Demographics:
18 years old, Male
Indication:
Right lower quadrant pain
Findings
Lower chest
- 7 mm nodule and scattered groundglass opacities in the left lower lobe
Abdomen/Pelvis
- Marked bowel wall thickening and mucosal hyperenhancement of the terminal ileum with surrounding fat stranding and adjacent peritoneal thickening
- Distal appendiceal wall thickening and dilation with periappendiceal stranding and a possible small fistulous connection between the appendix and the terminal ileum
- Mild fullness of the right renal collecting system
- Mild splenomegaly
- Small amount of free fluid in the right paracolic gutter and layering in the anatomic pelvis
- Multiple mildly enlarged ileocolic lymph nodes, likely reactive
MSK
- No acute findings
Diagnosis
Crohn disease
Sample Report
Marked inflammation of the terminal ileum consistent with infectious or inflammatory ileitis. Crohn disease is a primary consideration given location.
Distal appendiceal inflammation and possible fistula between the appendix and terminal ileum which may relate to acute appendicitis or appendiceal involvement of Crohn disease.
Mild fullness of the right renal collecting system likely reflecting delayed emptying due to secondary inflammatory changes of the right ureter.
Splenomegaly.
7 mm solid nodule and scattered groundglass nodules in the left lower lobe are likely infectious/inflammatory in etiology. Recommend follow-up chest CT after treatment to ensure resolution.
Discussion