There is good agreement between MR enterography and bowel ultrasound with regards to disease location and activity in paediatric inflammatory bowel disease

Saudi consensus guidance for the diagnosis and management of inflammatory bowel disease in children and adolescents

ABSTRACT

The management of inflammatory bowel disease (IBD) in children and adolescents is challenging. Clear evidence-based guidelines are required for this population. This article provides recommendations for managing IBD in Saudi children and adolescents aged 6-19 years, developed by the Saudi Ministry of Health in collaboration with the Saudi Society of Clinical Pharmacy and the Saudi Gastroenterology Association. All 57 guideline statements are based on the most up-to-date information for the diagnosis and management of pediatric IBD.

Role of noncontrast enhanced abdominal ultrasound in the diagnostic assessment of pediatric inflammatory bowel disease

OBJECTIVES

Assessment of small bowel involvement when diagnosing inflammatory bowel disease (IBD) delineates clinical subtype and disease extension. The gold standard for small bowel assessment is magnetic resonance enterography (MRE), but MRE is not always feasible for children. Standard, non-contrast enhanced abdominal ultrasound is an acceptable alternative. The study aimed to evaluate the utility of ultrasound in the diagnostic work-up of pediatric IBD to identify small bowel involvement.

METHODS

A retrospective study was conducted among children (< 18 years) who had abdominal ultrasound during assessment for IBD (2019-2023) at Christchurch Hospital, New Zealand. Descriptive analysis compares small bowel ultrasound to MRE, endoscopy and histology.

RESULTS

The cohort comprised 47 children, mean age 9.9 years (± 4.1), 23 (49%) males and 42 (89%) with Crohn's disease. All had endoscopy and histology data available for comparison, and 26 had MRE. Fourteen (30%) had no small bowel disease on ultrasound, MRE, endoscopy, or histology. Ultrasound confirmed small bowel disease diagnosed by other modalities for 12 (26%). Ultrasound identified small bowel disease for 7 (15%) that had not been seen during the diagnostic process by MRE, endoscopy or histology, possibly due to the limitations of endoscopy and time-delays between diagnosis and MRE. Small bowel disease was not picked up on ultrasound for 14 (30%) children, disease locations being duodenum (n = 6), TI (n = 5), proximal ileum (n = 3), and jejunum (n = 2).

CONCLUSIONS

Abdominal ultrasound is a valuable resource for assessing disease extent in suspected pediatric IBD. This study highlights the clinical benefit and feasibility of a multi-modal diagnostic approach.

Role of intestinal ultrasound in ulcerative colitis: A systematic review

BACKGROUND

Intestinal ultrasound (IUS) is an emerging, non-invasive, and highly sensitive diagnostic tool in inflammatory bowel disease (IBD), including ulcerative colitis (UC). Despite its potential, its adoption in clinical practice is limited due to a lack of standardization and awareness.

AIM

To perform a comprehensive scoping review based on a systematic literature review on IUS in UC to inform current practice.

METHODS

Ninety-nine original articles about ultrasonography in UC were identified among 7608 citations searching PubMed and EMBASE databases for systematic review.

RESULTS

IUS can be useful as an initial diagnostic strategy in patients with suspected IBD/UC. In UC, IUS can predict endoscopic response, histologic healing, and steroid responsiveness in acute severe cases. IUS can predict response to biologics/small molecules (as early as 2 wk). IUS correlates well with ileo-colonoscopy, but IUS could miss rectal, jejunal, and upper GI lesions in suspected IBD and colon polyps or extra-intestinal manifestations in known IBD. IUS is useful in special situations (children, pregnancy, and postoperative Crohn's disease). Inter-observer agreement is acceptable and trained physicians have comparable diagnostic accuracy. Point-of-care ultrasound impacted management in 40%-60% of cases. Hand-held IUS has excellent agreement with conventional IUS.

CONCLUSION

IUS is a non-invasive, highly sensitive tool in the diagnosis and monitoring of UC, offering excellent patient satisfaction. Point-of-care ultrasound by IBD physicians can significantly impact clinical decision-making.

