Systematic review: MRI enterography for assessment of small bowel involvement in paediatric Crohn's 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.

Intestinal ultrasound at diagnosis of pediatric inflammatory bowel disease compared to endoscopy

OBJECTIVES

Intestinal ultrasound (IU) has emerged as an alternative to detect bowel wall inflammation. The aim of this study was to compare IU findings to clinical disease, fecal calprotectin (FC), and endoscopic findings in newly diagnosed pediatric inflammatory bowel disease (IBD) patients.

METHODS

This study was a 1-year, single-center, prospective study. Any pediatric patient undergoing colonoscopy could be recruited. Following ileo-colonoscopy, subjects were divided into two groups: patients diagnosed with IBD and patients without IBD. Participants had an IU within 1 month. Endoscopists and radiologists were blinded to each other. The IU findings were compared with clinical disease activity, FC, and endoscopic findings.

RESULTS

A total of 50 subjects were enrolled in the study; 29 (58%) were females, median age was 13.5 years, and 25 (50%) were diagnosed with IBD. IU sensitivity was 76%, specificity 84%, positive predictive value (PPV) 83%, and negative predictive value (NPV) 78%. For detection of moderate to severe disease, sensitivity, specificity, PPV, and NPV were 91.3%, 86.21%, 84%, and 92.6%, respectively. A significant correlation was noted between IU and FC, Mayo score, and Simple Endoscopic Score (0.513, 0.565, and 0.731, respectively). Pediatric Ulcerative Colitis Activity Index and Pediatric Crohn's Disease Activity Index scores had Pearson correlations of 0.070 and -0.159, respectively.

CONCLUSIONS

IU can be considered a screening tool for pediatric IBD. It has reasonable sensitivity, specificity, PPV, and NPV, particularly for moderate-to-severe disease. The severity noted on IU correlated with FC and endoscopic disease activity but did not correlate with clinical disease activity.

Risk factors for surgery in stricturing small bowel Crohn's disease: A retrospective cohort study from the GETAID pédiatrique

OBJECTIVES

Previous studies have shown rates of surgical resection of up to 41% in stricturing pediatric Crohn's disease (CD). In this retrospective multicenter study, our aims were to identify clinical risk factors and magnetic resonance enterography (MRE) features of small bowel strictures associated with surgery.

METHODS

Pediatric patients with symptomatic stricturing small bowel CD (defined as obstructive symptoms or proximal dilatation on MRE) confirmed by MRE between 2010 and 2020 were recruited from 12 French tertiary hospitals. Patient characteristics were compared by surgical outcome multivariable Cox regression.

RESULTS

Fifty-six patients (61% boys) aged 12.2 ± 2.7 years at diagnosis of CD were included. Median duration of CD before diagnosis of stricture was 11.7 months (interquartile range [IQR]: 25-75: 1.2-29.9). Nineteen (34%) patients had stricturing phenotype (B2) at baseline. Treatments received  before stricture diagnosis included MODULEN-IBD (n = 31), corticosteroids (n = 35), antibiotics (n = 10), anti-TNF (n = 27), immunosuppressants (n = 28). Thirty-six patients (64%) required surgery, within 4.8 months (IQR: 25-75: 1.8-17.3) after stricture diagnosis. Parameters associated with surgical resection were antibiotic exposure before stricture diagnosis (adjusted odds ratio [aOR]: 15.62 [3.35-72.73], p = 0.0005), Crohn's disease obstructive symptoms score (CDOS) > 4 (aOR: 3.04 [1.15-8.03], p = 0.02) and dilation proximal to stricture >28 mm (aOR: 3.62 [1.17-11.20], p = 0.03).

CONCLUSION

In this study, antibiotic treatment before stricture diagnosis, intensity of obstructive symptoms, and diameter of dilation proximal to small bowel stricture on MRE were associated with risk for surgical resection.

