SHORT COMMUNICATION   

Il Giornale Italiano di Radiologia Medica 2019 Novembre-Dicembre;6(6):575-9

DOI: 10.23736/S2283-8376.19.00216-X

Copyright © 2019 EDIZIONI MINERVA MEDICA

language: English, Italian

Structured reporting of CT-Enterography

Nunzia CAPOZZI ¹ ✉, Francesca COPPOLA ¹, Alberta CAPPELLI ¹, Sara ZANARDI ², Monica GARATTONI ¹, Rita GOLFIERI ¹

¹ Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Sant’Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy; ² Department of Radiology, Maggiore Hospital, Bologna, Italy

Nowadays the importance of the radiology reports for patients’ management is clearly established. The aim of our center was to introduce the structured reporting (SR) in different radiological fields, beginning from the field of the inflammatory bowel diseases (IBD) and overall of the Crohn’s disease (CD). We introduced the standardization of the reports both for computed tomography-enterography and magnetic resonance-enterography mostly used to investigate IBD patients. The SR is formed by multiple sections. The first part is dedicated to the patient’s anamnesis, including the clinical and surgical history, recent symptomatology, laboratory test and medical treatment. Then, we focus on the patient preparation, on the execution technique, on the quality of the examination, on the grade and method of bowel distention, on the use and quantity of spasmolytic, on the use, quantity and speed of endovenous contrast media administration and on the number of phases acquired (bi-triphasic study). Regarding the section dedicated to diagnosis, we describe the type and extension of the lesions and in particular in CD we report the wall thickening and lumen narrowing, the presence of prestenotic dilation, of ulcers, of sub mucosal fat deposition, the type of contrast enhancement (homogeneous/layered). In the last section we describe the presence of complications such as fistulas and abscesses or even of perforation (especially in case of ulcerative colitis) and any other extra-enteric finding. Finally we are able to attach the significant images to emphasize the main radiological findings and facilitate communication to referring physicians. In conclusion, according to our experience, SR has proven to be a valuable tool for the radiologist, especially if not dedicated, discouraging the drafting of non-conclusive or confuse reports in order to emphasize only the most relevant findings. Finally, these models also allow to collect and re-elaborate all the selected data, using data reprocessing tools, for statistical studies and scientific purpose; we found this tool particularly useful in the IBDs research field.

KEY WORDS: Crohn disease; Computed tomography; Gastrointestinal tract