Radiation exposure in patients with inflammatory bowel disease and irritable bowel syndrome in the years 2001-2011

Cumulative Effective Dose from Medical Imaging in Inflammatory Bowel Disease

Inflammatory bowel diseases (IBD) are chronic and relapsing disorders usually requiring numerous medical imaging. IBD patients might be exposed to a large dose of radiation. As a cumulative effective dose (CED) ≥ 50 mSv is considered significant for stochastic risks of cancer, it is important to monitor the radiation exposure of IBD patients. In the present work, we aimed to quantify the mean CED in IBD patients and identify factors associated with exposure to high doses of diagnostic radiation. A retrospective chart view of patients with IBD hospitalized between 2015 and 2019 was performed. A total of 65 patients with Crohn's disease (CD) and 98 patients with ulcerative colitis (UC) were selected. Of all imaging studies performed, 73% were with doses of ionizing radiation. Mean CED (SD) amounted to 19.20 (15.64) millisieverts (mSv) and 6.66 (12.39) mSv, respectively, in patients with CD and UC (p < 0.00001). Only 1.84% of the patients received CED ≥ 50 mSv. We identified three factors associated with CED in the IBD patients: number of surgical procedures, and number and length of hospitalization. CD patients with strictures or penetrating disease and UC patients with extensive colitis were more likely to receive higher radiation doses.

Stereotactic body radiation therapy for the treatment of localized prostate cancer in men with underlying inflammatory bowel disease

BACKGROUND

Historically, IBD has been thought to increase the underlying risk of radiation related toxicity in the treatment of prostate cancer. In the modern era, contemporary radiation planning and delivery may mitigate radiation-related toxicity in this theoretically high-risk cohort. This is the first manuscript to report clinical outcomes for men diagnosed with prostate cancer and underlying IBD curatively treated with stereotactic body radiation therapy (SBRT).

METHODS

A large institutional database of patients (n = 4245) treated with SBRT for adenocarcinoma of the prostate was interrogated to identify patients who were diagnosed with underlying IBD prior to treatment. All patients were treated with SBRT over five treatment fractions using a robotic radiosurgical platform and fiducial tracking. Baseline IBD characteristics including IBD subtype, pre-SBRT IBD medications, and EPIC bowel questionnaires were reviewed for the IBD cohort. Acute and late toxicity was evaluated using the CTCAE version 5.0.

RESULTS

A total of 31 patients were identified who had underlying IBD prior to SBRT for the curative treatment of prostate cancer. The majority (n = 18) were diagnosed with ulcerative colitis and were being treated with local steroid suppositories for IBD. No biochemical relapses were observed in the IBD cohort with early follow up. High-grade acute and late toxicities were rare (n = 1, grade 3 proctitis) with a median time to any GI toxicity of 22 months. Hemorrhoidal flare was the most common low-grade toxicity observed (n = 3).

CONCLUSION

To date, this is one of the largest groups of patients with IBD treated safely and effectively with radiation for prostate cancer and the only review of patients treated with SBRT. Caution is warranted when delivering therapeutic radiation to patients with IBD, however modern radiation techniques appear to have mitigated the risk of GI side effects.

Are We Overradiating Patients with Irritable Bowel Syndrome?

Introduction

Protracted exposures to small doses of radiation, even cumulative effective doses (CED) as low as 50-100 mSv, may increase the risk for malignancy. Medical radiation exposure has not been rigorously examined for patients with irritable bowel syndrome (IBS). We examined medical radiation exposure in patients with IBS at a tertiary care center in the USA.

Methods

Patients diagnosed with IBS at our institute from 2009 to 2018 were included in a retrospective cohort study. Medical charts were examined to calculate total and annual CED.