Comparison of Diagnostic Performance of Ultrasonography and Magnetic Resonance Enterography in the Assessment of Active Bowel Lesions in Patients with Crohn’s Disease: A Systematic Review and Meta-Analysis

We aimed to evaluate and compare the diagnostic performances of ultrasonography (US) and magnetic resonance enterography (MRE) in assessing active bowel lesions in patients with Crohn’s disease (CD). Materials and Methods: We searched PubMed and EMBASE for studies in which US and MRE were used to assess active bowel lesions in CD patients. Bivariate random effect meta-analytic methods were used to estimate pooled sensitivity, specificity, and hierarchical summary receiver operating characteristic (HSROC) curves. We performed a meta-regression analysis to explore the source of study heterogeneity. Results: Eleven studies involving 752 patients were included. US exhibited a pooled sensitivity of 86% (95% confidence interval (CI) 72–94), pooled specificity of 88% (95% CI 78–94), and HSROC of 0.93 in 10 studies. MRE exhibited a pooled sensitivity of 88% (95% CI 76–95), pooled specificity of 87% (95% CI 73–95), and an HSROC of 0.94 in eight studies. In seven studies comparing the diagnostic performances of US and MRE, the summary sensitivity of US and MRE were 86% (95% CI 65–96, I² = 92.1) and 86% (95% CI 72–93, I² = 88.1) (p = 0.841), respectively. The summary specificity of US and MRE were 87% (95% CI 78–93, I² = 79.8%) and 84% (72–90, I² = 72.5%) (p = 0.431), respectively, which showed no statistical differences. On meta-regression analysis, studies from Europe (p = 0.002), those that used linear US probes (p = 0.012), those on small bowel lesions (p = 0.01), and those with outcomes as combined features (active inflammation) reported higher US sensitivity than those from other regions, those that used both linear and convex US probes, those on small and large bowels, and those with outcome as one feature (bowel wall thickening or ulcer). Studies with pediatric patients (p = 0.001), those with reference standards including US (p = 0.001), and outcomes as combined features (p = 0.01) reported higher MRE specificity than those with adult populations, reference standards other than the US, and outcomes as one feature. Conclusions: In spite of considerable heterogeneity in the included studies, both US and MRE can diagnose active bowel lesions with comparable diagnostic accuracy in patients with CD. The study region, type of US probe, lesion location, investigated outcome for US sensitivity and study population, reference standards, and investigated outcomes for MRE specificity were potential sources of heterogeneity.

Diagnostic Utility of Non-invasive Tests for Inflammatory Bowel Disease: An Umbrella Review

BACKGROUND

This study aims to consolidate evidence from published systematic reviews and meta-analyses evaluating the diagnostic performances of non-invasive tests for inflammatory bowel disease (IBD) in various clinical conditions and age groups.

METHODS

Two independent reviewers systematically identified and appraised systematic reviews and meta-analyses assessing the diagnostic utility of non-invasive tests for IBD. Each association was categorized as adults, children, and mixed population, based on the age ranges of patients included in the primary studies. We classified clinical scenarios into diagnosis, activity assessment, and predicting recurrence.

RESULTS

In total, 106 assessments from 43 reviews were included, with 17 non-invasive tests. Fecal calprotectin (FC) and fecal lactoferrin (FL) were the most sensitive for distinguishing IBD from non-IBD. However, anti-neutrophil cytoplasmic antibodies (ANCA) and FL were the most specific for it. FC and FL were the most sensitive and specific tests, respectively, to distinguish IBD from irritable bowel syndrome (IBS). Anti-Saccharomyces cerevisiae antibodies (ASCA), IgA, were the best test to distinguish Crohn's disease (CD) from ulcerative colitis (UC). Interferon-γ release assay was the best test to distinguish CD from intestinal tuberculosis (ITB). Ultrasound (US) and magnetic resonance enterography (MRE) were both sensitive and specific for disease activity, along with the high sensitivity of FC. Small intestine contrast ultrasonography (SICUS) had the highest sensitivity, and FC had the highest specificity for operative CD recurrence.

CONCLUSION

In this umbrella review, we summarized the diagnostic performance of non-invasive tests for IBD in various clinical conditions and age groups. Clinicians can use the suggested non-invasive test depending on the appropriate clinical situation in IBD patients.

