, um, 3T, uh, is also fine, uh,

53:45

with the newer sequences.

53:46

But if I had to choose, I would choose 1.5.

53:51

Any clues for finding bowel-to-bowel

53:53

fistulas? There are times they are difficult to find.

53:56

Um, thank you for your compliment.

53:58

Um, so, uh, they said, "Thanks

54:02

for the wonderful lecture anyway."

54:04

So any clues for finding bowel-to-bowel fistula?

54:08

You know what?

54:09

Adequate distension always helps.

54:12

And for me, like for the CT study in which there

54:16

was this perianal fistula, that was a hard one.

54:20

For the CT especially, windowing really helps.

54:23

I actually

54:24

window it down to the liver window

54:27

and then slightly adjust it.

54:29

And that kind of makes, especially in the

54:31

perianal region, it makes it more conspicuous.

54:35

Um, so for the CT, windowing definitely helps.

54:39

Bowel distension is a must.

54:41

And, uh—

54:42

For MRI, it's important for us

54:45

to have larger field of view.

54:47

And again, for MRI T2, fat sat is the key.

54:51

There are also, like, STIR images, which

54:53

are inversion recovery images, which also

54:55

are very sensitive to show the fistulas.

54:58

So spend more time on the T2 fat sat images.

55:02

Can 2% mannitol be used as a neutral contrast agent?

55:06

I did read an article on this

55:07

while doing research for this.

55:09

I don't have experience on this.

55:11

I think I would refer

55:12

you to do independent search.

55:14

I, I absolutely don't have experience on Mannitol.

55:18

Can we use pineapple juice as oral contrast?

55:20

You know what?

55:22

I was, I read an article on milk being used as oral

55:26

contrast, pineapple juice being used as oral contrast.

55:29

I do, you know what?

55:30

Technically, pineapple juice does

55:32

have all the sugary osmolal stuff.

55:34

So again, I don't know.

55:36

I do feel these are alternatives,

55:38

which is completely worth the try.

55:41

Um, as long as they're safe and your patients

55:43

are okay with that, try it on your patients.

55:45

Do a couple of MRs and see if

55:47

you're able to achieve this.

55:50

Technically, I feel anything

55:52

other than water should be good.

55:53

Uh, so, but I think if you, if you have

55:56

some experience with this, please share with

55:58

me how to know by CT and MRI, the cause of

56:01

stricture is more due to Crohn's or cancer.

56:04

Very good question.

56:06

Sometimes in early cancer, it's impossible to know.

56:10

Um, so that's why we ask for follow-up.

56:13

If the thickness of the wall is more than

56:16

one, one centimeter or 1.5 centimeters,

56:20

I am really concerned about malignancy.

56:23

Malignancy also restricts. Uh, so I would get a

56:26

short interval, but if it's between one to 1.5,

56:30

there is, and also in malignancy, you don't see much

56:32

inflammation around it. In Crohn's disease and MRI,

56:36

there is bowel wall thickening and there is

56:38

extensive restriction or prominent vasa recta, or like

56:42

all other features of inflammation around it.

56:45

With cancer, you can have a little bit of

56:47

inflammation, but not a lot of inflammation.

56:50

So if it is more than 1.5 centimeters

56:53

thickness in a well-standard bowel wall,

56:56

if without much inflammation around it,

56:58

I would be more concerned for malignancy.

57:01

But if it is between one to 1.5, you're

57:04

not sure, get a short interval follow-

57:06

up and, uh, see if this mass has grown.

57:10

And I would suggest like in short interval

57:12

follow-up in three months, we are—

57:15

Um, lactose mixed with water and

57:17

diluted Mannitol prescription.

57:19

That is good to know.

57:21

Um, so because that could be an alternative

57:24

for the previous questions, uh, which are

57:26

asked. Uh, I don't have experience, but

57:28

thank you for sharing water and Mannitol.

57:31

Can it be a good combination?

57:32

You know what, I need to really look into Mannitol.

57:34

I have no experience.

57:36

It could be. We have to look at the

57:38

literature for this post-treatment appearance.

57:42

Um.

57:44

Particularly biologicals.

57:45

You know what, I would like to—maybe as a

57:48

follow-up lecture, I could actually bring

57:51

cases post-treatment, but I think it's

57:53

like beyond the scope of this discussion.

57:55

But that's, that's a good question.

57:57

Um, thank you for your comments.

58:00

I think I've, uh, I think I've

58:02

like answered all the questions.

58:03

What do you think, Jill?

58:07

You do?

58:07

I think we're done.

58:08

Yes.

58:09

Yeah, as we bring this to a close, I want to thank you,

58:11

Dr. Tepa, for giving this lecture, and thanks to all

58:14

you guys for participating in our noon conference.

58:16

A quick reminder that this conference will

58:18

be available on demand on MRIonline.com,

58:21

in addition to all the previous noon conferences.

58:25

Tomorrow we're gonna be joined by Dr.

58:26

Maher Mehta for a replay lecture on

58:28

imaging of the gallbladder and bile ducts.

58:31

You can register for that at MRIonline.com, and

58:33

follow us on social media at MRI Online for

58:36

updates and reminders on upcoming noon conferences.

58:38

Thanks again and have a great day.

58:41

Thank you, Joe.

58:42

Thank you, guys.

58:43

Bye.