Results

221 patients were included; mean CED was 40.32 mSv (SD: 54.36). Fifty-nine participants (26.7%) received >50 mSv of CED with 27 participants (12.2%) exceeding 100 mSv. Conventional imaging, nuclear medicine, and fluoroscopy accounted for 74.08, 12.93, and 12.98% of total CED, respectively. CT scans contributed to 66.61% of total CED. Outpatient orders accounted for 37.96% of total CED, while 31.4% of total CED was ordered in the emergency department. Population-specific high total CED was calculated as 105.65 mSv. Multivariable binomial logistic regression model found that comorbid anxiety, chronic pain medication use, and diarrhea-predominant IBS were independently positively associated with population-specific high CED exposure. No significant temporal trend in peri-diagnostic mean CED was found.

Conclusion

Patients with IBS receive high amounts of medical radiation, with 1 in 4 patients reaching at-risk levels of 50 mSv or more. Usage of pain medication at home, comorbid anxiety, and IBS-D are independently linked to an increased risk of high CED.

Pouchogram Prior to Ileostomy Reversal after Ileal Pouch-Anal Anastomosis in Pediatric Patients: Is it Useful in the Setting of Routine EUA?

PURPOSE

To determine if there is a role for routine pouchogram before ileostomy reversal after IPAA in pediatric patients.

METHODS

The medical records of pediatric patients who underwent pouchogram between 2007 and 2017 prior to ileostomy reversal after IPAA at two affiliated hospitals were reviewed for concordance between exam under anesthesia (EUA) and pouchogram findings, management of abnormal pouchogram findings, and short and long-term outcomes after ileostomy reversal. Clinical notes were used to find patient-reported symptoms at the time of pouchogram.

RESULTS

Sixty patients (57% female) underwent pouchogram before planned ileostomy reversal. The median time from IPAA formation to pouchogram was 60.5 days (IQR: 46-77) and median follow-up was 4 years (IQR: 1-6). Fifty-seven patients (95%) were asymptomatic prior to reversal. Of the 40 asymptomatic patients with a normal EUA, pouchogram detected one stricture (3%), but reversal proceeded as planned. In the 16 patients with strictures on EUA, pouchogram only detected six (40%). One of 50 (2%) asymptomatic patients with normal pouchogram had anastomotic dehiscence found on EUA. Despite normal pouchogram and EUA, four asymptomatic patients required subsequent diversion for pouch-related complications between 13 and 60 months after ileostomy reversal. Three patients had pelvic pain prior to pouchogram; associated symptoms included perineal pain (n = 1) hematochezia (n = 1), and tenesmus (n = 1). EUA and pouchogram were concordant in two patients (n = 1 anastomotic complication, n = 1 pouch septum) and ileostomy reversal was delayed. In the remaining symptomatic patient, pouchogram detected an anastomotic leak where EUA detected only a stricture, and this prompted a delay in reversal. Long term, none of these patients required diversion or excision of their pouch.

CONCLUSION

Routine pouchogram in asymptomatic pediatric patients does not change management and can be omitted, thereby sparing patients discomfort and unnecessary radiation exposure. Pouchogram may have diagnostic value in symptomatic patients.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Study of Diagnostic Test.

Utilization of Diagnostic Imaging and Ionization Radiation Exposure Among an Inflammatory Bowel Disease Inception Cohort

BACKGROUND

Abdominal imaging is important in managing inflammatory bowel disease (IBD). We characterized utilization of imaging and exposure to ionizing radiation.

METHODS

We enumerated abdominal diagnostic imaging in a population-based cohort of IBD patients between 1994 and 2016. Trends in utilization of abdominal computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound were characterized. Cumulative doses of ionizing radiation were compared between IBD patients and non-IBD controls and between Crohn's disease (CD) and ulcerative colitis (UC) patients. Regression models were constructed to assess predictors of high ionizing radiation exposure.