Diagnostic performance of magnetic resonance enterography and ultrasound in children with inflammatory bowel diseases: a diagnostic test accuracy meta-analysis

OBJECTIVES

Magnetic resonance enterography (MRE) and ultrasound (US) can be used to diagnose inflammatory bowel diseases (IBD) in children. This meta-analysis aimed to determine the diagnostic performance of MRE and US in pediatric patients with IBD.

METHODS

PubMed, Embase, and the Cochrane Library were searched for eligible studies published up to June 1, 2020. The outcomes were the performances of MRE and US at the segment and patient levels. Pooled sensitivity, specificity, positive and negative likelihood ratios (PLR and NLR), diagnostic odds ratio (DOR), and the area under the summary receiver operating characteristic curves value (SROC) were analyzed.

RESULTS

Eight studies (340 children) were included. Compared with the reference standard, MRE showed pooled sensitivity of 93.0% (95% confidence interval (CI): 90.0-95.4%), specificity of 94.6% (95% CI: 92.1-96.5%), PLR of 11.146 (95% CI: 5.027-24.713), NLR of 0.094 (95% CI: 0.057-0.155), and DOR of 134.21 (95% CI: 40.72-442.29), with a SROC of 0.9721. Similar results were observed at the patient and segment levels. Compared with the reference standard, US had pooled sensitivity of 84.1% (95% CI: 69.9-93.4%), specificity of 82.9% (95% CI: 66.4-93.4%), PLR of 4.924 (95% CI: 2.351-10.310), NLR of 0.207 (95% CI: 0.103-0.413), and DOR of 25.919 (95% CI: 7.63-88.07), but only two studies were included. US (reader 1) had a similar diagnostic value to US (reader 2).

CONCLUSIONS

The present meta-analysis shows that MRE has good performance in detecting IBD in pediatric patients. Only two studies used US, and additional studies are necessary to confirm the diagnostic performance of US for IBD in children.

KEY POINTS

• MRE has good performance in the detection of IBD in pediatric patients. • Similar results were observed at the patient and segment levels for MRE. • Only two studies were included for US, without differentiating patient/segment.

Use of Small Bowel Ultrasound to Predict Response to Infliximab Induction in Pediatric Crohn's Disease

GOAL

The goal of this study was to explore the utility of small bowel ultrasound (SBUS) as a noninvasive tool to assess induction response to infliximab (IFX) in pediatric Crohn's disease (CD).

BACKGROUND

Inflammatory bowel disease management has shifted to a treat-to-target and tight control strategy utilizing noninvasive serum and fecal markers to monitor disease activity in response to therapy. Bowel wall changes as seen on cross-sectional imaging may be a more accurate marker of treatment success.

MATERIALS AND METHODS

Pediatric patients with CD with small bowel involvement initiating IFX were prospectively enrolled. Clinical activity, biomarkers, and SBUS findings were evaluated at baseline (T0) and postinduction at week 14 (T1). The primary outcome was to describe the changes in SBUS parameters pre and post IFX induction and how they associate with clinical and biomarker response. Descriptive statistics summarized the data and univariate analysis tested associations.

RESULTS

All 13 CD patients achieved steroid-free clinical remission (P<0.001) and a decrease in C-reactive protein (P=0.01) postinduction. Bowel wall hyperemia (BWH) (P=0.01) and bowel segment length involved (P=0.07) decreased postinduction. Decrease in fecal calprotectin at T1 moderately correlated with a decrease in bowel segment length (r=0.57; P=0.04). No correlation was seen with a change in bowel wall thickness or BWH postinduction.

CONCLUSIONS

Our pilot study suggests that SBUS is a feasible, noninvasive tool to measure early treatment response to IFX. BWH, not bowel wall thickness, is the first parameter to change. Larger longitudinal studies are warranted to validate the utility of SBUS as part of a disease monitoring strategy.

