Female 36 years old Reason: 36 y.o female with a h/o of Crohn's disease with current flare. Please eval for extent of disease. History: N/V, diarrhea 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: Suboptimal evaluation of the small bowel due to poor distention. Within this limitation, there is wall thickening and hyperenhancement of the terminal ileum for a 18 cm segment. This includes the ileocecal valve. There is a linear connection between 2 loops of distal ileum in the right mid abdomen suspicious for a interloop fistula. There is also and inflamed loop of bowel in the left upper abdomen most likely representing a portion of proximal ileum that is suboptimally evaluated due to poor distention.There is thickening and hyperenhancement of the descending colon from the level of the splenic flexure to the rectum compatible with active inflammation.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.PELVIS:UTERUS, ADNEXA: No significant abnormality noted.BLADDER: No significant abnormality noted.LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: See aboveBONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.
1.Active inflammation involving the terminal ileum with findings suspicious for an interloop fistula.2.Additional areas of inflammation likely involving the proximal ileum suboptimally evaluated due to poor bowel distention.3.Active inflammation involving the descending colon.