|
1
|
Rodríguez-Lago I, Casas-Deza D, Rimola J, Calafat M, Ferreiro-Iglesias R, Pellino G, Avellaneda N, Iborra M, Barreiro-de Acosta M, Gutiérrez Casbas A, Menchén L, Ordás I, Rodríguez-Moranta F, Zabana Y. Spanish Working Group in Crohn's Disease and Ulcerative Colitis (GETECCU) position paper for the management of non-perianal fistulizing Crohn's disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2025:502450. [PMID: 40250758 DOI: 10.1016/j.gastrohep.2025.502450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2025] [Accepted: 04/11/2025] [Indexed: 04/20/2025]
Abstract
Crohn's disease consists on a complex condition where, despite most patients initially present with an inflammatory behavior, a significant proportion develop complicated lesions such as strictures, fistulas, abscesses, or even perforations. These lesions progressively increase over time and are associated with a higher risk of surgery and hospitalization. Despite significant advances in their management after the introduction of biological therapies, particularly anti-TNF agents, these complications continue to pose challenges for the multiple professionals involved in their care. Fistulas that do not involve the perianal region (entero-enteric, entero-urinary, or entero-cutaneous) require a multidisciplinary strategy that combines medical, interventional, and surgical approaches. Their treatment ranges from general supportive measures to the use of antibiotics or, frequently, advanced therapies. Nevertheless, in cases of certain septic complications or those refractory to medical treatment, percutaneous drainage or surgical intervention remains essential. Although these lesions have a significant impact, evidence regarding the best strategies in this context, as well as the efficacy and safety of different therapies in these patients, remains limited. This is highlighted by the absence of specific recommendations in current guidelines. The objective of this document is to provide a comprehensive overview of non-perianal fistulizing Crohn's disease, addressing its epidemiological, clinical, and therapeutic aspects from a multidisciplinary perspective.
Collapse
Affiliation(s)
- Iago Rodríguez-Lago
- Servicio de Aparato Digestivo, Hospital Universitario de Galdakao; Instituto de Investigación Sanitaria Biobizkaia, Galdakao, Bizkaia, España.
| | - Diego Casas-Deza
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet; Instituto de Investigación Sanitaria de Aragón (IISA), Zaragoza, España
| | - Jordi Rimola
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Radiodiagnóstico, Hospital Clínic, Barcelona, España
| | - Margalida Calafat
- Servicio de Aparato Digestivo, Hospital Universitari Germans Trias i Pujol; Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Barcelona, España
| | - Rocío Ferreiro-Iglesias
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Santiago de Compostela; Fundación Galega de Investigación Sanitaria (IDIS), Santiago de Compostela, A Coruña, España
| | - Gianluca Pellino
- Servicio de Cirugía Colorrectal, Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - Nicolás Avellaneda
- Unidad de Investigación, Hospital Universitario CEMIC, Buenos Aires, Argentina
| | - Marisa Iborra
- Gastroenterología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Manuel Barreiro-de Acosta
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Santiago de Compostela; Fundación Galega de Investigación Sanitaria (IDIS), Santiago de Compostela, A Coruña, España
| | - Ana Gutiérrez Casbas
- Servicio de Aparato Digestivo, Hospital General Universitario Dr. Balmis; Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL); Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Alicante, España
| | - Luis Menchén
- Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón; Instituto de Investigación Sanitaria Gregorio Marañón; Universidad Complutense, Madrid, España
| | - Ingrid Ordás
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología, Hospital Clínic, Barcelona; Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS); Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas (CIBERehd), España
| | - Francisco Rodríguez-Moranta
- Servicio de Aparato Digestivo, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - Yamile Zabana
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital Universitari Mútua Terrassa; Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Terrassa, Barcelona, España
| |
Collapse
|
|
2
|
Amadu M, Soldera J. Duodenal Crohn's disease: Case report and systematic review. World J Methodol 2024; 14:88619. [PMID: 38577197 PMCID: PMC10989410 DOI: 10.5662/wjm.v14.i1.88619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/16/2023] [Accepted: 01/18/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Inflammatory bowel disease, including ulcerative colitis, microscopic colitis, and Crohn's disease (CD), has a global impact. This review focuses on duodenal CD (DCD), a rare subtype affecting the duodenum. DCD's rarity and asymptomatic nature create diagnostic challenges, impacting prognosis and patient well-being. Delayed diagnosis can worsen DCD outcomes. AIM To report a rare case of DCD and to discuss the diagnostic challenges and its implications on prognosis. METHODS A systematic literature search, following the PRISMA statement, was conducted. Relevant studies were identified and analysed using specific Medical Subject Terms (MeSH) from PubMed/MEDLINE, American Journal of Gastroenterology, and the University of South Wales database. Data collection included information from radiology scans, endoscopy procedures, biopsies, and histopathology results. RESULTS The review considered 8 case reports and 1 observational study, involving 44 participants diagnosed with DCD, some of whom developed complications due to delayed diagnosis. Various diagnostic methods were employed, as there is no gold standard workup for DCD. Radiology scans [magnetic resonance imaging (MRI), computed tomography (CT), and upper gastrointestinal X-ray], endoscopy procedures (colonoscopy and esophagogastroduodenoscopy), biopsies, and clinical suspicions were utilized. CONCLUSION This review discusses DCD diagnosis challenges and the roles of CT, MRI, and fluoroscopy. It notes their limitations and compares findings with endoscopy and histopathology studies. Further research is needed to improve diagnosis, emphasizing scan interpretation, endoscopy procedures, and biopsies, especially in high-risk patients during routine endoscopy.
Collapse
Affiliation(s)
- Muniratu Amadu
- Department of Gastroenterology, University of South Wales, Cardiff CF37 1DL, United Kingdom
| | - Jonathan Soldera
- Department of Gastroenterology, University of South Wales, Cardiff CF37 1DL, United Kingdom
| |
Collapse
|
|
3
|
Bartlett DJ, Ramos GP, Fletcher JG, Bruining DH. Imaging Evaluation of Inflammatory Bowel Disease Complications. Gastrointest Endosc Clin N Am 2022; 32:651-673. [PMID: 36202508 DOI: 10.1016/j.giec.2022.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory condition that can progress to fibrostenotic and penetrating complications. Cross-sectional imaging is often needed for accurate diagnosis of IBD complication and for planning the appropriate management strategy. Computed tomography enterography, magnetic resonance enterography, and IBD ultrasound have become key tools for clinicians and interventional endoscopists. This article highlights and discusses various radiologic imaging techniques and their application to the diagnosis and management of IBD complications.
Collapse
Affiliation(s)
- David J Bartlett
- Department of Radiology, Mayo Clinic College of Medicine, 200 1st Street, SW, Rochester, MN 55905, USA; Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 1st Street, SW, Rochester, MN 55905, USA
| | - Guilherme Piovezani Ramos
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 1st Street, SW, Rochester, MN 55905, USA
| | - Joel G Fletcher
- Department of Radiology, Mayo Clinic College of Medicine, 200 1st Street, SW, Rochester, MN 55905, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 1st Street, SW, Rochester, MN 55905, USA.
| |
Collapse
|
|
4
|
The Role of Magnetic Resonance Enterography in Crohn’s Disease: A Review of Recent Literature. Diagnostics (Basel) 2022; 12:diagnostics12051236. [PMID: 35626391 PMCID: PMC9140029 DOI: 10.3390/diagnostics12051236] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/06/2022] [Accepted: 05/13/2022] [Indexed: 11/17/2022] Open
Abstract
Inflammatory bowel disease (IBD) is the term used to identify a form of chronic inflammation of the gastrointestinal tract that primarily contemplates two major entities: ulcerative colitis (UC) and Crohn’s disease (CD). The classic signs are abdominal pain and diarrhoea that correlate with the localization of gastro-enteric disease, although in this pathology extraintestinal symptoms may coexist. The diagnosis of CD relies on a synergistic combination of clinical, laboratory (stool and biochemical), cross-sectional imaging evaluation, as well as endoscopic and histologic assessments. The purpose of this paper is to prove the role of imaging in the diagnosis and follow-up of patients with CD with particular focus on recent innovations of magnetic resonance enterography (MRE) as a pivotal diagnostic tool, analysing the MRE study protocol and imaging features during the various phases of disease activity and its complications.
Collapse
|
|
5
|
Novak KL, Nylund K, Maaser C, Petersen F, Kucharzik T, Lu C, Allocca M, Maconi G, de Voogd F, Christensen B, Vaughan R, Palmela C, Carter D, Wilkens R. Expert Consensus on Optimal Acquisition and Development of the International Bowel Ultrasound Segmental Activity Score [IBUS-SAS]: A Reliability and Inter-rater Variability Study on Intestinal Ultrasonography in Crohn's Disease. J Crohns Colitis 2021; 15:609-616. [PMID: 33098642 PMCID: PMC8023841 DOI: 10.1093/ecco-jcc/jjaa216] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Intestinal ultrasound [IUS] is an accurate, patient-centreed monitoring tool that objectively evaluates Crohn's disease [CD] activity. However no current, widely accepted, reproducible activity index exists to facilitate consistent IUS identification of inflammatory activity. The aim of this study is to identify key parameters of CD inflammation on IUS, evaluate their reliability, and develop an IUS index reflecting segmental activity. METHODS There were three phases: [1] expert consensus Delphi method to derive measures of IUS activity; [2] an initial, multi-expert case acquisition and expert interpretation of 20 blinded cases, to measure inter-rater reliability for individual measures; [3] refinement of case acquisition and interpretation by 12 international experts, with 30 blinded case reads with reliability assessment and development of a segmental activity score. RESULTS Delphi consensus: 11 experts representing seven countries identified four key parameters including: [1] bowel wall thickness [BWT]; [2] bowel wall stratification; [3] hyperaemia of the wall [colour Doppler imaging]; and [4] inflammatory mesenteric fat. Blind read: each variable exhibited moderate to substantial reliability. Optimal, standardised image and cineloop acquisition were established. Second blind read and score development: intra-class correlation coefficient [ICC] for BWT was almost perfect at 0.96 [0.94-0.98]. All four parameters correlated with the global disease activity assessment and were included in the final International Bowel Ultrasound Segmental Activity Score with almost perfect ICC (0.97 [0.95-0.99, p <0.001]). CONCLUSIONS Using expert consensus and standardised approaches, identification of key activity measurements on IUS has been achieved and a segmental activity score has been proposed, demonstrating excellent reliability.