Evidence-based clinical practice guidelines for inflammatory bowel disease 2020

Inflammatory bowel disease (IBD) is a general term for chronic or remitting/relapsing inflammatory diseases of the intestinal tract and generally refers to ulcerative colitis (UC) and Crohn's disease (CD). Since 1950, the number of patients with IBD in Japan has been increasing. The etiology of IBD remains unclear; however, recent research data indicate that the pathophysiology of IBD involves abnormalities in disease susceptibility genes, environmental factors and intestinal bacteria. The elucidation of the mechanism of IBD has facilitated therapeutic development. UC and CD display heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management depends on the understanding and tailoring of evidence-based interventions by physicians. In 2020, seventeen IBD experts of the Japanese Society of Gastroenterology revised the previous guidelines for IBD management published in 2016. This English version was produced and modified based on the existing updated guidelines in Japanese. The Clinical Questions (CQs) of the previous guidelines were completely revised and categorized as follows: Background Questions (BQs), CQs, and Future Research Questions (FRQs). The guideline was composed of a total of 69 questions: 39 BQs, 15 CQs, and 15 FRQs. The overall quality of the evidence for each CQ was determined by assessing it with reference to the Grading of Recommendations Assessment, Development and Evaluation approach, and the strength of the recommendation was determined by the Delphi consensus process. Comprehensive up-to-date guidance for on-site physicians is provided regarding indications for proceeding with the diagnosis and treatment.

Magnetic resonance enterography compared with ultrasonography in newly diagnosed and relapsing Crohn's disease patients: the METRIC diagnostic accuracy study

BACKGROUND

Magnetic resonance enterography and enteric ultrasonography are used to image Crohn's disease patients. Their diagnostic accuracy for presence, extent and activity of enteric Crohn's disease was compared.

OBJECTIVE

To compare diagnostic accuracy, observer variability, acceptability, diagnostic impact and cost-effectiveness of magnetic resonance enterography and ultrasonography in newly diagnosed or relapsing Crohn's disease.

DESIGN

Prospective multicentre cohort study.

SETTING

Eight NHS hospitals.

PARTICIPANTS

Consecutive participants aged ≥ 16 years, newly diagnosed with Crohn's disease or with established Crohn's disease and suspected relapse.

INTERVENTIONS

Magnetic resonance enterography and ultrasonography.

MAIN OUTCOME MEASURES

The primary outcome was per-participant sensitivity difference between magnetic resonance enterography and ultrasonography for small bowel Crohn's disease extent. Secondary outcomes included sensitivity and specificity for small bowel Crohn's disease and colonic Crohn's disease extent, and sensitivity and specificity for small bowel Crohn's disease and colonic Crohn's disease presence; identification of active disease; interobserver variation; participant acceptability; diagnostic impact; and cost-effectiveness.

RESULTS

Out of the 518 participants assessed, 335 entered the trial, with 51 excluded, giving a final cohort of 284 (133 and 151 in new diagnosis and suspected relapse cohorts, respectively). Across the whole cohort, for small bowel Crohn's disease extent, magnetic resonance enterography sensitivity [80%, 95% confidence interval (CI) 72% to 86%] was significantly greater than ultrasonography sensitivity (70%, 95% CI 62% to 78%), with a 10% difference (95% CI 1% to 18%; p = 0.027). For small bowel Crohn's disease extent, magnetic resonance enterography specificity (95%, 95% CI 85% to 98%) was significantly greater than ultrasonography specificity (81%, 95% CI 64% to 91%), with a 14% difference (95% CI 1% to 27%). For small bowel Crohn's disease presence, magnetic resonance enterography sensitivity (97%, 95% CI 91% to 99%) was significantly greater than ultrasonography sensitivity (92%, 95% CI 84% to 96%), with a 5% difference (95% CI 1% to 9%). For small bowel Crohn's disease presence, magnetic resonance enterography specificity was 96% (95% CI 86% to 99%) and ultrasonography specificity was 84% (95% CI 65% to 94%), with a 12% difference (95% CI 0% to 25%). Test sensitivities for small bowel Crohn's disease presence and extent were similar in the two cohorts. For colonic Crohn's disease presence in newly diagnosed participants, ultrasonography sensitivity (67%, 95% CI 49% to 81%) was significantly greater than magnetic resonance enterography sensitivity (47%, 95% CI 31% to 64%), with a 20% difference (95% CI 1% to 39%). For active small bowel Crohn's disease, magnetic resonance enterography sensitivity (96%, 95% CI 92% to 99%) was significantly greater than ultrasonography sensitivity (90%, 95% CI 82% to 95%), with a 6% difference (95% CI 2% to 11%). There was some disagreement between readers for both tests. A total of 88% of participants rated magnetic resonance enterography as very or fairly acceptable, which is significantly lower than the percentage (99%) of participants who did so for ultrasonography. Therapeutic decisions based on magnetic resonance enterography alone and ultrasonography alone agreed with the final decision in 122 out of 158 (77%) cases and 124 out of 158 (78%) cases, respectively. There were no differences in costs or quality-adjusted life-years between tests.