Novelties and Perspectives of Intestinal Ultrasound in the Personalised Management of Patients with Inflammatory Bowel Diseases-A Systematic Review

Inflammatory bowel diseases (IBDs) affect over 4.9 million individuals worldwide. Colonoscopy (CS) is the gold-standard technique for diagnosis. The remissive-recurrent pattern of evolution raises the need for non-invasive techniques to monitor disease activity. This review aims to present the advantages of intestinal ultrasound (IUS) in managing IBDs. Our search was conducted on the PubMed, Embase, and Cochrane (CENTRAL) databases, selecting original studies comparing IUS with other imaging and invasive monitoring methods. Our search yielded 8654 results, of which 107 met the inclusion criteria. Increased bowel wall thickness (BWT) and colour Doppler signal (CDS) are discriminative for disease activity. IUS can predict disease outcomes and detect response to treatment or postoperative recurrence. Contrast-enhanced ultrasound (CEUS) and elastography help differentiate fibrotic from inflammatory stenoses. The difficult rectal assessment limits the use of IUS in ulcerative colitis (UC). Transmural healing may develop as a therapeutic target as it is associated with better outcomes. Patients are compliant with this technique, and its results correlate well with CS and other imaging methods. In conclusion, IUS proves to be essential in assessing IBD activity and treatment response, predicting outcomes and detecting complications. CEUS and elastography are researched to improve the diagnostic values of IUS.

Evaluation of bowel wall flow by color Doppler ultrasound in the assessment of inflammatory bowel disease activity in pediatric patients

Objective

To assess inflammatory bowel disease (IBD) activity with Doppler ultrasound in pediatric patients, comparing the accuracy of the ultrasound findings with that of the concentrations of fecal calprotectin (FC).

Materials and Methods

In a consecutive series, we evaluated 53 examinations of 44 pediatric patients seen between 2014 and 2020: 28 with Crohn's disease, 15 with ulcerative colitis, and one with IBD unclassified. The diagnosis of IBD was made in accordance with the Porto criteria. The alteration studied in the greatest detail was bowel wall flow, which was classified by the lead investigator and two pediatric radiologists, all of whom were blinded to the FC concentrations and the other ultrasound findings. Bowel wall flow was categorized as low if there were up to 2 Doppler ultrasound signals/cm2, moderate if there were 3-5 signals/cm2, and high if there were more than 5 signals/cm2.

Results

The agreement among the radiologists was substantial (kappa = 0.73). In cases in which ultrasound showed low bowel wall flow, the median FC concentration was 92 µg/g (interquartile range, 33-661 µg/g), whereas it was 2,286 µg/g (interquartile range, 1,728-5,612 µg/g) in those in which ultrasound showed high bowel wall flow. In the sample as a whole, the sensitivity and specificity of ultrasound was 89.7% and 92.0%, respectively, for the detection of inflammatory activity; 95.5% and 90.9%, respectively, for the detection of Crohn's disease; and 81.3% and 100.0%, respectively, for the detection of ulcerative colitis.

Conclusion

Ultrasound of the bowel wall showed a strong correlation with FC concentrations in the assessment of inflammatory activity in pediatric patients with IBD.

Treat to transmural healing: how to incorporate intestinal ultrasound into the treatment of inflammatory bowel disease

Intestinal ultrasound (IUS) is emerging as a key tool to achieving the therapeutic target of transmural healing in inflammatory bowel disease (IBD). IUS is a non-invasive, radiation-free, imaging modality comparable to MRI, CT and ileocolonoscopy (IC). With the appropriate training and equipment, IUS can be an easily repeatable bedside test for IBD diagnosis and disease monitoring, including treatment response. Core to successful high quality IUS employment are appropriate training and expert techniques; however, the training pathway will not be explored in this review. Given the increasing shift towards objective assessment for tight disease control, gastroenterologist-led IUS should be incorporated into the armamentarium of imaging modalities alongside radiologists, to enhance our diagnostic and monitoring toolbox. This comprehensive review aims to outline the current literature around IUS and propose the placement of IUS in a treat-to-target algorithm in IBD. Ultimately, IUS facilitates timely management decisions to optimise patient care with potential to revolutionise patient outcomes, moving towards transmural healing as the holy grail of therapy in IBD.