Collapse
Affiliation(s)
- Kerri L Novak
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, AB, Canada
| | - Kim Nylund
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
- Institute of Clinical Medicine, University in Bergen, Klinisk institutt 1, Bergen, Norway
| | - Christian Maaser
- Outpatient Department of Gastroenterology, Department of Geriatric Medicine, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Frauke Petersen
- Department of Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Torsten Kucharzik
- Department of Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Cathy Lu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, AB, Canada
| | - Mariangela Allocca
- Humanitas Clinical and Research Centre, Rozzano, Italy
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences. FBF- L.Sacco University Hospital, Milan. Italy
| | - Floris de Voogd
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Britt Christensen
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, VIC Australia
| | - Rose Vaughan
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, VIC Australia
| | - Carolina Palmela
- Division of Gastroenterology, Department of General Surgery, Hospital Beatriz Ângelo, Loures, Portugal
| | - Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Centre, Tel Hashomer, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rune Wilkens
- Gastrounit, Division of Medicine, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
- Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents and Adults, University of Copenhagen, Hvidovre Hospital, Copenhagen, Denmark
| |
Collapse
|
|
6
|
V Celentano, Garofalo E, Spinelli A, Pellino G, Flashman K, Frasson M, Carvello M, de'Angelis N, Garcia-Granero A, Harper M, Warusavitarne J, Coleman M, Espin E, Selvaggi F. Video-laparoscopic assessment of the small bowel in Crohn's disease: a comparative study to evaluate surgeons' inter-observer variability. Surg Endosc 2021; 35:1378-1384. [PMID: 32240380 DOI: 10.1007/s00464-020-07521-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 03/26/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Assessment of the entire small bowel is advocated during Crohn's disease (CD) surgery, as intraoperative detection of new lesions may lead to change in the planned procedure. The aim of this study was to evaluate the inter-observer variability in the assessment of extent and severity of CD at the small bowel laparoscopic "walkthrough". METHODS A survey on laparoscopic assessment of the small bowel in patients with CD, including items adapted from the MREnterography or ultrasound in Crohn's disease (METRIC) study and from the classification of severity of mesenteric disease was developed by an invited committee of colorectal surgeons. Anonymous laparoscopic videos demonstrating the small bowel "walkthrough" in ileocolonic resection for primary and recurrent CD were distributed to the committee members together with the anonymous survey. The primary outcome was the rate of inter-observer variability on assessment of strictures, dilatations, complications and severity of mesenteric inflammation. RESULTS 12 assessors completed the survey on 8 small bowel walkthrough videos. The evaluation of the small bowel thickening and of the mesenteric fat wrapping were the most reliable assessments with an overall agreement of 87.1% (k = 0.31; 95% CI - 0.22, 0.84) and 82.7% (k = 0.35; 95% CI - 0.04, 0.73), respectively. The presence of strictures and pre-stenotic dilatation demonstrated agreement of 75.2% (k = 0.06: 95% CI - 0.33, 0.45) and 71.2% (k = 0.33; 95% CI 0.15, 0.51), respectively. Evaluation of fistulae had an overall agreement of 75.3%, while there was a significant variation in the evaluation of mild, moderate and severe mesenteric disease with overall agreement ranging from 33.3 to 100%. CONCLUSION Laparoscopic assessment of the small bowel thickening and of the presence of mesenteric fat wrapping is reliable for the intraoperative evaluation of CD with high inter-rater agreement. There is significant heterogeneity in the assessment of the severity of the mesenteric disease involvement.
Collapse
Affiliation(s)
- V Celentano
- Colorectal Unit, Queen Alexandra Hospital - Portsmouth Hospitals NHS Trust, Portsmouth, UK
- University of Portsmouth, Portsmouth, UK
| | | | - A Spinelli
- Humanitas Clinical and Research Center - IRCCS, via Manzoni 56, 20089, Rozzano (Milan), Italy
- Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - G Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá Della Campania Luigi Vanvitelli, Naples, Italy
| | - K Flashman
- Colorectal Unit, Queen Alexandra Hospital - Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - M Frasson
- Department of General Surgery, Colorectal Unit, La Fe University and Polytechnic Hospital, University of Valencia, Valencia, Spain
| | - M Carvello
- Colon and Rectal Surgery Division, Humanitas University, Rozzano (Milan), Italy
| | - N de'Angelis
- Department of Digestive Surgery, Assistance Publique Hôpitaux de Paris, Henri Mondor Hospital, Université Paris-Est (UEP), Créteil, France
| | - A Garcia-Granero
- Colorectal Unit, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - M Harper
- University of Portsmouth, Portsmouth, UK
| | - J Warusavitarne
- Department of Colorectal Surgery, St Mark's Hospital, Harrow, Middlesex, UK
| | - M Coleman
- Department of Colorectal Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - E Espin
- Department of General Surgery, Hospital Valle de Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - F Selvaggi
- Department of Advanced Medical and Surgical Sciences, Universitá Della Campania Luigi Vanvitelli, Naples, Italy
| |
Collapse
|
|
7
|
Moreno Sánchez N, Paredes JM, Ripollés T, Sanz de la Vega J, Latorre P, Martínez MJ, Richart J, Vizuete J, Moreno-Osset E. Treatment of abdominal fistulas in Crohn's disease and monitoring with abdominal ultrasonography. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:240-245. [PMID: 33226252 DOI: 10.17235/reed.2020.6884/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE to assess the usefulness of medical treatment to achieve closure of internal fistulas detected on abdominal ultrasound in a series of patients with fistulizing Crohn's disease. MATERIAL AND METHODS a retrospective analysis was performed of the medical records of patients with Crohn's disease with a fistula detected on abdominal ultrasound from 2010 to 2018. The study included patients who received medical treatment after the diagnosis of this complication and underwent ultrasonographic monitoring of the therapeutic response. The factors associated with the response to medical treatment or the need for surgery were investigated. RESULTS forty-six patients were included in the study. Enteromesenteric (69.6 %) was the most common type of fistula and associated abscesses were found in 14 (30.4 %) patients. Fistulas were classified as complex in 20 patients. Treatment with immunosuppressants was started in 14 (30.4 %) cases and a biologic drug was added in 18 (39.1 %) patients. Complete closure of the abdominal fistula was observed with ultrasonography in 24 (52.2 %) of the 46 patients. The only factor related to fistula closure was the type of fistula and was more likely to occur in patients with an enteromesenteric fistula. Thirteen (28 %) of the 46 patients needed a surgical resection. The only factor with a significant correlation with a lower need for surgery was fistula closure after treatment (8.3 % vs 50 %, p = 0.002). CONCLUSION medical treatment achieves internal fistula closure in more than half of cases and almost a third require surgical treatment. Abdominal ultrasound can detect abdominal fistulas at an earlier stage and allow prompt treatment changes.
Collapse
Affiliation(s)
| | | | | | | | | | | | - José Richart
- Cirugía General, Hospital Universitario Dr. Peset
| | | | | |
Collapse
|
|
8
|
Kim DH, Chang KJ, Fowler KJ, Cash BD, Garcia EM, Kambadakone AR, Levy AD, Liu PS, Mace SE, Marin D, Moreno C, Peterson CM, Pietryga JA, Solnes LB, Weinstein S, Carucci LR. ACR Appropriateness Criteria® Crohn Disease. J Am Coll Radiol 2020; 17:S81-S99. [PMID: 32370980 DOI: 10.1016/j.jacr.2020.01.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 01/22/2020] [Indexed: 02/08/2023]
Abstract
Three common clinical scenarios involving use of imaging in Crohn disease are covered. These include the initial evaluation of Crohn disease when the diagnosis has not been previously established, the evaluation for anticipated exacerbation of known disease, and the evaluation of disease activity during therapy monitoring. The appropriateness of a given imaging modality for each scenario is rated as one of three categories (usually appropriate, may be appropriate, usually not appropriate) to help guide evaluation. Pediatric presentation of Crohn disease and the appropriateness of imaging are not covered in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Collapse
Affiliation(s)
- David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin.
| | | | - Kathryn J Fowler
- Panel Vice-Chair, University of California San Diego, San Diego, California
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | | | - Angela D Levy
- Medstar Georgetown University Hospital, Washington, District of Columbia
| | | | - Sharon E Mace
- Cleveland Clinic, Cleveland, Ohio; American College of Emergency Physicians
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | | | | | | | | | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
| |
Collapse
|
|
9
|
Guglielmo FF, Anupindi SA, Fletcher JG, Al-Hawary MM, Dillman JR, Grand DJ, Bruining DH, Chatterji M, Darge K, Fidler JL, Gandhi NS, Gee MS, Grajo JR, Huang C, Jaffe TA, Park SH, Rimola J, Soto JA, Taouli B, Taylor SA, Baker ME. Small Bowel Crohn Disease at CT and MR Enterography: Imaging Atlas and Glossary of Terms. Radiographics 2020; 40:354-375. [DOI: 10.1148/rg.2020190091] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
|
10
|
Kedia S, Sharma R, Makharia G, Ahuja V, Desai D, Kandasamy D, Eapen A, Ganesan K, Ghoshal UC, Kalra N, Karthikeyan R, Madhusudhan KS, Philip M, Puri A, Puri S, Sinha SK, Banerjee R, Bhatia S, Bhat N, Dadhich S, Dhali GK, Goswami BD, Issar SK, Jayanthi V, Misra SP, Nijhawan S, Puri P, Sarkar A, Singh SP, Srivastava A, Abraham P, Ramakrishna BS. Indian guidelines on imaging of the small intestine in Crohn's disease: A joint Indian Society of Gastroenterology and Indian Radiology and Imaging Association consensus statement. Indian J Radiol Imaging 2019; 29:111-132. [PMID: 31367083 PMCID: PMC6639863 DOI: 10.4103/ijri.ijri_153_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients suspected to have or having Crohn's disease. The 29 consensus statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.
