45-year-old male with decreased appetite and abdominal pain. Evaluate extent and severity of Crohn's disease (ileocolonic). ABDOMEN:LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: No significant abnormality noted.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: There is marked wall thickening of the distal and terminal ileum over a length of approximately 20 cm with alternating areas of narrowing and dilation and surrounding fibrofatty proliferation, most compatible with acute on chronic inflammatory bowel disease. There is complex fistulization seen in the lower abdomen with a large fistula between the rectum and cecum (series 14/42) and a smaller fistula between the rectum and sigmoid colon (series 14/50). There are two small interloop abscesses also seen in this area anteriorly (series 14/45).BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.
Findings most compatible with active on chronic inflammatory bowel disease of the distal and terminal ileum. There is also complex fistulization with colocolic fistulas and interloop abscesses, as detailed above.