ACR Appropriateness Criteria® Crohn Disease-Child

Crohn disease is an inflammatory condition of the gastrointestinal tract with episodes of exacerbation and remission occurring in children, adolescents, and adults. Crohn disease diagnosis and treatment depend upon a combination of clinical, laboratory, endoscopic, histological, and imaging findings. Appropriate use of imaging provides critical information in the settings of diagnosis, assessment of acute symptoms, disease surveillance, and therapy monitoring. Four variants are discussed. The first variant discusses the initial imaging for suspected Crohn disease before established diagnosis. The second variant pertains to appropriateness of imaging modalities during suspected acute exacerbation. The third variant is a substantial discussion of recommendations related to disease surveillance and monitoring of Crohn disease. Finally, panel recommendations and discussion of perianal fistulizing disease imaging completes the 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.

Point-of-Care Testing and Home Testing: Pragmatic Considerations for Widespread Incorporation of Stool Tests, Serum Tests, and Intestinal Ultrasound

Breaking through the biologic therapy efficacy plateau for inflammatory bowel disease requires the strategic development of personalized biomarkers in the tight control model. After risk stratification early in the disease course, targeted serial monitoring consistently to assess clinical outcomes in response to therapy allows for quick therapeutic adjustments before bowel damage can occur. Point-of-care intestinal ultrasound performed by the treating gastroenterologist is an accurate cross- sectional biomarker that monitors intestinal inflammation in real-time, enhances patient care, and increases shared understanding to help achieve common treatment goals. Combining intestinal ultrasound during a clinic visit with existing serum and stool biomarkers in a home testing setup with electronic health monitoring allows for an optimized, patient-centered personalized treatment algorithm that may improve treatment outcomes. Here, we review the current state, pragmatic considerations, and future implications of point-of-care testing and home testing for noninvasive inflammatory bowel disease monitoring in the tight control model.

Diagnostic Accuracy of Non-Invasive Imaging for Detection of Colonic Inflammation in Patients with Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

Endoscopy is the gold standard for objective assessment of colonic disease activity in inflammatory bowel disease (IBD). Non-invasive colonic imaging using bowel ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) may have a role in quantifying colonic disease activity. We reviewed the diagnostic accuracy of these modalities for assessment of endoscopically or histopathologically defined colonic disease activity in IBD. We searched Embase, MEDLINE, and the Web of Science from inception to 20 September 2021. QUADAS-2 was used to evaluate the studies' quality. A meta-analysis was performed using a bivariate model approach separately for MRI and US studies only, and summary receiver operating characteristic (ROC) curves were obtained. CT studies were excluded due to the absence of diagnostic test data. Thirty-seven studies were included. The mean sensitivity and specificity for MRI studies was 0.75 and 0.91, respectively, while for US studies it was 0.82 and 0.90, respectively. The area under the ROC curves (AUC) was 0.88 (95% CI, 0.82 to 0.93) for MRI, and 0.90 (95% CI, 0.75 to 1.00) for US. Both MRI and US show high diagnostic accuracy in the assessment of colonic disease activity in IBD patients.

Paediatric gastrointestinal and hepatobiliary radiology: why do we need subspecialists, and what is new?

We present the case for subspecialisation in paediatric gastrointestinal and hepato-pancreatico-biliary radiology. We frame the discussion around a number of questions: What is different about the paediatric patient and paediatric gastrointestinal system? What does the radiologist need to do differently? And finally, what can be translated from these subspecialty areas into everyday practice? We cover conditions that the sub-specialist might encounter, focusing on entities such as inflammatory bowel disease and hepatic vascular anomalies. We also highlight novel imaging techniques that are a focus of research in the subspecialties, including contrast-enhanced ultrasound, MRI motility, magnetisation transfer factor, and magnetic resonance elastography.

Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the use of abdominal ultrasound in inflammatory bowel disease

Ultrasound has an excellent diagnostic performance when Crohn's disease is suspected, when performing an activity assessment, or determining the extension and location of Crohn's disease, very similar to other examinations such as MRI or CT. It has a good correlation with endoscopic lesions and allows the detection of complications such as strictures, fistulas or abscesses. It complements colonoscopy in the diagnosis and, given its tolerance, cost and immediacy, it can be considered as a good tool for disease monitoring. In ulcerative colitis, its role is less relevant, being limited to assessing the extent and activity when it is not possible with other diagnostic techniques or if there are doubts with these. Despite its advantages, its use in inflammatory bowel disease (IBD) is not widespread in Spain. For this reason, this document reviews the advantages and disadvantages of the technique to promote knowledge about it and implementation of it in IBD Units.