Collapse
Affiliation(s)
- Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Radiadiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Devendra Desai
- Division of Gastroenterology, P D Hinduja Hospital, Mumbai, Maharashtra, India
| | | | - Anu Eapen
- Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
| | - Karthik Ganesan
- Department of Radiodiagnosis, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
| | - Naveen Kalra
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - R Karthikeyan
- Department of Radiodiagnosis, SRM Institute of Medical Sciences and Research, Chennai, India
| | | | - Mathew Philip
- Department of Gastroenterology, PVS Memorial Hospital, Kochi, Kerala, India
| | - Amarender Puri
- Department of Gastroenterology, GB Pant Institute of Medical Education and Research, New Delhi, India
| | - Sunil Puri
- Department of Radiodiagnosis, GB Pant Institute of Medical Education and Research, New Delhi, India
| | - Saroj K Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rupa Banerjee
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Shobna Bhatia
- Department of Gastroenterology, KEM Hospital, Mumbai, India
| | - Naresh Bhat
- Department of Gastroenterology, Aster CMI Hospital, Bengaluru, Karnataka, India
| | - Sunil Dadhich
- Department of Gastroenterology, SN Medical College, Jodhpur, Rajasthan, India
| | - G K Dhali
- Department of Gastroenterology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, West Bengal, India
| | - B D Goswami
- Department of Gastroenterology, Guwahati Medical College, Guwahati, Assam, India
| | - S K Issar
- Department of Gastroenterology, Jawaharlal Nehru Hospital and Research Centre, Bhilai, Chhattishgarh, India
| | - V Jayanthi
- Department of Gastroenterology, Gleneagles Global Hospitals, Chennai, India
| | - S P Misra
- Department of Gastroenterology, MLN Medical College, Allahabad, UP, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, Gleneagles Global Hospitals, Chennai, India
| | - Pankaj Puri
- Department of Gastroenterology, Military Hospital, Jodhpur, Rajasthan, India
| | - Avik Sarkar
- Department of Radiodiagnosis, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, West Bengal, India
| | - S P Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Odisha, India
| | - Anshu Srivastava
- Department of Paediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
| | - Philip Abraham
- Division of Gastroenterology, P D Hinduja Hospital, Mumbai, Maharashtra, India
| | - B S Ramakrishna
- Department of Gastroenterology, SRM Institute of Medical Sciences and Research, Chennai, India
| |
Collapse
|
|
11
|
Maaser C, Sturm A, Vavricka SR, Kucharzik T, Fiorino G, Annese V, Calabrese E, Baumgart DC, Bettenworth D, Borralho Nunes P, Burisch J, Castiglione F, Eliakim R, Ellul P, González-Lama Y, Gordon H, Halligan S, Katsanos K, Kopylov U, Kotze PG, Krustinš E, Laghi A, Limdi JK, Rieder F, Rimola J, Taylor SA, Tolan D, van Rheenen P, Verstockt B, Stoker J. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis 2019; 13:144-164. [PMID: 30137275 DOI: 10.1093/ecco-jcc/jjy113] [Citation(s) in RCA: 1117] [Impact Index Per Article: 186.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Andreas Sturm
- Department of Gastroenterology, DRK Kliniken Berlin I Westend, Berlin, Germany
| | | | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Gionata Fiorino
- Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic & American Hospital, Dubai, UAE
| | - Emma Calabrese
- Department of Systems Medicine, University of Rome, Tor Vergata, Italy
| | - Daniel C Baumgart
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, Münster, Germany
| | - Paula Borralho Nunes
- Department of Anatomic Pathology, Hospital Cuf Descobertas; Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital; Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Fabiana Castiglione
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Pierre Ellul
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Yago González-Lama
- Department of Gastroenterology, University Hospital Puerta De Hierro, Majadahonda [Madrid], Spain
| | - Hannah Gordon
- Department of Gastroenterology, Royal London Hospital, London, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Paraná [PUCPR], Curitiba, Brazil
| | - Eduards Krustinš
- Department of of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Andrea Laghi
- Department of Clinical and Surgical Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester; Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Damian Tolan
- Clinical Radiology, St James's University Hospital, Leeds, UK
| | - Patrick van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, Groningen, The Netherlands
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven and CHROMETA - Translational Research in Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Center [AMC], University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
|
12
|
Hyde BJ, Byrnes JN, Occhino JA, Sheedy SP, VanBuren WM. MRI review of female pelvic fistulizing disease. J Magn Reson Imaging 2018; 48:1172-1184. [DOI: 10.1002/jmri.26248] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/03/2018] [Accepted: 05/04/2018] [Indexed: 01/14/2023] Open
Affiliation(s)
- Brenda J. Hyde
- Mayo Clinic Department of Radiology; Rochester Minnesota USA
| | - Jenifer N. Byrnes
- Mayo Clinic Department of Obstetrics and Gynecology, Division of Urogynecology; Rochester Minnesota USA
| | - John A. Occhino
- Mayo Clinic Department of Obstetrics and Gynecology, Division of Urogynecology; Rochester Minnesota USA
| | | | | |
Collapse
|
|
13
|
Baker ME, Fletcher JG, Al-Hawary M, Bruining D. Interdisciplinary Updates in Crohn’s Disease Reporting Nomenclature, and Cross-Sectional Disease Monitoring. Radiol Clin North Am 2018; 56:691-707. [DOI: 10.1016/j.rcl.2018.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
|
14
|
Abstract
Computed tomography (CT) enterography is a noninvasive imaging modality with superb spatial and temporal resolution, specifically tailored to evaluate the small bowel. It has several advantages over other radiologic and optical imaging modalities, all of which serve as complementary investigations to one another. This article describes CTE technique, including dose reduction techniques, special considerations for the pediatric population, common technical and interpretive pitfalls, and reviews some of the more common small bowel entities seen with CTE.
Collapse
Affiliation(s)
- Shannon P Sheedy
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Amy B Kolbe
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Joel G Fletcher
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Jeff L Fidler
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| |
Collapse
|
|
15
|
Bruining DH, Zimmermann EM, Loftus EV, Sandborn WJ, Sauer CG, Strong SA. Consensus Recommendations for Evaluation, Interpretation, and Utilization of Computed Tomography and Magnetic Resonance Enterography in Patients With Small Bowel Crohn's Disease. Gastroenterology 2018; 154:1172-1194. [PMID: 29329905 DOI: 10.1053/j.gastro.2017.11.274] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Computed tomography and magnetic resonance enterography have become routine small bowel imaging tests to evaluate patients with established or suspected Crohn's disease, but the interpretation and use of these imaging modalities can vary widely. A shared understanding of imaging findings, nomenclature, and utilization will improve the utility of these imaging techniques to guide treatment options, as well as assess for treatment response and complications. Representatives from the Society of Abdominal Radiology Crohn's Disease-Focused Panel, the Society of Pediatric Radiology, the American Gastroenterological Association, and other experts, systematically evaluated evidence for imaging findings associated with small bowel Crohn's disease enteric inflammation and established recommendations for the evaluation, interpretation, and use of computed tomography and magnetic resonance enterography in small bowel Crohn's disease. This work makes recommendations for imaging findings that indicate small bowel Crohn's disease, how inflammatory small bowel Crohn's disease and its complications should be described, elucidates potential extra-enteric findings that may be seen at imaging, and recommends that cross-sectional enterography should be performed at diagnosis of Crohn's disease and considered for small bowel Crohn's disease monitoring paradigms. A useful morphologic construct describing how imaging findings evolve with disease progression and response is described, and standard impressions for radiologic reports that convey meaningful information to gastroenterologists and surgeons are presented.
Collapse
Affiliation(s)
- David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ellen M Zimmermann
- Department of Gastroenterology, University of Florida, Gainesville, Florida
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Cary G Sauer
- Division of Pediatric Gastroenterology, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Scott A Strong
- Division of GI Surgery, Northwestern Medicine, Chicago, Illinois
| | | |
Collapse
|
|
16
|
Bruining DH, Zimmermann EM, Loftus EV, Sandborn WJ, Sauer CG, Strong SA. Consensus Recommendations for Evaluation, Interpretation, and Utilization of Computed Tomography and Magnetic Resonance Enterography in Patients With Small Bowel Crohn's Disease. Radiology 2018; 286:776-799. [PMID: 29319414 DOI: 10.1148/radiol.2018171737] [Citation(s) in RCA: 204] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Computed tomography and magnetic resonance enterography have become routine small bowel imaging tests to evaluate patients with established or suspected Crohn's disease, but the interpretation and use of these imaging modalities can vary widely. A shared understanding of imaging findings, nomenclature, and utilization will improve the utility of these imaging techniques to guide treatment options, as well as assess for treatment response and complications. Representatives from the Society of Abdominal Radiology Crohn's Disease-Focused Panel, the Society of Pediatric Radiology, the American Gastroenterological Association, and other experts, systematically evaluated evidence for imaging findings associated with small bowel Crohn's disease enteric inflammation and established recommendations for the evaluation, interpretation, and use of computed tomography and magnetic resonance enterography in small bowel Crohn's disease. This work makes recommendations for imaging findings that indicate small bowel Crohn's disease, how inflammatory small bowel Crohn's disease and its complications should be described, elucidates potential extra-enteric findings that may be seen at imaging, and recommends that cross-sectional enterography should be performed at diagnosis of Crohn's disease and considered for small bowel Crohn's disease monitoring paradigms. A useful morphologic construct describing how imaging findings evolve with disease progression and response is described, and standard impressions for radiologic reports that convey meaningful information to gastroenterologists and surgeons are presented. ©2018, RSNA, AGA Institute, and Society of Abdominal Radiology This article is being published jointly in Radiology and Gastroenterology.
Collapse
Affiliation(s)
- David H Bruining
- From the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn (D.H.B., E.V.L); Department of Gastroenterology, University of Florida, Gainesville, Fla (E.M.Z.); Division of Gastroenterology, University of California San Diego, San Diego, Calif (W.J.S); Division of Pediatric Gastroenterology, Emory University, Children's Healthcare of Atlanta, Ga (C.G.S); and Division of GI Surgery, Northwestern Medicine, Chicago, Ill (S.A.S)
| | - Ellen M Zimmermann
- From the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn (D.H.B., E.V.L); Department of Gastroenterology, University of Florida, Gainesville, Fla (E.M.Z.); Division of Gastroenterology, University of California San Diego, San Diego, Calif (W.J.S); Division of Pediatric Gastroenterology, Emory University, Children's Healthcare of Atlanta, Ga (C.G.S); and Division of GI Surgery, Northwestern Medicine, Chicago, Ill (S.A.S)
| | - Edward V Loftus
- From the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn (D.H.B., E.V.L); Department of Gastroenterology, University of Florida, Gainesville, Fla (E.M.Z.); Division of Gastroenterology, University of California San Diego, San Diego, Calif (W.J.S); Division of Pediatric Gastroenterology, Emory University, Children's Healthcare of Atlanta, Ga (C.G.S); and Division of GI Surgery, Northwestern Medicine, Chicago, Ill (S.A.S)
| | - William J Sandborn
- From the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn (D.H.B., E.V.L); Department of Gastroenterology, University of Florida, Gainesville, Fla (E.M.Z.); Division of Gastroenterology, University of California San Diego, San Diego, Calif (W.J.S); Division of Pediatric Gastroenterology, Emory University, Children's Healthcare of Atlanta, Ga (C.G.S); and Division of GI Surgery, Northwestern Medicine, Chicago, Ill (S.A.S)
| | - Cary G Sauer
- From the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn (D.H.B., E.V.L); Department of Gastroenterology, University of Florida, Gainesville, Fla (E.M.Z.); Division of Gastroenterology, University of California San Diego, San Diego, Calif (W.J.S); Division of Pediatric Gastroenterology, Emory University, Children's Healthcare of Atlanta, Ga (C.G.S); and Division of GI Surgery, Northwestern Medicine, Chicago, Ill (S.A.S)
| | - Scott A Strong
- From the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn (D.H.B., E.V.L); Department of Gastroenterology, University of Florida, Gainesville, Fla (E.M.Z.); Division of Gastroenterology, University of California San Diego, San Diego, Calif (W.J.S); Division of Pediatric Gastroenterology, Emory University, Children's Healthcare of Atlanta, Ga (C.G.S); and Division of GI Surgery, Northwestern Medicine, Chicago, Ill (S.A.S)
| | -
- From the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minn (D.H.B., E.V.L); Department of Gastroenterology, University of Florida, Gainesville, Fla (E.M.Z.); Division of Gastroenterology, University of California San Diego, San Diego, Calif (W.J.S); Division of Pediatric Gastroenterology, Emory University, Children's Healthcare of Atlanta, Ga (C.G.S); and Division of GI Surgery, Northwestern Medicine, Chicago, Ill (S.A.S)
| |
Collapse
|
|
17
|
Choi IY, Park SH, Park SH, Yu CS, Yoon YS, Lee JL, Ye BD, Kim AY, Yang SK. CT Enterography for Surveillance of Anastomotic Recurrence within 12 Months of Bowel Resection in Patients with Crohn's Disease: An Observational Study Using an 8-Year Registry. Korean J Radiol 2017; 18:906-914. [PMID: 29089823 PMCID: PMC5639156 DOI: 10.3348/kjr.2017.18.6.906] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/17/2017] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To investigate the diagnostic yield and accuracy of CT enterography (CTE) for early (< 12 postoperative months) surveillance of anastomotic recurrence after bowel resection for Crohn's disease (CD). MATERIALS AND METHODS We analyzed 88 adults (60 males and 28 females; mean age, 31.4 ± 9.6 years) who underwent bowel surgery for CD that created ileocolic anastomosis without enteric stoma, and underwent CTE for surveillance of CD recurrence/aggravation within 12 post-operative months. The CD activity index (CDAI) at the time of CTE was < 150 (i.e., clinically silent) in 51 patients, and ≥ 150 in 37 patients. Diagnostic yields of CTE regarding CD recurrence in the ileocolic anastomosis and extraluminal penetrating complications were determined. CTE-related step-up therapy was recorded. These outcomes were compared between the two CDAI groups after accounting for major risk factors for CD recurrence. In a subgroup of 31 patients who underwent both CTE and ileocolonoscopy within 1 month, CTE accuracy for anastomotic recurrence was assessed using the Rutgeerts scoring as the reference standard. RESULTS CTE diagnostic yield was 35.2% (31/88) for the anastomotic recurrence and 9.1% (8/88) for penetrating complications. 20.5% (18/88) of the patients underwent step-up therapy after CTE detection of anastomotic recurrence. These outcomes were not significantly different between CDAI < 150 and CDAI ≥ 150, except that CTE yield for extraluminal penetrating complications was significantly higher in CDAI ≥ 150 (16.2% [6/37] vs. 3.9% [2/51]; multivariable-adjusted p = 0.029). CTE showed 92.3% (12/13) sensitivity and 83.3% (15/18) specificity for anastomotic recurrence. CONCLUSION CTE may be a viable option for the early postsurgical surveillance of recurred disease in CD patients.
