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Normal CT Enterography Report Template
Normal CT enterography report template: enteric-phase small bowel wall, terminal ileum and mesentery sections, with distension and Crohn activity wording notes.
EXAMINATION: CT enterography. CLINICAL HISTORY: [indication] COMPARISON: None available. TECHNIQUE: Axial helical images through the abdomen and pelvis in the enteric phase following intravenous contrast administration and large-volume neutral oral contrast, with coronal and sagittal reformats. FINDINGS: Small bowel: Well distended with neutral oral contrast. Normal wall thickness and mural enhancement throughout. No stricture, mural hyperenhancement, wall thickening or upstream dilatation. Terminal ileum: Normal caliber, wall thickness and enhancement. Colon: Normal caliber and wall thickness. Mesentery: No fibrofatty proliferation, engorged vasa recta or mesenteric stranding. No abscess, fistula or sinus tract. Lymph nodes: No mesenteric or retroperitoneal lymphadenopathy by size criteria. Solid organs: The liver, gallbladder, pancreas, spleen, adrenal glands and kidneys are unremarkable. Free fluid and free air: None. Bladder and pelvic organs: Unremarkable. Bones: No acute osseous abnormality. IMPRESSION: 1. No CT evidence of active small bowel inflammation, stricture or penetrating complication.
Dictation notes
- State the quality of small bowel distension before anything else — a collapsed loop mimics wall thickening and mural hyperenhancement, and most false positives live there.
- Separate active from chronic disease in the wording: mural hyperenhancement with wall edema is active inflammation; fibrofatty proliferation and a fixed stricture are chronic.
- Always close the loop on penetrating disease — fistula, sinus tract and abscess — and look at the perianal region on the sagittal images before signing a Crohn study as normal.
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