Bowel Ultrasound Scan Predicts Corticosteroid Failure in Children With Acute Severe Colitis

BACKGROUND AND OBJECTIVE

Acute severe colitis (ASC) is a potentially life-threatening event. Optimal timing for second-line treatment in children is mainly based on the clinical score Pediatric Ulcerative Colitis Activity Index. The aim of our study was to evaluate the potential role of bowel ultrasound scan (BUS) in predicting the need of second-line therapy in ASC.

METHODS

Patients younger than 18 years admitted to a single tertiary referral center with ASC were included. We retrospectively reviewed medical records collecting clinical and BUS data. Colonic wall thickness (CWT), loss of colonic wall stratification (CWS), presence of hyperechoic lymph nodes, and colonic wall flow evaluated at power Doppler were assessed at BUS performed within the third day of hospitalization.

RESULTS

Sixty-nine ASC episodes from 52 different patients were identified. CWT showed significantly higher values in patients who required second-line therapy (5.14 vs 3.69 mm; P < 0.001). Loss of CWS was present in 17 of 36 (47.2%) of steroid-resistant ASC versus only 1 of 33 of those responding to intravenous corticosteroids (P < 0.001, sensitivity = 47%, specificity = 97%). Using a receiver operating characteristic curve, a cut-off of 3.4 mm was individuated for CWT to predict steroid treatment failure, showing a sensitivity of 92% and a specificity of 52%. The multivariable binary logistic regression analysis identified thickened colonic wall (CWT >3.4 mm) and loss of CWS as independent predictors of steroid resistance.

CONCLUSIONS

BUS is a noninvasive, easily accessible, and cost-effective resource that may identify at an early stage first-line therapy failure in pediatric ASC.

Diagnostic Accuracy of Transabdominal Ultrasound in Detecting Intestinal Inflammation in Paediatric IBD Patients-a Systematic Review

BACKGROUND AND AIMS

Currently used non-invasive tools for monitoring children with inflammatory bowel disease [IBD], such as faecal calprotectin, do not accurately reflect the degree of intestinal inflammation and do not provide information on disease location. Ultrasound [US] might be of added value. This systematic review aimed to assess the diagnostic test accuracy of transabdominal US in detecting intestinal inflammation in children with IBD in both diagnostic and follow-up settings.

METHODS

We systematically searched PubMed, Embase [Ovid], Cochrane Library, and CINAHL [EBSCO] databases for studies assessing diagnostic accuracy of transabdominal US for detection of intestinal inflammation in patients diagnosed or suspected of IBD, aged 0-18 years, with ileo-colonoscopy and/or magnetic resonance enterography [MRE] as reference standards. Studies using US contrast were excluded. Risk of bias was assessed with QUADAS-2.

RESULTS

The search yielded 276 records of which 14 were included. No meta-analysis was performed, because of heterogeneity in study design and methodological quality. Only four studies gave a clear description of their definition for an abnormal US result. The sensitivity and specificity of US ranged from 39-93% and 90-100% for diagnosing de novo IBD, and 48-93% and 83-93% for detecting active disease during follow-up, respectively.

CONCLUSIONS

The diagnostic accuracy of US in detecting intestinal inflammation as seen on MRE and/or ileo-colonoscopy in paediatric IBD patients remains inconclusive, and there is currently no consensus on defining an US result as abnormal. Prospective studies with adequate sample size and methodology are needed before US can be used in the diagnostics and monitoring of paediatric IBD.