Collapse
Affiliation(s)
- In Young Choi
- Department of Radiology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan 15355, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Seong Ho Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Chang Sik Yu
- Department of Colorectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Yong Sik Yoon
- Department of Colorectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Jong Lyul Lee
- Department of Colorectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Ah Young Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| |
Collapse
|
|
18
|
Kedia S, Sharma R, Makharia GK, Ahuja V, Desai D, Kandasamy D, Eapen A, Ganesan K, Ghoshal UC, Kalra N, Karthikeyan D, Madhusudhan KS, Philip M, Puri AS, Puri S, Sinha SK, Banerjee R, Bhatia S, Bhat N, Dadhich S, Dhali GK, Goswami BD, Issar SK, Jayanthi V, Misra SP, Nijhawan S, Puri P, Sarkar A, Singh SP, Srivastava A, Abraham P, Ramakrishna BS. Imaging of the small intestine in Crohn's disease: Joint position statement of the Indian Society of Gastroenterology and Indian Radiological and Imaging Association. Indian J Gastroenterol 2017; 36:487-508. [PMID: 29307029 DOI: 10.1007/s12664-017-0804-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 11/26/2017] [Indexed: 02/07/2023]
Abstract
The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients with suspected or known Crohn's disease. These 29 position statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.
Collapse
Affiliation(s)
- Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Devendra Desai
- Division of Gastroenterology, P D Hinduja Hospital and Medical Research Centre, Veer Sawarkar Marg, Mumbai, 400 016, India
| | - Devasenathipathy Kandasamy
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Anu Eapen
- Department of Radiodiagnosis, Christian Medical College, Vellore, 632 004, India
| | - Karthik Ganesan
- Department of Radiodiagnosis, Sir H N Reliance Foundation Hospital and Research Centre, Prarthana Samaj, Raja Rammohan Roy Road, Mumbai, 400 004, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Naveen Kalra
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - D Karthikeyan
- Department of Radiodiagnosis, SRM Institutes for Medical Science, 1, Jawaharlal Nehru Salai, Vadapalani, Chennai, 600 026, India
| | | | - Mathew Philip
- Department of Gastroenterology, PVS Memorial Hospital, Kochi, 682 017, India
| | - Amarender Singh Puri
- Department of Gastroenterology, GB Pant Institute of Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi, 110 002, India
| | - Sunil Puri
- Department of Radiodiagnosis, GB Pant Institute of Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi, 110 002, India
| | - Saroj K Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Rupa Banerjee
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad, 500 082, India
| | - Shobna Bhatia
- Department of Gastroenterology, KEM Hospital, Acharya Donde Marg, Parel, Mumbai, 400 012, India
| | - Naresh Bhat
- Department of Gastroenterology, Aster CMI Hospital, 43/2, New Airport Road, NH.7, Sahakara Nagar, Bengaluru, 560 092, India
| | - Sunil Dadhich
- Department of Gastroenterology, SN Medical College, Residency Road, Shastri Nagar, Jodhpur, 342 003, India
| | - G K Dhali
- Department of Gastroenterology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, 700 020, India
| | - B D Goswami
- Department of Gastroenterology, Guwahati Medical College, GMC Hospital Road, Bhangagarh, Guwahati, 781 032, India
| | - S K Issar
- Department of Gastroenterology, Jawaharlal Nehru Hospital and Research Centre, Hospital Sector, Bhilai, 490 009, India
| | - V Jayanthi
- Department of Gastroenterology, Gleneagles Global Hospitals, 439, Cheran Nagar, Perumbakkam, Chennai, 600 100, India
| | - S P Misra
- Department of Gastroenterology, MLN Medical College, Allahabad, 211 002, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, SMS Medical College, J L N. Marg, Jaipur, 302 004, India
| | - Pankaj Puri
- Department of Gastroenterology, Military Hospital, Cantt Area, Jodhpur, 342 006, India
| | - Avik Sarkar
- Department of Radiodiagnosis, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, 700 020, India
| | - S P Singh
- Department of Gastroenterology, SCB Medical College, Dock Road, Manglabag, Cuttack, 753 007, India
| | - Anshu Srivastava
- Department of Paediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Philip Abraham
- Division of Gastroenterology, P D Hinduja Hospital and Medical Research Centre, Veer Sawarkar Marg, Mumbai, 400 016, India
| | - B S Ramakrishna
- Institute of Gastroenterology, SRM Institutes for Medical Science, 1, Jawaharlal Nehru Salai, Vadapalani, Chennai, 600 026, India
| |
Collapse
|
|
19
|
Brouquet A, Rangheard AS, Ifergan J, Lazure T, Carbonnel F, Penna C, Benoist S. The accuracy of preoperative imaging in measuring the length of the ileocolic segment affected by Crohn's disease: a prospective cohort study. Colorectal Dis 2017; 19:437-445. [PMID: 27607894 DOI: 10.1111/codi.13502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 07/11/2016] [Indexed: 12/22/2022]
Abstract
AIM The study aimed to evaluate the accuracy of imaging for measurement of the length of the ileocolic segment affected by Crohn's disease. METHOD Fifty-four consecutive patients who underwent resection between 2011 and 2014 for ileocolic Crohn's disease were prospectively studied. All had preoperative MR or CT enterography. Two independent radiologists measured the length of the diseased intestinal segment. The measurements were compared with the length of disease assessed on pathology of the non-fixed surgical specimen. RESULTS The median preoperative length of the Crohn's disease segment on imaging was 20.5 (2-73) cm and 20 (3-90) cm, as measured by the two radiologists. Interobserver agreement was substantial (κ = 0.69) with a correlation coefficient (r) of 0.82 (P < 0.001). The median length of the Crohn's disease segment on pathological examination was 16.5 (2-75) cm and was closely correlated with the radiological measurement (r = 0.76, P < 0.001). The length of the Crohn's disease segment on imaging was correct to within 5 cm of the value on pathology. It was correct in 30 (55%) patients and was underestimated and overestimated in 6 (11.1%) and 18 (33.3%). A length of disease of less than 20 cm found on imaging in 26 patients was confirmed in 25 (96%) on pathology, whereas a length of more than 20 cm found on imaging in 28 patients was confirmed in 18 (64%) on pathology. The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of imaging for predicting a length of less than 20 cm were 71%, 95%, 96%, 64% and 79%. CONCLUSION Imaging accurately identifies the length of the ileocolic segment of Crohn's disease when it is 20 cm or less on pathological examination. In patients with more extensive disease, imaging tends to overestimate the length and should be interpreted with caution.
Collapse
Affiliation(s)
- A Brouquet
- Department of Digestive and Oncologic Surgery, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, University Paris-Sud, Le Kremlin-Bicêtre, France
| | - A-S Rangheard
- Department of Radiology, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, University Paris-Sud, Le Kremlin-Bicêtre, France
| | - J Ifergan
- Department of Radiology, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, University Paris-Sud, Le Kremlin-Bicêtre, France
| | - T Lazure
- Department of Pathology, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, University Paris-Sud, Le Kremlin-Bicêtre, France
| | - F Carbonnel
- Department of Gastroenterology, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, University Paris-Sud, Le Kremlin-Bicêtre, France
| | - C Penna
- Department of Digestive and Oncologic Surgery, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, University Paris-Sud, Le Kremlin-Bicêtre, France
| | - S Benoist
- Department of Digestive and Oncologic Surgery, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, University Paris-Sud, Le Kremlin-Bicêtre, France
| |
Collapse
|
|
20
|
Deepak P, Park SH, Ehman EC, Hansel SL, Fidler JL, Bruining DH, Fletcher JG. Crohn's disease diagnosis, treatment approach, and management paradigm: what the radiologist needs to know. Abdom Radiol (NY) 2017; 42:1068-1086. [PMID: 28210767 DOI: 10.1007/s00261-017-1068-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Crohn's disease is one of the major subtypes of idiopathic inflammatory bowel disease and is characterized by chronic transmural intestinal inflammation of the gastrointestinal tract anywhere from mouth to the anus, with a predilection for the small bowel. Cross-sectional imaging with computed tomography and magnetic resonance enterography plays a key role in confirming diagnosis, identifying and managing complications, assessing disease severity, and identifying response to medical therapy. This review will focus on the role of radiologists in the diagnosis and assessment of Crohn's disease. Additionally, a review of current medical therapy approaches, available medications, and side effects will be discussed. The review will also highlight key complications of medical therapy and associated diseases that should be evaluated by the radiologist with cross-sectional imaging.
