14-year-old male with presumed Crohn's disease, vomiting, history of fistula PELVIS:PROSTATE/SEMINAL VESICLES: No significant abnormality noted.BLADDER: Moderately distended with fluid.LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: A thin enhancing T2 bright tract extends from the anus (3 o'clock) to the left gluteal fold, unchanged from the prior exam. An additional thin enhancing T2 bright tract extends from the anus (7 o'clock) to the medial right gluteal fold with a small associated phlegmon but no fluid collection. Moderate perianal enhancement and wall thickening. No loculated fluid collection or abscess.BONES, SOFT TISSUES: The SI joints are normal.OTHER: Moderate lower abdominal and pelvic ascites likely relates to the patient's active inflammatory bowel disease better evaluated on recent CT.
1.Perianal inflammatory changes with persistent left and new right perianal fistulas as described above. Small phlegmon along the right medial gluteal cleft without evidence of abscess.2.Moderate pelvic ascites.