Diagnostic pathways in Crohn's disease

The management of Crohn's disease (CD) is shifting from a stepwise, incremental approach based on symptom control to more aggressive early combined immunosuppression in an attempt to induce remission more rapidly and avoid long-term bowel damage. Accurately defining disease activity is a major challenge, as there is often a disconnect between symptomatology and underlying disease status. The role of imaging in CD has evolved such that it now plays a central role establishing the initial diagnosis, characterising disease phenotype, activity assessment, disease surveillance, and assessing response to therapy. Furthermore, the "treat-to-target" approach is being investigated in CD, with resolution of transmural inflammation on cross-sectional imaging being the treatment goal. In this review, we summarise the principal imaging techniques available to the radiologist, the key findings, and provide some guidance on the preferred imaging option in the diagnostic pathway. We consider the relative merits and drawbacks of each imaging technique before offering a brief discussion of some current developments and research avenues in CD imaging. We discuss how imaging may be useful in a "treat-to-target" approach. Finally, we highlight some practical considerations around service configuration and delivery to optimise imaging in CD in an accurate, cost-effective manner.

Comparison of small intestinal contrast ultrasound with magnetic resonance enterography in pediatric Crohn's disease

Aim

To compare the diagnostic yield of small intestinal contrast ultrasonography (SICUS) with magnetic resonance enterography (MRE) in routine clinical practice in a cohort of pediatric patients investigated for Crohn's disease (CD) attending a UK tertiary center.

Methods and Results

Patients with suspected or established CD who underwent SICUS were identified retrospectively. SICUS was compared to conventional transabdominal ultrasound (TUS), ileocolonoscopy (IC), and MRE. The accuracy and agreement of SICUS in detecting small bowel lesions and CD-related complications were assessed using kappa (κ) coefficient statistics. A total of 93 patients (median age 15 years, range 2-17, 49 male) underwent SICUS; 58 had suspected and 35 had established CD. In suspected CD, sensitivity and specificity of SICUS in detecting CD small bowel lesions were 81.8 and 100% and for TUS 85.7 and 87.5%, respectively. In established CD, sensitivity and specificity of SICUS were 98.7 and 100% and TUS 80 and 100%, respectively. Agreement between SICUS and IC was substantial for the presence of lesions (κ = 0.73) but fair in TUS (κ = 0.31). Agreement between SICUS and IC was almost perfect for detecting strictures (κ = 0.84), with a sensitivity of 100% and specificity of 97.6%. When comparing SICUS and TUS with MRE, agreement for the presence of lesions was substantial (κ = 0.63) and moderate (κ = 0.53), respectively. Agreement between SICUS and MRE was substantial for detecting strictures (κ = 0.77) and dilatation (κ = 0.68).

Conclusions

SICUS offers a radiation-free alternative for assessing pediatric small bowel CD, with diagnostic accuracy that is comparable to MRE and IC, supporting its wider use in routine practice.

Detecting inflammation in inflammatory bowel disease - how does ultrasound compare to magnetic resonance enterography using standardised scoring systems?

BACKGROUND

Magnetic resonance enterography (MRE) is the current gold standard for imaging in inflammatory bowel disease, but ultrasound (US) is a potential alternative.

OBJECTIVE

To determine whether US is as good as MRE for the detecting inflamed bowel, using a combined consensus score as the reference standard.

MATERIALS AND METHODS

We conducted a retrospective cohort study in children and adolescents <18 years with inflammatory bowel disease (IBD) at a tertiary and quaternary centre. We included children who underwent MRE and US within 4 weeks. We scored MRE using the London score and US using a score adapted from the METRIC (MR Enterography or Ultrasound in Crohn's Disease) trial. Four gastroenterologists assessed an independent clinical consensus score. A combined consensus score using the imaging and clinical scores was agreed upon and used as the reference standard to compare MRE with US.

RESULTS

We included 53 children. At a whole-patient level, MRE scores were 2% higher than US scores. We used Lin coefficient to assess inter-observer variability. The repeatability of MRE scores was poor (Lin 0.6). Agreement for US scoring was substantial (Lin 0.95). There was a significant positive correlation between MRE and clinical consensus scores (Spearman's rho = 0.598, P=0.0053) and US and clinical consensus scores (Spearman's rho = 0.657, P=0.0016).

CONCLUSION

US detects as much clinically significant bowel disease as MRE. It is possible that MRE overestimates the presence of disease when using a scoring system. This study demonstrates the feasibility of using a clinical consensus reference standard in paediatric IBD imaging studies.