Collapse
Affiliation(s)
- Parakkal Deepak
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Sang Hyoung Park
- Department of Gastroenterology, Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Eric C Ehman
- Division of Abdominal Imaging, Mayo Clinic College of Medicine, 200 First Street, SW, Rochester, MN, 55905, USA
| | - Stephanie L Hansel
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Jeff L Fidler
- Division of Abdominal Imaging, Mayo Clinic College of Medicine, 200 First Street, SW, Rochester, MN, 55905, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Joel G Fletcher
- Division of Abdominal Imaging, Mayo Clinic College of Medicine, 200 First Street, SW, Rochester, MN, 55905, USA.
| |
Collapse
|
|
21
|
Burlin S, Favaro LR, Bretas EAS, Taniguchi LS, Loch AP, Argollo MC, Ambrogini Junior O, D'Ippolito G. Using computed tomography enterography to evaluate patients with Crohn's disease: what impact does examiner experience have on the reproducibility of the method? Radiol Bras 2017; 50:13-18. [PMID: 28298727 PMCID: PMC5347498 DOI: 10.1590/0100-3984.2015.0131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Objective To assess the impact that examiner experience has on the reproducibility and
accuracy of computed tomography (CT) enterography in the detection of
radiological signs in patients with Crohn's disease. Materials and Methods This was a retrospective, cross-sectional observational study involving the
analysis of CT enterography scans of 20 patients with Crohn's disease. The
exams were analyzed independently by two radiologists in their last year of
residence (duo I) and by two abdominal imaging specialists (duo II). The
interobserver agreement of each pair of examiners in identifying the main
radiological signs was calculated with the kappa test. The accuracy of the
examiners with less experience was quantified by using the consensus among
three experienced examiners as a reference. Results Duo I and duo II obtained a similar interobserver agreement, with a moderate
to good correlation, for mural hyperenhancement, parietal thickening, mural
stratification, fat densification, and comb sign (kappa: 0.45-0.64). The
less experienced examiners showed an accuracy > 80% for all signs, except
for lymph nodes and fistula, for which it ranged from 60% to 75%. Conclusion Less experienced examiners have a tendency to present a level of
interobserver agreement similar to that of experienced examiners in
evaluating Crohn's disease through CT enterography, as well as showing
satisfactory accuracy in identifying most radiological signs of the
disease.
Collapse
Affiliation(s)
- Stênio Burlin
- MD, Radiologist in the Department of Diagnostic Imaging of the Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Larissa Rossini Favaro
- MD, Radiologist, Specialist in Abdominal Imaging in the Department of Diagnostic Imaging of the Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Elisa Almeida Sathler Bretas
- MD, Radiologist, Graduate Student in Abdominal Imaging in the Department of Diagnostic Imaging of the Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Lincoln Seiji Taniguchi
- MD, Radiologist, Specialist in Abdominal Imaging in the Department of Diagnostic Imaging of the Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Ana Paula Loch
- Pharmacist, Graduate Student in Preventive Medicine at the Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Marjorie Costa Argollo
- MD, Graduate Student in Clinical Gastroenterology, Discipline of Clinical Medicine, Department of Medicine of the Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Orlando Ambrogini Junior
- PhD, Affiliate Professor, Discipline of Clinical Medicine, Department of Medicine of the Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Giuseppe D'Ippolito
- Tenured Adjunct Professor in the Department of Diagnostic Imaging of the Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| |
Collapse
|
|
22
|
Bhatnagar G, Von Stempel C, Halligan S, Taylor SA. Utility of MR enterography and ultrasound for the investigation of small bowel Crohn's disease. J Magn Reson Imaging 2016; 45:1573-1588. [PMID: 27943484 DOI: 10.1002/jmri.25569] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/11/2016] [Indexed: 12/18/2022] Open
Abstract
Cross sectional Imaging plays an increasingly important role the diagnosis and management of Crohn's disease. Particular emphasis is placed on MRI and Ultrasound as they do not impart ionising radiation. Both modalities have reported high sensitivity for disease detection, activity assessment and evaluation of extra-luminal complications, and have positive effects on clinical decision making. International Guidelines now recommend MRI and Ultrasound in the routine management of Crohn's disease patients. This article reviews the current evidence base supporting both modalities with an emphasis on the key clinical questions. We describe current protocols, basic imaging findings and highlight areas in need of further research. LEVEL OF EVIDENCE 5 Technical Efficacy: Stage 4 J. MAGN. RESON. IMAGING 2017;45:1573-1588.
Collapse
Affiliation(s)
- Gauraang Bhatnagar
- Frimley Park Hospital NHS Foundation Trust, London, UK.,Centre for Medical Imaging, University College London, London, UK
| | | | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| |
Collapse
|
|
23
|
van Munster SN, Stolk MFJ, Kuypers KC, Wiezer R, Bollen TL. Magnetic resonance enterography findings of a gastrocolic fistula in Crohn's disease. Quant Imaging Med Surg 2016; 6:482-485. [PMID: 27709089 DOI: 10.21037/qims.2016.08.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sanne N van Munster
- Department of Surgery, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Mark F J Stolk
- Department of Gastroenterology and Hepatology, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Karel C Kuypers
- Department of Pathology, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Rene Wiezer
- Department of Surgery, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Thomas L Bollen
- Department of Radiology, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
| |
Collapse
|
|
24
|
Kim DH, Carucci LR, Baker ME, Cash BD, Dillman JR, Feig BW, Fowler KJ, Gage KL, Noto RB, Smith MP, Yaghmai V, Yee J, Lalani T. ACR Appropriateness Criteria Crohn Disease. J Am Coll Radiol 2016; 12:1048-57.e4. [PMID: 26435118 DOI: 10.1016/j.jacr.2015.07.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/08/2015] [Indexed: 12/11/2022]
Abstract
Crohn disease is a chronic inflammatory disorder involving the gastrointestinal tract, characterized by episodic flares and times of remission. Underlying structural damage occurs progressively, with recurrent bouts of inflammation. The diagnosis and management of this disease process is dependent on several clinical, laboratory, imaging, endoscopic, and histologic factors. In recent years, with the maturation of CT enterography, and MR enterography, imaging has played an increasingly important role in relation to Crohn Disease. In addition to these specialized examination modalities, ultrasound and routine CT have potential uses. Fluoroscopy, radiography, and nuclear medicine may be less beneficial depending on the clinical scenario. The imaging modality best suited to evaluating this disease may change, depending on the target population, severity of presentation, and specific clinical situation. This document presents seven clinical scenarios (variants) in both the adult and pediatric populations and rates the appropriateness of the available imaging options. They are summarized in a consolidated table, and the underlying rationale and supporting literature are presented in the accompanying narrative. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Collapse
Affiliation(s)
- David H Kim
- University of Wisconsin Hospital and Clinics, Madison, Wisconsin.
| | - Laura R Carucci
- Virginia Commonwealth University Medical Center, Richmond, Virginia
| | | | | | | | - Barry W Feig
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Richard B Noto
- Brown University Rhode Island Hospital, Providence, Rhode Island
| | - Martin P Smith
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Judy Yee
- University of California San Francisco, San Francisco, California
| | - Tasneem Lalani
- Inland Imaging Associates and University of Washington, Seattle, Washington
| |
Collapse
|
|
25
|
Taxonera C, Barreiro-de-Acosta M, Bastida G, Martinez-Gonzalez J, Merino O, García-Sánchez V, Gisbert JP, Marín-Jiménez I, López-Serrano P, Gómez-García M, Iglesias E, Lopez-Sanroman A, Chaparro M, Saro C, Bermejo F, Pérez-Carazo L, Plaza R, Olivares D, Alba C, Mendoza JL, Fernández-Blanco I. Outcomes of Medical and Surgical Therapy for Entero-urinary Fistulas in Crohn's Disease. J Crohns Colitis 2016; 10:657-62. [PMID: 26786982 DOI: 10.1093/ecco-jcc/jjw016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 01/07/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS The aims of this study were to evaluate the frequency of entero-urinary fistulas in a cohort of Crohn's disease (CD) patients and to analyse the outcomes of medical and surgical therapy. METHODS This multicentre retrospective study included all CD patients with entero-urinary fistulas diagnosed by the presence of clinical symptoms and confirmed at surgery or by radiological or endoscopic techniques. We evaluated outcomes of medical and surgical therapy. We defined remission as absence of clinical symptoms with a radiological confirmation of fistula closure. Cox regression analysis was performed to evaluate factors predictive of achieving remission without need for surgery. RESULTS Of 6081 CD patients screened, 97 had entero-urinary fistulas (frequency 1.6%). Seventy-five percent of fistulas occurred in men. After a median follow-up of 91 months, 96% of patients were in sustained remission. Thirty-three patients (35%) received anti-tumour necrosis factor (TNF) therapy. Of these, 45% achieved sustained remission (median follow-up 35 months) without needing surgery. More than 80% of patients required surgery, which induced remission (median follow-up 101 months) in 99% of them. Only the use of anti-TNF agents was associated with an increased rate of remission without need for surgery (hazard ratio 0.23, 95% confidence interval 0.12-0.44; p < 0.001). CONCLUSION In this large cohort of CD patients, the frequency of entero-urinary fistulas was lower than previously described. More than 80% of patients required surgery, and in all but one of them surgery induced sustained remission. In a selected subgroup of patients, anti-TNF may induce long-term fistula remission and radiographic closure, making it possible to avoid surgery.
Collapse
Affiliation(s)
- Carlos Taxonera
- Inflammatory Bowel Disease Unit, Department of Gastroenterology, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | | | - Guillermo Bastida
- Department of Gastroenterology, Hospital La Fe, Valencia, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Spain
| | | | - Olga Merino
- Department of Gastroenterology, Hospital de Cruces, Bilbao, Spain
| | - Valle García-Sánchez
- Department of Gastroenterology, Hospital Reina Sofía and IMIBIC, Universidad de Córdoba, Córdoba, Spain
| | - Javier P Gisbert
- Department of Gastroenterology, Hospital de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Spain
| | | | | | - María Gómez-García
- Department of Gastroenterology, Hospital Virgen de las Nieves, Granada, Spain
| | - Eva Iglesias
- Department of Gastroenterology, Hospital Reina Sofía and IMIBIC, Universidad de Córdoba, Córdoba, Spain
| | | | - María Chaparro
- Department of Gastroenterology, Hospital de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Spain
| | - Cristina Saro
- Department of Gastroenterology, Hospital de Cabueñes, Gijón, Spain
| | - Fernando Bermejo
- Department of Gastroenterology, Hospital de Fuenlabrada, Madrid, Spain
| | | | - Rocio Plaza
- Department of Gastroenterology, Hospital Infanta Leonor, Madrid, Spain
| | - David Olivares
- Inflammatory Bowel Disease Unit, Department of Gastroenterology, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Cristina Alba
- Inflammatory Bowel Disease Unit, Department of Gastroenterology, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Juan L Mendoza
- Inflammatory Bowel Disease Unit, Department of Gastroenterology, Hospital Clínico San Carlos and Instituto de Investigación del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | | |
Collapse
|
|
26
|
Kaye TL, Wilkinson C. Curriculum based clinical review: small bowel imaging in Crohn's disease. Frontline Gastroenterol 2016; 7:141-149. [PMID: 28839849 PMCID: PMC5369467 DOI: 10.1136/flgastro-2014-100547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 02/10/2015] [Accepted: 02/11/2015] [Indexed: 02/04/2023] Open
Abstract
The multidisciplinary management of patients with small bowel Crohn's disease is complex with an increasing reliance on imaging to guide management. The use of barium fluoroscopy is in decline with a shift towards the cross-sectional modalities. This article provides an overview of the various techniques used to image the small bowel, and highlights the clinical scenarios where imaging tests are most useful.