LIMITATIONS

Magnetic resonance enterography and ultrasonography scans were interpreted by practitioners blinded to clinical data (but not participant cohort), which does not reflect use in clinical practice.

CONCLUSIONS

Magnetic resonance enterography has higher accuracy for detecting the presence, extent and activity of small bowel Crohn's disease than ultrasonography does. Both tests have variable interobserver agreement and are broadly acceptable to participants, although ultrasonography produces less participant burden. Diagnostic impact and cost-effectiveness are similar. Recommendations for future work include investigation of the comparative utility of magnetic resonance enterography and ultrasonography for treatment response assessment and investigation of non-specific abdominal symptoms to confirm or refute Crohn's disease.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN03982913.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 42. See the NIHR Journals Library website for further project information.

The Medical Management of Paediatric Crohn's Disease: an ECCO-ESPGHAN Guideline Update

OBJECTIVE

We aimed to provide an evidence-supported update of the ECCO-ESPGHAN guideline on the medical management of paediatric Crohn's disease [CD].

METHODS

We formed 10 working groups and formulated 17 PICO-structured clinical questions [Patients, Intervention, Comparator, and Outcome]. A systematic literature search from January 1, 1991 to March 19, 2019 was conducted by a medical librarian using MEDLINE, EMBASE, and Cochrane Central databases. A shortlist of 30 provisional statements were further refined during a consensus meeting in Barcelona in October 2019 and subjected to a vote. In total 22 statements reached ≥ 80% agreement and were retained.

RESULTS

We established that it was key to identify patients at high risk of a complicated disease course at the earliest opportunity, to reduce bowel damage. Patients with perianal disease, stricturing or penetrating behaviour, or severe growth retardation should be considered for up-front anti-tumour necrosis factor [TNF] agents in combination with an immunomodulator. Therapeutic drug monitoring to guide treatment changes is recommended over empirically escalating anti-TNF dose or switching therapies. Patients with low-risk luminal CD should be induced with exclusive enteral nutrition [EEN], or with corticosteroids when EEN is not an option, and require immunomodulator-based maintenance therapy. Favourable outcomes rely on close monitoring of treatment response, with timely adjustments in therapy when treatment targets are not met. Serial faecal calprotectin measurements or small bowel imaging [ultrasound or magnetic resonance enterography] are more reliable markers of treatment response than clinical scores alone.

CONCLUSIONS

We present state-of-the-art guidance on the medical treatment and long-term management of children and adolescents with CD.

Value of magnetic resonance enterography in diagnosis and treatment follow up in Crohn's disease in children

PURPOSE

Crohn's disease (CD) is a chronic inflammatory disease which can affect all parts of the gastrointestinal tract. Magnetic resonance enterography (MRE) enables detection of pathologic changes in the small intestine, which are not accessible by conventional endoscopy. The aim of the study was to assess the value of MRE in imaging of small bowel lesions, their location and extent, in CD patients and its correlation with clinical and endoscopic activity.

