Fistula in Crohn's Disease

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AP radiograph (image 1) and focused AP radiograph of the right lower quadrant (image 2) during small bowel follow-through show findings of Crohn disease with affecting the terminal ileum (arrow). The terminal ileum is isolated, has luminal narrowing, and a irregularity of the luminal surface. Crohn disease is is an inflammatory bowel disease. It is most commonly diagnosed in the second or 3rd decade of life. The terminal ileum is the most commonly affected segment of bowel although any bowel segment can be affected. Features of Crohn disease include skip lesions, transmural inflammation, and stricturing or penetrating complications.

Axial T2 weighted MRI (images 1-3) in an adolescent with Crohn's disease shows a perianal fistula (arrowhead) arising from the 6 o'clock position. Edema tracks to the right and left gluteal crease with a more focal collection (arrow) on the left buttock. Crohn disease is an inflammatory bowel disease associated by transmural inflammation. Perianal fistulas can be difficult to identify on enterography. Dedicated small field-of-view imaging of the pelvis should be performed. Perianal fistulas appear as fine linear tracts best seen on T2 weighted images. It can be associated with subcutaneous abscesses. An abscess is better diagnosed with postcontrast images showing a small area that does not enhance. The edema and perianal inflammation (arrow) is highlighted on the coronal T2 weighted image (image 4). Sacroiliitis (dashed arrow), a potential extraintestinal manifestation of Crohn's disease is also present.

40 YO M PMH T1DM and Crohn’s disease. Medications include insulin and remicaide every 6 weeks. Rash developed over 3 days and no change since onset per patient. Rash is asymptomatic and no systemic symptoms. No recent infections, antibiotics or other new medications. No topical treatment has been attempted.

AP (image 1), zoomed AP (image 2), and upright (image 3) radiograph of the abdomen shows two small magnets (arrow) opposing each other within the right lower quadrant. The presence of air-fluid levels on the upright view is concerning for ileus and suggest that a bowel perforation has occurred. Ingestion of multiple magnets is an emergency. The magnets can attract each other across bowel loops causing pressure necrosis and leading to bowel perforation. If the magnets remain within the stomach, they should be removed. If they have passed beyond the upper gastrointestinal tract, they are often observed with serial radiographs and routine physical examination.