Collapse
Affiliation(s)
- Tom L Kaye
- York Teaching Hospital NHS Foundation Trust, York, UK
| | | |
Collapse
|
|
27
|
CT and MR enterography in Crohn's disease: current and future applications. ACTA ACUST UNITED AC 2016; 40:965-74. [PMID: 25637127 DOI: 10.1007/s00261-015-0360-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
|
28
|
Abstract
CT enterography is a first-line test at many institutions to investigate potential small bowel disorders. While numerous articles have focused on the ability of CT enterography to diagnose and stage Crohn's disease, small bowel neoplasia, and malabsorptive or vascular disorders, this article reviews CT enterography limitations, technical and interpretive pitfalls, image review tactics, and complementary radiologic and endoscopic examinations to improve diagnostic accuracy. CT enterography limitations include its inability to demonstrate isolated mucosal abnormalities such as aphthous ulcers and its use of ionizing radiation. The most common technical pitfall of CT enterography is inadequate small bowel distention resulting from inadequate ingestion, gastric retention, or rapid small bowel transit of a large volume of neutral enteric contrast material. Additionally, segments of jejunum are frequently collapsed. Interpretive pitfalls commonly result from peristaltic contractions, transient intussusception and opaque intraluminal debris. Opaque debris is especially problematic during multiphasic CT enterography performed to identify potential small bowel sources of obscure gastrointestinal bleeding. False-negative examinations may result from inadequate radiation dose. Examinations complementary to CT enterography include small bowel follow through, enteroclysis, CT enteroclysis, MR enterography, MR enteroclysis, capsule endoscopy, and balloon-assisted endoscopy. Properly performed and accurately interpreted CT enterography contributes to the diagnosis and management of small bowel disease by itself and as a complement to other radiologic and optical small bowel imaging examinations.
Collapse
|
|
29
|
Haas K, Rubesova E, Bass D. Role of imaging in the evaluation of inflammatory bowel disease: How much is too much? World J Radiol 2016; 8:124-131. [PMID: 26981221 PMCID: PMC4770174 DOI: 10.4329/wjr.v8.i2.124] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 11/24/2015] [Accepted: 01/07/2016] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a lifelong condition with waxing and waning disease course that requires reassessment of disease status as well as screening for complications throughout a patient’s lifetime. Laboratory testing, endoscopic assessment, and fecal biomarkers are often used in the initial diagnosis and ongoing monitoring of a patient with IBD. Imaging plays an integral role in the diagnosis and evaluation of IBD. Different imaging modalities can be used over the course of a patient’s lifetime, from the initial screening and diagnosis of IBD, to determining the extent of intestinal involvement, monitoring for disease activity, and evaluating for complications of uncontrolled IBD. The various imaging modalities available to the provider each have a unique set of risks and benefits when considering cost, radiation exposure, need for anesthesia, and image quality. In this article we review the imaging techniques available for the evaluation of IBD including fluoroscopic small bowel follow-through, computed tomography enterography, magnetic resonance enterography, and transabdominal ultrasound with particular focus on the judicious use of imaging and the risks and benefits of each option. We also review the risks of ionizing radiation, strategies to reduce exposure to ionizing radiation, and current imaging guidelines among pediatric and adult patient with IBD.
Collapse
|
|
30
|
|
|
31
|
|
|
32
|
Mollard BJ, Smith EA, Dillman JR. Pediatric MR enterography: technique and approach to interpretation-how we do it. Radiology 2015; 274:29-43. [PMID: 25531478 DOI: 10.1148/radiol.14122449] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Magnetic resonance (MR) enterography is an increasingly important pediatric imaging modality that is most often used to evaluate inflammatory bowel disease ( IBD inflammatory bowel disease ), while sparing children and adolescents from potential risks of ionizing radiation exposure. MR enterography allows for evaluation of the bowel lumen and wall, adjacent mesentery and soft tissues, as well as a variety of extraintestinal abdominopelvic IBD inflammatory bowel disease manifestations. While MR enterography can be used to initially confirm the diagnosis of IBD inflammatory bowel disease , particularly small bowel Crohn disease, it has also proven useful in assessing the degree inflammatory activity over time, serving as a radiologic biomarker for response to medical therapy, and identifying a variety of disease-related complications, including strictures, fistulae, and abscesses. The purpose of this review article is to provide radiologists with a systematic approach for MR enterography review and interpretation in children and adolescents with known or suspected of having IBD inflammatory bowel disease and to illustrate both common and infrequent but important imaging findings. Additionally, the authors will present their well-established and clinically successful pediatric MR enterography protocol, up-to-date clinical indications for MR enterography, and briefly mention the role of MR enterography in assessing non- IBD inflammatory bowel disease abnormalities affecting the bowel. Online supplemental material is available for this article .
Collapse
Affiliation(s)
- Brett J Mollard
- From the Department of Radiology (B.J.M., E.A.S., J.R.D.), Section of Pediatric Radiology (E.A.S., J.R.D.), University of Michigan Health System, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., SPC 4252, Ann Arbor, MI 48109-4252
| | | | | |
Collapse
|
|
33
|
Huang X, Liao WD, Yu C, Tu Y, Pan XL, Chen YX, Lv NH, Zhu X. Differences in clinical features of Crohn's disease and intestinal tuberculosis. World J Gastroenterol 2015; 21:3650-3656. [PMID: 25834333 PMCID: PMC4375590 DOI: 10.3748/wjg.v21.i12.3650] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 09/08/2014] [Accepted: 01/30/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the clinical features of Crohn’s disease (CD) and intestinal tuberculosis (ITB) with a scoring system that we have developed.
METHODS: A total of 25 CD and 40 ITB patients were prospectively enrolled from August 2011 to July 2012. Their characteristics and clinical features were recorded. Laboratory, endoscopic, histologic and radiographic features were determined. The features with a high specificity were selected to establish a scoring system. The features supporting CD scored +1, and those supporting ITB scored -1; each patient received a final total score. A receiver operating characteristic (ROC) curve was used to determine the best cut-off value for distinguishing CD from ITB.
RESULTS: Based on a high specificity of differentiating between CD and ITB, 12 features, including longitudinal ulcers, nodular hyperplasia, cobblestone-like mucosa, intestinal diseases, intestinal fistula, the target sign, the comb sign, night sweats, the purified protein derivative test, the interferon-γ release assay (T-SPOT.TB), ring ulcers and ulcer scars, were selected for the scoring system. The results showed that the average total score of the CD group was 3.12 ± 1.740, the average total score of the ITB group was -2.58 ± 0.984, the best cutoff value for the ROC curve was -0.5, and the diagnostic area under the curve was 0.997, which was statistically significant (P < 0.001). The patients whose total scores were higher than -0.5 were diagnosed with CD; otherwise, patients were diagnosed with ITB. Overall, the diagnostic accuracy rate and misdiagnosis rate of this scoring system were 97% and 3%, respectively.
CONCLUSION: Some clinical features are valuable for CD and ITB diagnosis. The described scoring system is key to differentiating between CD and ITB.
Collapse
|
|
34
|
Accuracy of CT enterography and magnetic resonance enterography imaging to detect lesions preoperatively in patients undergoing surgery for Crohn's disease. Dis Colon Rectum 2014; 57:1364-70. [PMID: 25380001 DOI: 10.1097/dcr.0000000000000244] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND CT enterography and magnetic resonance enterography have emerged as first-line imaging technologies for the evaluation of the gastrointestinal tract in Crohn's disease. OBJECTIVE The purpose of this work was to evaluate the accuracy of these imaging modalities to identify Crohn's disease lesions preoperatively. DESIGN This was a retrospective chart review. SETTINGS The study was conducted at a single institution. PATIENTS Seventy-six patients with Crohn's disease with preoperative CT enterography and/or magnetic resonance enterography were included in the study. MAIN OUTCOME MEASURES The number of stenoses, fistulas, and abscesses on CT enterography and/or magnetic resonance enterography before surgery were compared with operative findings. RESULTS Forty patients (53%) were women, 46 (60%) underwent surgery for recurrent Crohn's disease, and 46 (57%) had previous abdominal surgery. Thirty-six (47%) had a preoperative CT enterography and 43 (57%) had a preoperative magnetic resonance enterography. CT enterography sensitivity was 75% for stenosis and 50% for fistula. MRE sensitivity was 68% for stenosis and 60% for fistula. The negative predictive values of CT enterography and magnetic resonance enterography for stenosis were very low (54% and 65%) and were 85% and 81% for fistula. CT enterography had 76% accuracy for stenosis and 79% for fistula; magnetic resonance enterography had 78% accuracy for stenosis and 85% for fistula. Both were accurate for abscess. False-negative rates for CT enterography were 50% for fistula and 25% for stenosis. False-negative rates for magnetic resonance enterography were 40% for fistula and 32% for stenosis. Unexpected intraoperative findings led to modification of the planned surgical procedure in 20 patients (26%). LIMITATIONS This study was limited by its small sample size, its retrospective nature, and that some studies were performed at outside institutions. CONCLUSIONS CT enterography and magnetic resonance enterography in patients with Crohn's disease were accurate for the identification of abscesses but not for fistulas or stenoses. Surgeons should search for additional lesions intraoperatively. Patients should be appropriately counseled regarding the need for unexpected interventions (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A162).
