Case discussion
01Clinical context
A patient without prior diagnosis of inflammatory bowel disease underwent contrast-enhanced CT for abdominal and pelvic evaluation due to severe symptoms. The imaging aimed to assess for possible causes of acute abdominal pain and inflammation.
02Key imaging findings
CT shows marked, extensive circumferential mural thickening and enhancement involving the entire colon and terminal ileum, consistent with severe active pancolitis and ileitis. Adjacent mesenteric vascular congestion is prominent. A tubular right adnexal structure measuring about 2.4 × 1.4 cm is inseparable from the inflamed terminal ileum, suspicious for right-sided salpingitis, pyosalpinx, or developing tubo-ovarian abscess. Tiny gas locules near the cervicoendometrial junction raise the possibility of an enteroadnexal or enterogenital fistula, though no definite fistulous tract is seen. Additional findings include marked hepatosplenomegaly with diffuse hepatic steatosis, gallbladder sludge without cholecystitis, and a small left adrenal nodule likely adenoma.
03Diagnostic reasoning
The diagnosis was established on contrast-enhanced CT showing extensive circumferential mural thickening and enhancement of the colon and terminal ileum, with prominent mesenteric vascular congestion indicating active inflammation. The adjacent right adnexal tubular structure inseparable from the inflamed ileum raised suspicion for salpingitis or tubo-ovarian abscess. Tiny gas locules near the cervicoendometrial junction suggested possible fistulous communication, although no tract was directly visualized. The differential includes severe infectious ileocolitis versus inflammatory bowel disease, with imaging features insufficient to distinguish them definitively. Additional hepatosplenomegaly and adrenal findings were noted. Multiplanar reformations aided in assessing anatomical relationships and extent of disease.
04Questions for clinical practice
What is the significance of the right adnexal abnormality? It suggests possible salpingitis, pyosalpinx, or tubo-ovarian abscess, potentially secondary to adjacent ileal inflammation. Is fistula confirmed? No definite fistulous tract is seen on CT; further dedicated imaging is needed. How to differentiate infectious from inflammatory bowel disease? Imaging alone cannot reliably distinguish; clinical, microbiological, and endoscopic correlation is essential. What are the next steps? Urgent multidisciplinary consultation, dedicated gynecological imaging, and gastrointestinal investigations including ileocolonoscopy are recommended.
05Teaching point
Severe active ileocolitis with adjacent right adnexal inflammation can mimic or complicate inflammatory bowel disease, especially Crohn disease. Imaging alone cannot reliably distinguish infectious from inflammatory causes. The close anatomical relationship raises suspicion for secondary adnexal involvement or fistulous communication, necessitating multidisciplinary evaluation including dedicated gynecological imaging and gastrointestinal correlation to guide management.
Shown for education. De-identified — no identifiable patient data. A radiology report is a specialist opinion and must be read with the full clinical context by the treating physician.