RESULTS

There were 72,933 incident cases of IBD. During the first 5 years of diagnosis, IBD patients were exposed to nearly 6-fold higher exposure to cumulative ionizing radiation attributable to abdominal imaging compared with non-IBD controls (18.6 mSv vs 2.9 mSv). Cumulative ionizing radiation exposure was higher in CD than UC (26.0 mSv vs 12.0 mSv; P < 0.001). Crohn's disease patients were more than twice as likely as UC patients to exceed 50 mSv (15.6% vs 6.2%; P < 0.001) and 100 mSV (5.0% vs 2.1%; P < 0.001). There was geographic variation in ionizing radiation exposure, and individuals of lower income were more likely to have high exposure. Utilization of abdominal MRI has increased substantially, peaking between 2007 and 2012 and increasing annually at 34%, which coincided with an annual 2% decline in the use of abdominal CT.

CONCLUSIONS

Crohn's disease patients are at highest risk for high exposure to ionizing radiation, with a subgroup receiving potentially harmful levels. Increasing utilization and access to abdominal MRI may alleviate exposure.

Utilization of Diagnostic Imaging and Ionizing Radiation Exposure-Has the Tide Already Turned?

Inflammatory bowel diseases require repetitive abdominal imaging for diagnosis, follow-up, or management of complications. This editorial comments on the large incident-based case-control study on utilization of diagnostic imaging and ionizing radiation exposure by Nguyen and colleagues published in this issue.

Multinational data on cumulative radiation exposure of patients from recurrent radiological procedures: call for action

OBJECTIVES

To have a global picture of the recurrent use of CT imaging to a level where cumulative effective dose (CED) to individual patients may be exceeding 100 mSv at which organ doses typically are in a range at which radiation effects are of concern METHODS: The IAEA convened a meeting in 2019 with participants from 26 countries, representatives of various organizations, and experts in radiology, medical physics, radiation biology, and epidemiology. Participants were asked to collect data prior to the meeting on cumulative radiation doses to assess the magnitude of patients above a defined level of CED.

RESULTS

It was observed that the number of patients with CED ≥ 100 mSv is much larger than previously known or anticipated. Studies were presented in the meeting with data from about 3.2 million patients who underwent imaging procedures over periods of between 1 and 5 years in different hospitals. It is probable that an additional 0.9 million patients reach the CED ≥ 100 mSv every year globally.

CONCLUSIONS

There is a need for urgent actions by all stakeholders to address the issue of high cumulative radiation doses to patients. The actions include development of appropriateness criteria/referral guidelines by professional societies for patients who require recurrent imaging studies, development of CT machines with lower radiation dose than today by manufacturers, and development of policies by risk management organizations to enhance patient radiation safety. Alert values for cumulative radiation exposures of patients should be set up and introduced in dose monitoring systems.

KEY POINTS

• Recurrent radiological imaging procedures leading to high radiation dose to patients are more common than ever before. • Tracking of radiation exposure of individual patients provides useful information on cumulative radiation dose. • There is a need for urgent actions by all stakeholders to address the issue of high cumulative radiation doses to patients.

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

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.

Review of the role of abdominal imaging in irritable bowel syndrome

The role of radiologic imaging in the investigation of irritable bowel syndrome (IBS) remains a subject of debate and there is some evidence, from recent studies of utilization of imaging in IBS, which focused on associated costs and radiation exposure, that imaging is being used relatively widely in these patients. This review aims to assess current best evidence to accurately define the role of radiologic imaging in IBS patients. Primary and secondary literature searches were performed. Evidence suggests that the lack of "red flag" or alarm features in IBS patients should reassure the clinician that the diagnosis of IBS is correct and United States and United Kingdom guidelines recommend no radiologic imaging for IBS patients if alarm features are not present. In patients presenting with IBS symptoms and alarm features, radiologic testing may be used to exclude an alternative diagnosis and the imaging modality should be chosen based on the most likely alternative diagnosis.

Imaging of the small intestine in Crohn's disease: Joint position statement of the Indian Society of Gastroenterology and Indian Radiological and Imaging Association

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.