MATERIALS AND METHODS

MRE was performed in 108 children with CD, aged 5.5 to 18 years. The diagnosis was based on the Porto criteria. Location and clinical manifestation was evaluated according to the Paris classification. Clinical CD activity was assessed with PCDAI and endoscopic activity with SES-CD. In 36 children, control MRE was performed.

RESULTS

The most common endoscopic location of the disease was the colon (41.7%), terminal ileum and colon (24.1%). Inflammation as the main clinical manifestation was dominant (81.5%). In MRE, inflammatory changes were found in 40.8% of children, strictures in 11.1%. The EIA value (activity in MRE) increased along with PCDAI score and SES-CD. MRE performed during follow up, showed transmural healing in 16.7% of patients and improvement in 55.5%.

CONCLUSIONS

MRE is an efficient diagnostic tool in proper characterization of disease location in pediatric CD. As positive correlation of the results of MRE with the endoscopic and clinical activity has been found, taking into account good tolerance and non-invasiveness of the procedure it can be recommended to be used in reassessment.

Comparison of the use of wireless capsule endoscopy with magnetic resonance enterography in children with inflammatory bowel disease

BACKGROUND

Magnetic resonance enterography (MRE) and wireless capsule endoscopy (WCE) are equally accepted modalities for noninvasive screening of small bowel involvement (SBI) in children with Crohn’s disease (CD) and indeterminate colitis (IC) albeit there is a paucity of data comparing the two and thereby guiding the clinician in selecting the ideal diagnostic approach. Therefore, the goal of this study is to provide additional evidence for capsule endoscopy role in the evaluation of established Crohn’s disease exacerbation compared to MRE in relation to Pediatric Crohn's Disease Activity Index (PCDAI), and histological indices.

AIM

To prospectively compare the findings of MRE and WCE and their agreement with PCDAI or histology in children with CD or IC.

METHODS

Consecutive patients diagnosed with CD and IC were screened for inclusion. After informed consent, patient’s demographic and clinical data was abstracted. The current pediatric disease activity index (PCDAI) and endoscopic findings were included. Patients underwent MRE and WCE including preprocedural patency capsule within a maximum of 7 d of each other. Pathological presence of active small bowel disease in ileal and duodenal biopsies were collected if the endoscopy was performed within 2 mo of the WCE study. Patients who failed to pass the PC were excluded from the study. WCE was read by two different experienced gastroenterologists (Attard TM and Colombo JM) blinded to each other's findings and to the findings on MRE (Mardis NJ). Agreement between WCE reviewers, WCE and MRE findings and concordance between positive PCDAI and SBI based on MRE compared with WCE was computed.

RESULTS

Forty-five patients were included in the study, 18 withdrew and 27 (20 males and 20 CD), mean age (standard deviation) 13.46 (2.4) years, completed the study protocol. There were no instances of capsule retention. Concordance between gastroenterologist reviewers was excellent for the diagnosis of small intestinal CD with good correlation between the two Lewis scores (r = 0.875, P < 0.001). Concordance between WCE and MRE was poor (69%). In CD patients, when both MRE and WCE were compared using PCDAI > 10 as the standard reference reflecting active small intestinal CD, the sensitivity of MRE and WCE were 100% and 83% respectively and the specificity of MRE and WCE were 57.14% and 78.6%, respectively. If the histology in ileum or/and duodenum was used as the reference for active small bowel involvement, WCE had a higher specificity as compared to MRE (83.3% vs 50%). In patients with Crohn’s disease, those with a positive PCDAI (> 10) were more likely to have a positive WCE as compared to those with a negative PCDAI (83% vs 21%; P = 0.018).

CONCLUSION

We suggest that MRE and WCE have a complementary role in the assessment of SBI in CD. WCE detected SBI with a much higher specificity while MRE had a higher sensitivity.

