Female 30 years old Reason: ileocolic Crohn's disease off therapy for 3 years, re-staging disease for stricture or inflammation History: abdominal pain ABDOMEN:LIVER, BILIARY TRACT: Liver is normal in morphology. Probable small hepatic cysts.SPLEEN: There is normal in size. There is a small splenule near the hilum.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: Small bowel is normal in caliber. There is severe bowel wall thickening and inflammation involving the terminal ileum. The segment of inflamed bowel measures at least 12 to 15-cm in length and involves the ileocecal valve. The area appears slightly patulous although there are certain points in the inflamed bowel pattern narrowed. Ileocecal valve is narrowed.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.PELVIS:UTERUS, ADNEXA: The right ovary is adjacent to the inflamed bowel. There is some adjacent peritoneal thickening.BLADDER: No significant abnormality noted.LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Please see aboveBONES, SOFT TISSUES: No pelvic abscess is evident. There is a small amount of pelvic free fluid.OTHER: No significant abnormality noted.
1.Findings of active inflammatory bowel disease involving the terminal ileum as detailed above.