Management of pancreatic, gastrointestinal and liver complications in adult cystic fibrosis

Preliminary results of abdominal simultaneous multi-slice accelerated diffusion-weighted imaging with motion-correction in patients with cystic fibrosis and impaired compliance

OBJECTIVES

The aim of this prospective study was to compare scan time, image quality, signal-to-noise Ratio (SNR), and apparent diffusion coefficient (ADC) values of simultaneous multi-slice accelerated diffusion-weighted imaging with motion-correction (DWI SMS Moco) to standard diffusion-weighted imaging (sDWI) in free-breathing abdominal magnetic resonance imaging (MRI) in pediatric and young adult patients with cystic fibrosis (CF).

MATERIAL AND METHODS

16 patients (7 male and 9 female, 12-41 years old) with CF were examined prospectively in a single-center from November 2020 to March 2021 on a 1.5 Tesla clinical MR scanner. The characteristics of overall image quality and delimitability of mesenteric lymph nodes were evaluated using a 5-point Likert scale by two experienced pediatric radiologists independently from each other. Quantitative parameters with SNR and ADC values were assessed in 8 different locations and compared using a Wilcoxon signed-rank test.

RESULTS

The acquisition time for DWI SMS Moco was 32% shorter than for sDWI. Regarding quality comparison, overall image quality and delimitability of mesenteric lymph nodes were significant higher in DWI SMS Moco (p ≤ 0.05 for both readers). The readers preferred DWI SMS Moco to sDWI in all cases (16/16). Mean SNR values from DWI SMS Moco and sDWI were similar in 7 from 8 locations. The ADC values showed no significant difference between DWI SMS Moco and sDWI in any of the evaluated locations (p > 0.05).

CONCLUSIONS

The DWI SMS Moco improves overall image quality and delimitability of mesenteric lymph nodes compared to sDWI with similar SNR and ADC values and a distinguished reduction of scan time in free-breathing by one third. We conclude that MRI with DWI SMS Moco could be helpful in monitoring the effect of the high-efficiency modulator (HEM) therapy in cystic fibrosis (CF) patients homozygous or heterozygous for F508del in the abdomen.

[Liver disease, gastrointestinal complications, nutritional management and feeding disorders in pediatric cystic fibrosis]

In cystic fibrosis (CF), approximately 5-8% of the patients develop multilobular cirrhosis during the first decade of life. Annual screening (clinical examination, liver biochemistry, ultrasonography) is recommended in order to identify early signs of liver involvement, initiate ursodeoxycholic acid therapy and detect complications (portal hypertension and liver failure). Management should focus on nutrition and prevention of variceal bleeding. The gut may also be involved in children with CF. Gastroesophageal reflux is frequent, although often neglected and should be investigated by pH monitoring and impedancemetry, if available. Acute pancreatitis occurs in patients with persistent exocrine pancreatic activity. Intussusception, appendicular mucocele, distal intestinal occlusion syndrome, small bowel bacterial overgrowth and Clostridium difficile colitis should be considered in case of abdominal pain. Preventive nutritional support should be started as soon as possible after diagnosis of CF. Attainment of normal growth is one of the main goals and can be achieved with hypercaloric and salt supplemented food. Pancreatic enzyme replacement therapy should be started as soon as exocrine pancreatic insufficiency is confirmed and ingested immediately prior to meals with intake of fat-soluble vitamins. Curative nutritional interventions are more likely to be effective in the early stages of pulmonary disease. Feeding disorders, related to the physiopathology and the psychologic aspects of the disease are frequent. Repeated corporeal aggressions, associated with inappropriate medical and parental pressure, may increase the child's refusal of food. The multidisciplinary team should guide parents in order to avoid all intrusive feeding practices and promote pleasant mealtimes.

Individualized medicine using intestinal responses to CFTR potentiators and correctors

Cystic fibrosis transmembrane conductance regulator (CFTR) modulators that target the mutant CFTR protein are being introduced for treatment of cystic fibrosis. Stratification of subjects based on their CFTR genotype has been proven essential to demonstrate clinical efficacy of these novel treatments. Despite this stratification, considerable heterogeneity between subjects receiving CFTR modulators is still observed which remains largely uncharacterized. The CFTR genotype, and additional genetic and environmental factors that impact either tissue-specific CFTR protein characteristics or the pharmacokinetic properties of treatments will likely determine the individual response to therapy. The development of intestinal biomarkers for CFTR modulators may help to better quantitate individual responses to treatment, with potential to optimize treatments for subjects with limited responses, and the selection of responsive subjects that currently do not receive treatments. Here, recent advances concerning the use of intestinal biomarkers for CFTR modulator treatments are reviewed, with a focus on biomarkers of CFTR function in ex vivo rectal biopsies and in vitro cultured primary intestinal organoids. Their potential value is considered in the context of the current unmet needs for better treatments for the majority of subjects with CF, and individual biomarkers that enable the prediction of long term therapeutic responses to CFTR modulators. Pediatr Pulmonol. 2016;51:S23-S34. © 2016 Wiley Periodicals, Inc.