Up-to-date overview of imaging techniques in the diagnosis and management of inflammatory bowel diseases

Radiological examination occupies a significant role, complementary to endoscopic studies, in the diagnostic process of inflammatory bowel disease (IBD). Both ulcerative colitis and Crohn’s disease, due to multiple remissions and relapses, require repetitive examinations to evaluate the disease extent, severity, and response to pharmacological treatment. Whereas the use of barium contrast studies is progressively reduced, plain radiography confirms its utility as a first-line imaging tool for acute abdomen. Computed tomography remains an easily accessible and effective method to demonstrate disease activity and extraintestinal manifestations. However, the related radiation exposure reduces its applicability to urgent situations. Ultrasound and magnetic resonance, with the great advantage of avoiding ionising radiation, are highly recommended to present the complications of IBD. Use of oral and intravenous contrast in computed tomography enterography and magnetic resonance enterography demonstrates IBD involvement in the small intestine wall, which is difficult to assess in other radiological and endoscopic examinations.

Diagnostic accuracy of magnetic resonance enterography and small bowel ultrasound for the extent and activity of newly diagnosed and relapsed Crohn's disease (METRIC): a multicentre trial

BACKGROUND

Magnetic resonance enterography (MRE) and ultrasound are used to image Crohn's disease, but their comparative accuracy for assessing disease extent and activity is not known with certainty. Therefore, we did a multicentre trial to address this issue.

METHODS

We recruited patients from eight UK hospitals. Eligible patients were 16 years or older, with newly diagnosed Crohn's disease or with established disease and suspected relapse. Consecutive patients had MRE and ultrasound in addition to standard investigations. Discrepancy between MRE and ultrasound for the presence of small bowel disease triggered an additional investigation, if not already available. The primary outcome was difference in per-patient sensitivity for small bowel disease extent (correct identification and segmental localisation) against a construct reference standard (panel diagnosis). This trial is registered with the International Standard Randomised Controlled Trial, number ISRCTN03982913, and has been completed.

FINDINGS

284 patients completed the trial (133 in the newly diagnosed group, 151 in the relapse group). Based on the reference standard, 233 (82%) patients had small bowel Crohn's disease. The sensitivity of MRE for small bowel disease extent (80% [95% CI 72-86]) and presence (97% [91-99]) were significantly greater than that of ultrasound (70% [62-78] for disease extent, 92% [84-96] for disease presence); a 10% (95% CI 1-18; p=0·027) difference for extent, and 5% (1-9; p=0·025) difference for presence. The specificity of MRE for small bowel disease extent (95% [85-98]) was significantly greater than that of ultrasound (81% [64-91]); a difference of 14% (1-27; p=0·039). The specificity for small bowel disease presence was 96% (95% CI 86-99) with MRE and 84% (65-94) with ultrasound (difference 12% [0-25]; p=0·054). There were no serious adverse events.

INTERPRETATION

Both MRE and ultrasound have high sensitivity for detecting small bowel disease presence and both are valid first-line investigations, and viable alternatives to ileocolonoscopy. However, in a national health service setting, MRE is generally the preferred radiological investigation when available because its sensitivity and specificity exceed ultrasound significantly.

FUNDING

National Institute of Health and Research Health Technology Assessment.

Associations Among Mucosal and Transmural Healing and Fecal Level of Calprotectin in Children With Crohn's Disease

BACKGROUND & AIMS

Bowel healing is an important goal of therapy for patients with Crohn's disease (CD). Although there have been many studies of mucosal healing, transmural healing (ie, in the bowel wall) has not been investigated in children. We analyzed data from the ImageKids study to determine associations among mucosal, transmural healing and levels of calprotectin and C-reactive protein in children with CD.

METHODS

We collected data from a multi-center study designed to develop 2 magnetic resonance enterography (MRE)-based measures for children with CD (6-18 years old). In our analysis of 151 children (mean age, 14.2 ± 2.4 years), all patients underwent MRE and a complete ileocolonoscopic evaluation; fecal levels of calprotectin and blood levels of C-reactive protein were measured. Mucosal healing was defined as simple endoscopic severity index in CD score below 3, transmural healing as an MRE visual analogue score below 20 mm, and deep healing as a combination of transmural and mucosal healing.