Collapse
|
|
35
|
Spinelli A, Allocca M, Jovani M, Danese S. Review article: optimal preparation for surgery in Crohn's disease. Aliment Pharmacol Ther 2014; 40:1009-22. [PMID: 25209947 DOI: 10.1111/apt.12947] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 04/16/2014] [Accepted: 08/13/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND One-third of Crohn's disease (CD) patients will undergo abdominal surgery within the first 5 years of diagnosis. AIM To review the available evidence on pre-operative optimisation of CD patients. METHODS The literature regarding psychological support, radiological imaging, abdominal abscess management, nutritional support, thromboembolic prophylaxis and immunosuppression in the perioperative setting was reviewed. RESULTS For diagnosis of fistulas, abscesses and stenosis, ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) have a high diagnostic accuracy. Under either CT or US guidance, it is possible to perform abscess percutaneous drainage (PD), which, with systemic antibiotic therapy, should be the first-line approach to intra-abdominal abscesses. CD patients with weight loss <10% within the last 3-6 months, body mass index < 18.5 kg/m(2) and/or albumin levels <30 g/L, are at an increased risk of post-operative complications. Pre-operative nutritional support should be used in these patients. IBD patients undergoing surgery have a higher risk of venous thromboembolic disease than patients with colorectal cancer, and current guidelines recommend that they should receive prophylaxis with heparin. Whether the use of anti-TNF agents before surgery increases the likelihood of post-operative complications, is the subject of much debate. To date, cumulative evidence from most studies (all retrospective) suggests that there is no such risk increment. Prospective studies are necessary to firmly establish this conclusion. CONCLUSIONS Preparation for surgery requires close interaction between surgeons, gastroenterologist, radiologists, psychologists and the patient. Correct pre-operative planning of surgical treatment has a major impact on the outcome of such treatment.
Collapse
Affiliation(s)
- A Spinelli
- IBD Surgery Unit, Department of Surgery, Istituto Clinico Humanitas IRCCS, Milan, Italy; Department of Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | | | | | | |
Collapse
|
|
36
|
Towbin AJ, Sullivan J, Denson LA, Wallihan DB, Podberesky DJ. CT and MR enterography in children and adolescents with inflammatory bowel disease. Radiographics 2014; 33:1843-60. [PMID: 24224581 DOI: 10.1148/rg.337105140] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The term inflammatory bowel disease (IBD) is used to describe multiple idiopathic disorders of the gastrointestinal tract. As many as one-quarter of patients with IBD initially present in childhood or adolescence. Multiple methods can be used to diagnose IBD in this age group, including computed tomographic (CT) enterography, magnetic resonance (MR) enterography, small bowel follow-through examination, ileocolonoscopy, and capsule endoscopy. However, CT enterography and MR enterography have become the imaging modalities of choice due to their exquisite image quality, rapid acquisition time, lack of need for bowel preparation, and ability to help diagnose the extraintestinal complications of IBD. In addition to being radiation free, MR enterography can help evaluate peristalsis, has high contrast resolution, and allows the use of diffusion-weighted imaging. The authors discuss the use of CT enterography and MR enterography in the context of pediatric IBD in terms of advantages and disadvantages, protocol, and imaging findings.
Collapse
Affiliation(s)
- Alexander J Towbin
- From the Departments of Radiology (A.J.T., J.S., D.B.W., D.J.P.) and Gastroenterology (L.A.D.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, ML 5031, Cincinnati, OH 45241
| | | | | | | | | |
Collapse
|
|
37
|
Outcomes of computed tomography and magnetic resonance enterography in clinical practice of inflammatory bowel disease. Dig Dis Sci 2014; 59:838-49. [PMID: 24323180 DOI: 10.1007/s10620-013-2964-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 11/15/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Computed tomography (CT) and magnetic resonance (MR) enterography are now widely used to diagnose and monitor Crohn's disease. AIM We sought to assess the use of enterography for management of inflammatory bowel disease (IBD) in our medical center. METHODS We performed a retrospective review of all patients diagnosed with IBD who underwent MR or CT enterography from November 1, 2010 to October 25, 2012 at our institution. We assessed disease complications identified by enterography, agreement between disease activity determined by endoscopy and enterography, association between inflammatory markers and enterography-determined disease activity and recommended changes in medical and surgical management following enterography. RESULTS A total of 311 enterography studies (291 MR and 20 CT enterographies) were performed on 270 patients, including 258 (83.0 %) on patients with presumed Crohn's disease and 53 (17.0 %) with presumed ulcerative colitis. Active small bowel (SB) disease was noted in 73/311 (23.5 %) studies. Complications including strictures, perianal fistulas, abscesses and SB fistulas were noted in 108/311 (34.7 %) studies. Endoscopic and enterography defined active disease had an agreement of κ = 0.36 in the ileum (n = 179). A total of 142/311 (45.7 %) enterographies were associated with recommended medication changes within 90 days while surgery or endoscopic dilation of stricture was recommended following 41/311 (13.2 %) enterographies. Enterography resulted in a change in diagnosis from ulcerative colitis to Crohn's in 5/311 (1.6 %) studies. CONCLUSION Enterography reveals active disease and complications not evident on endoscopy and should be considered in the initial diagnosis, assessment of disease activity, and monitoring of therapy in patients with IBD.
Collapse
|
|
38
|
Fidler JL, Fletcher JG, Bruining DH, Trenkner SW. Current status of CT, magnetic resonance, and barium in inflammatory bowel disease. Semin Roentgenol 2014; 48:234-44. [PMID: 23796374 DOI: 10.1053/j.ro.2013.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jeff L Fidler
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.
| | | | | | | |
Collapse
|
|
39
|
Del Gaizo AJ, Fletcher JG, Yu L, Paden RG, Spencer GC, Leng S, Silva AM, Fidler JL, Silva AC, Hara AK. Reducing radiation dose in CT enterography. Radiographics 2014; 33:1109-24. [PMID: 23842974 DOI: 10.1148/rg.334125074] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Computed tomographic (CT) enterography is a diagnostic examination that is increasingly being used to evaluate disorders of the small bowel. An undesirable consequence of CT, however, is patient exposure to ionizing radiation. This is of particular concern with CT enterography because patients tend to be young and require numerous follow-up examinations. There are multiple strategies to reduce radiation dose at CT enterography, including adjusting acquisition parameters, reducing scan length, and reducing tube voltage or tube current. The drawback to dose reduction strategies is degradation of image quality due to increased image noise. However, image noise can be reduced with commercial iterative reconstruction and denoising techniques. With a combination of low-dose techniques and noise-control strategies, one can markedly reduce radiation dose at CT enterography while maintaining diagnostic accuracy.
Collapse
Affiliation(s)
- Andrew J Del Gaizo
- Department of Radiology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
40
|
Faubion WA, Fletcher JG, O'Byrne S, Feagan BG, de Villiers WJ, Salzberg B, Plevy S, Proctor DD, Valentine JF, Higgins PD, Harris JM, Diehl L, Wright L, Tew GW, Luca D, Basu K, Keir ME. EMerging BiomARKers in Inflammatory Bowel Disease (EMBARK) study identifies fecal calprotectin, serum MMP9, and serum IL-22 as a novel combination of biomarkers for Crohn's disease activity: role of cross-sectional imaging. Am J Gastroenterol 2013; 108:1891-900. [PMID: 24126633 DOI: 10.1038/ajg.2013.354] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 09/03/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In Crohn's disease (CD), clinical symptoms correspond poorly to inflammatory disease activity. Biomarkers reflective of mucosal and bowel wall inflammation would be useful to monitor disease activity. The EMBARK study evaluated disease activity in patients with ulcerative colitis (UC) and CD, and used endoscopy with or without cross-sectional imaging for biomarker discovery. METHODS UC (n=107) and CD (n=157) patients were characterized and underwent ileocolonoscopy (ICO). A subset of CD patients (n=66) also underwent computed tomography enterography (CTE). ICO and CTE were scored by a gastroenterologist and radiologist who incorporated findings of inflammation into a single score (ICO-CTE) for patients that underwent both procedures. Serum and fecal biomarkers were evaluated for association with the Mayo Clinic endoscopy score in UC patients and with ICO alone or ICO-CTE in CD patients. Individual biomarkers with a moderate degree of correlation (P≤0.3) were evaluated using multivariate analysis with model selection using a stepwise procedure. RESULTS In UC, ordinal logistic regression using Mayo Clinic endoscopy subscore selected the combination of fecal calprotectin and serum matrix metalloproteinase 9 (MMP9; pseudo R(2)=0.353). In CD, we found that use of the ICO-CTE increased specificity of known biomarkers. Using ICO-CTE as the dependent variable for biomarker discovery, the selected biomarkers were the combination of fecal calprotectin, serum MMP9, and serum IL-22 (r=0.699). CONCLUSIONS Incorporation of both ICO and CTE into a single measure increased biomarker performance in CD. Combinations of fecal calprotectin and serum MMP9 for UC, and combinations of fecal calprotectin, serum MMP9, and serum interleukin-22 in CD, demonstrated the strongest association with imaging/endoscopy-defined inflammation.
Collapse
Affiliation(s)
- William A Faubion
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
41
|
Panes J, Bouhnik Y, Reinisch W, Stoker J, Taylor SA, Baumgart DC, Danese S, Halligan S, Marincek B, Matos C, Peyrin-Biroulet L, Rimola J, Rogler G, van Assche G, Ardizzone S, Ba-Ssalamah A, Bali MA, Bellini D, Biancone L, Castiglione F, Ehehalt R, Grassi R, Kucharzik T, Maccioni F, Maconi G, Magro F, Martín-Comín J, Morana G, Pendsé D, Sebastian S, Signore A, Tolan D, Tielbeek JA, Weishaupt D, Wiarda B, Laghi A. Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines. J Crohns Colitis 2013; 7:556-585. [PMID: 23583097 DOI: 10.1016/j.crohns.2013.02.020] [Citation(s) in RCA: 474] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 02/20/2013] [Indexed: 12/12/2022]
Abstract
The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence of complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic techniques for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.
Collapse
Affiliation(s)
- J Panes
- Gastroenterology Department, Hospital Clinic Barcelona, CIBERehd, IDIBAPS, Barcelona, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
42
|
Park MJ, Lim JS. Computed tomography enterography for evaluation of inflammatory bowel disease. Clin Endosc 2013; 46:327-66. [PMID: 23964329 PMCID: PMC3746137 DOI: 10.5946/ce.2013.46.4.327] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 06/27/2013] [Accepted: 06/27/2013] [Indexed: 12/16/2022] Open
Abstract
Computed tomography enterography (CTE) has become a main modality for the evaluation of inflammatory bowel disease (IBD). It simultaneously offers visualization of the small bowel and extraintestinal status, which is helpful for diagnosing IBD. Crohn disease has long segmental enhancing wall thickening related with the eccentric longitudinal distribution. In addition, mural stratification, fibrofatty proliferation, positive comb sign by increased mesenteric vascularity and internal/perianal fistula are characteristics of Crohn disease and can be identified on CTE. Short segmental inflammatory wall thickening and the central low attenuated lymph nodes are favorable CT finding of intestinal tuberculosis. A geographic, relatively large, and deep penetrating ulcer with bowel wall thickening and mural hyperenhancement in ileocecal area are characteristics of intestinal Behcet disease. Each of CTE findings for the IBDs is helpful for differential diagnosis. The main disadvantage of this technique is the requisite radiation exposure of patients, particularly in young patients. However, recent development of advanced CT techniques is promising for radiation dose reduction without compromising diagnostic image quality.
Collapse
Affiliation(s)
- Min Jung Park
- Department of Radiology, Yonsei University Health System, Yonsei University College of Medicine, Seoul, Korea
| | | |
Collapse
|
|
43
|
Novak KL, Wilson SR. The Role of Ultrasound in the Evaluation of Inflammatory Bowel Disease. Semin Roentgenol 2013; 48:224-33. [DOI: 10.1053/j.ro.2013.03.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
|
44
|
Mao R, Gao X, Zhu ZH, Feng ST, Chen BL, He Y, Cui Y, Li ZP, Hu PJ, Chen MH. CT enterography in evaluating postoperative recurrence of Crohn's disease after ileocolic resection: complementary role to endoscopy. Inflamm Bowel Dis 2013; 19:977-82. [PMID: 23511036 DOI: 10.1097/mib.0b013e318280758c] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Ileocolonoscopy is the gold standard to assess postoperative recurrence (POR) in patients with Crohn's disease (CD) who have undergone ileocolic resection. Although computed tomographic enterography (CTE) yields striking findings in the small bowel of CD, its role in POR is undefined. The aim of this study was to compare ileocolonoscopy and CTE for evaluating POR in CD. METHODS The analysis included 32 patients with CD with ileocolic resection. Ileocolonoscopy and CTE were performed within 1 week. Endoscopic recurrence was defined using Rutgeerts score (i0-i4), whereas CTE recurrence was assessed according to a previously validated CTE score (CTE0-CTE3). Patients were followed up for a maximum of 30 months, and the primary endpoint was reoperation. RESULTS There was a good correlation between endoscopic and CTE recurrence (r = 0.782, P < 0.0001). Moreover, CTE identified the presence of jejunal and proximal ileum disease (n = 7), fistula (n = 3), and abscess (n = 4). Therapeutic management was thereby modified in 8 of 32 patients (25.0%). Eleven patients received major reoperation. There was no significant difference regarding the rate of reoperation between subgroups' Rutgeerts score i3-4 and i0-2 (P > 0.05), whereas there was significant difference between subgroups' CTE2-CTE3 and CTE0-CTE1 (P < 0.05). CONCLUSIONS CTE is a reliable method in assessing POR in patients with CD who have undergone ileocolic resection. CTE may serve as an important complementary tool to endoscopy for evaluation of the postoperative course of CD.
Collapse
Affiliation(s)
- Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
45
|
Yu C, Xiao XZ. Application of MSCT enterography in the evaluation of Crohn's disease. Shijie Huaren Xiaohua Zazhi 2013; 21:233-238. [DOI: 10.11569/wcjd.v21.i3.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The assessment of small bowel abnormalities has always been a challenging task for radiologists and gastroenterologists. Conventional radiologic and endoscopic evaluations are often limited by the length and caliber of small bowel loops. CT enterography, a robust new method with high spatial and isotropic spatial resolution, is a variant of conventional CT technique optimized for the evaluation of the small bowel. Crohn's disease is an inflammatory disease which can involve different areas of the gastrointestinal tract, and it was characterized by segmental and transmural inflammation, with the terminal ileum being the most common site of involvement. CT enterography is well tolerated by these patients and enables accurate, efficient assessment of lesions arising from the small bowel wall or surrounding organs. In this article, we discuss the principle of CT enterography and its use in the evaluation of Crohn's disease.
Collapse
|
|
46
|
Al-Hawary MM, Kaza RK, Platt JF. CT Enterography: Concepts and Advances in Crohn's Disease Imaging. Radiol Clin North Am 2013. [DOI: 10.1016/j.rcl.2012.09.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
|
47
|
Afifi AH, Kassem MI. Crohn’s disease: Activity, complications and treatment. Evaluation using MDCT enterography and endoscopy. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2012. [DOI: 10.1016/j.ejrnm.2012.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
|
|
48
|
Paparo F, Bacigalupo L, Garello I, Biscaldi E, Cimmino MA, Marinaro E, Rollandi GA. Crohn's disease: prevalence of intestinal and extraintestinal manifestations detected by computed tomography enterography with water enema. ACTA ACUST UNITED AC 2012; 37:326-37. [PMID: 22160373 DOI: 10.1007/s00261-011-9832-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Computed tomography enterography (CTE) may detect the presence, severity, and extent of bowel inflammation in patients with Crohn's disease (CD). The aim of our study was to assess, among a cohort of 22 histologically proven CD patients, the prevalence of disease distribution, behavior, anastomotic recurrence and extraintestinal manifestations detected by an original CTE technique. METHODS Two radiologists reviewed 221 CTEs performed providing both small and large bowel distension by oral administration of neutral contrast material and trans-rectal introduction of a water enema (CTE-WE). RESULTS Ileal CD was detected in 116 CTE-WEs (52.4%), including 71/116 (61.2%) non-stricturing/non-penetrating, 17/116 (14.6%) stricturing, and 28/116 (24.1%) penetrating forms. Colonic CD was appreciable in 35 (15.8%) patients, including 18/35 (51.4%) non-stricturing/non-penetrating, 6/35 (17.1%) stricturing, and 11/35 (31.4%) penetrating forms. Ileocolic CD was present in 52 (23.5%) CTE-WEs, including 30/52 (57.7%) non-stricturing/ non-penetrating; 3/52 (5.7%) stricturing, and 19/52 (36.5%) penetrating forms. In 10/221 patients (4.5%), upper gastrointestinal involvement (UGI) was present. Perianal disease was observed in 17/221 patients (7.7%). Fistulas were present in 52 (23.5%) and abscesses in 24 (10.8%) CTE-WEs, respectively. Among 57/221 (25.8%) patients who had undergone a disease-related intestinal resection, in 30/57 cases (52.6%) CD recurrence at the anastomosis was present. 4/221 patients (1.8%) with a histologically confirmed intestinal neoplastic stenosis were observed. Sacroiliitis (24%) was found to be prevalent over hepatic steatosis (10.8%), cholelithiasis (8.6%), and nephrolithiasis (4%). CONCLUSIONS CTE-WE represents a comprehensive imaging technique which may demonstrate bowel inflammation and CD extraintestinal manifestations. A peculiar prevalence of UGI involvement and neoplastic strictures were observed. In our study the prevalence of sacroiliitis resulted higher than previously reported.
Collapse
Affiliation(s)
- F Paparo
- Department of Radiology, E.O. Ospedali Galliera, Genova, Italy.
| | | | | | | | | | | | | |
Collapse
|
|
49
|
Butcher RO, Nixon E, Sapundzieski M, Filobbos R, Limdi JK. Radiation exposure in patients with inflammatory bowel disease--primum non nocere? Scand J Gastroenterol 2012; 47:1192-9. [PMID: 22827741 DOI: 10.3109/00365521.2012.706829] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients with Inflammatory Bowel disease (IBD) are frequently exposed to diagnostic medical radiation for the diagnosis and evaluation of their disease. Despite increasing awareness of the potentially serious downstream effects, few studies have quantified radiation exposure in IBD patients. METHODS We conducted a retrospective review of 280 consecutive patients attending IBD clinics at our hospital. All incidences of diagnostic medical radiation from initial diagnosis until 30 June 2010 inclusive were recorded. The radiation dose for each procedure was obtained from standardized tables and the effective dose for each procedure calculated by multiplying this value by the number of procedures during the study period. The sum of doses received was the cumulative effective dose. RESULTS The mean and median cumulative effective radiation doses were 10.17 mSv and 4.12 mSv respectively. Crohn's disease patients had significantly higher cumulative effective radiation exposure than UC patients (p < 0.001) with exposure exceeding 10 mSv in 58.3%, 25 mSv in 18.1% and 50 mSv in 6.3%, respectively. Smoking status, disease duration, and previous surgery were significant predictors for increased radiation exposure even after adjusting for other predictors. 47 small bowel magnetic resonance (MR) studies were undertaken as an alternative to ionising radiation in the last 3 years. CONCLUSIONS Patients with IBD, particularly those with Crohn's disease, are exposed to significant amounts of diagnostic medical radiation in their lifetime. Clinicians must remain vigilant to the risk of cumulative radiation when evaluating these patients and consider non-ionizing alternatives such as intestinal ultrasound and MR imaging where clinically appropriate.
Collapse
Affiliation(s)
- Rhys Owain Butcher
- Division of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | | | | |
Collapse
|
|
50
|
Desmond AN, O'Regan K, Malik N, McWilliams S, O'Neill S, Quigley EM, Shanahan F, Maher MM. Selection of symptomatic patients with Crohn's disease for abdominopelvic computed tomography: role of serum C-reactive protein. Can Assoc Radiol J 2012; 63:267-74. [PMID: 22421709 DOI: 10.1016/j.carj.2011.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 06/08/2011] [Accepted: 06/14/2011] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Results of previous studies have shown that repeated abdominopelvic computed tomography (CT) examinations can lead to substantial cumulative diagnostic radiation exposure in patients with Crohn's disease (CD). Improved selection of patients referred for CT will reduce unnecessary radiation exposure. This study examines if serum C-reactive protein (CRP) concentration predicts which symptomatic patients with CD are likely to have significant disease activity or disease complications (such as abscess) detected on abdominopelvic CT. METHODS All abdominopelvic CTs performed on patients with CD at a tertiary referral centre during the period June 2003 to June 2008 were identified. CT findings were coded by a pair of independent blinded senior radiologists for (i) small bowel luminal disease, (ii) large bowel luminal disease, (iii) mesenteric inflammatory changes, (iv) penetrating disease (fistulas, abscess, or phlegmon), (v) acute disease complications (obstruction or perforation), and (vi) acute non-CD findings. Imaging findings were correlated with serum CRP checked within 14 days before imaging. The reference range for CRP was defined as 0-5 mg/L. RESULTS A total of 147 patients with symptomatic CD had a CRP assay performed within 14 days before undergoing abdominopelvic CT. The median time from CRP assay to imaging was 2 days (interquartile range, 0-6 days). Median CRP before imaging was 24 mg/L (interquartile range, 6-88 mg/L). CT was normal in 34 of 147 case (23.1%). Patients with normal CRP (n = 36) were significantly less likely to have penetrating disease (odds ratio [OR], 0.04 [95% confidence interval {CI}, 0.01-0.7]; P < .001) or large bowel luminal disease (OR, 0.3 [95% CI, 0.1-0.8]; P < .05). Normal CRP excluded penetrating disease with a sensitivity of 1.0 (95% CI, 0.87-1.0). CRP levels did not correlate with the presence of small bowel luminal disease (n = 82), mesenteric inflammatory changes (n = 68), or acute disease complications (n = 10). CONCLUSION Symptomatic patients with CD and normal serum CRP are unlikely to have evidence of abscess, fistulating disease, or large bowel luminal disease detected on abdominopelvic CT. However, abdominopelvic CT may demonstrate evidence of clinically significant non-penetrating CD or complications, including perforation and acute obstruction, regardless of serum CRP concentration.
Collapse
Affiliation(s)
- Alan N Desmond
- Alimentary Pharmabiotic Centre, University College Cork, National University of Ireland and Cork University Hospital, Cork, Ireland
| | | | | | | | | | | | | | | |
Collapse
|