RESULTS

We identified mucosal healing with transmural inflammation in 9 children (6%), transmural healing with mucosal inflammation in 38 children (25%), deep healing in 21 children (14%), and mucosal and transmural inflammation in 83 children (55%). The median level of calprotectin was lowest in children with deep healing (mean level, 10 μg/g; interquartile range, 10-190 μg/g), followed by children with either transmural or mucosal inflammation, and highest in children with mucosal and transmural inflammation (810 μg/g; interquartile range, 539-1737 μg/g) (P < .001). Fecal level of calprotectin identified children with deep healing with an area under the receiver operating characteristic curve value of 0.93 (95% CI, 0.89-0.98); level of C-reactive protein identified children with deep healing with an area under the receiver operating characteristic curve value of 0.81 (95% CI, 0.71-0.9). A calprotectin cutoff value of 100 μg/g identified children with deep healing with 71% sensitivity and 92% specificity; a cutoff value of 300 μg/g identified children with mucosal healing with 80% sensitivity and 81% specificity.

CONCLUSIONS

In a prospective study of children with CD, we found that one-third have healing in only the mucosa or the bowel wall (not both). Levels of fecal calprotectin below 300 μg/identify children with mucosal healing, but a lower cutoff value (below 100 μg/g) is needed to identify children with deep healing. Clinicaltrials.gov no: NCT01881490.

Magnetic Resonance Enterography Cannot Replace Upper Endoscopy in Pediatric Crohn Disease: An Imagekids Sub-study

OBJECTIVES

Although magnetic resonance enterography (MRE) can accurately reflect ileal inflammation in pediatric Crohn disease (CD), there are no pediatric data on the accuracy of MRE to detect upper gastrointestinal tract (UGI) lesions. We aimed to compare MRE and esophagogastroduodenoscopy (EGD) in detecting the spectrum and severity of UGI disease in children.

METHODS

This is an ancillary study of the prospective multi-center ImageKids study focusing on pediatric MRE. EGD was performed within 2 weeks of MRE (at disease onset or thereafter) and explicitly scored by SES-CD modified for the UGI and physician global assessment. Local and central radiologists scored the UGI region of the MRE blinded to the EGD. Accuracy of MRE compared with EGD was examined using correlational coefficients (r) and area under receiver operating characteristic curves (AUC).

RESULTS

One hundred and eighty-eight patients were reviewed (mean age 14 ± 1 years, 103 [55%] boys); 66 of 188 (35%) children had macroscopic ulcerations on EGD (esophagus, 13 [7%]; stomach, 34 [18%]; duodenum, 45 [24%]). Most children had aphthous ulcers, but 10 (5%) had larger ulcers (stomach, 2 [1%]; duodenum, 8 [4%]). There was no agreement between local and central radiologists on the presence or absence of UGI inflammation on MRE (Kappa = -0.02, P = 0.71). EGD findings were not accurately detected by MRE, read locally or centrally (r = -0.03 to 0.11, P = 0.18-0.88; AUC = 0.47-0.55, P = 0.53-1.00).No fistulae or narrowings were identified on either EGD or MRE.

CONCLUSIONS

MRE cannot reliably assess the UGI in pediatric CD and cannot replace EGD for this purpose.

Evidence-based clinical practice guidelines for inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic disorder involving mainly the intestinal tract, but possibly other gastrointestinal and extraintestinal organs. Although etiology is still uncertain, recent knowledge in pathogenesis has accumulated, and novel diagnostic and therapeutic modalities have become available for clinical use. Therefore, the previous guidelines were urged to be updated. In 2016, the Japanese Society of Gastroenterology revised the previous versions of evidence-based clinical practice guidelines for ulcerative colitis (UC) and Crohn's disease (CD) in Japanese. A total of 59 clinical questions for 9 categories (1. clinical features of IBD; 2. diagnosis; 3. general consideration in treatment; 4. therapeutic interventions for IBD; 5. treatment of UC; 6. treatment of CD; 7. extraintestinal complications; 8. cancer surveillance; 9. IBD in special situation) were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases. The guidelines were developed with the basic concept of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Recommendations were made using Delphi rounds. This English version was produced and edited based on the existing updated guidelines in Japanese.

The role of imaging in the preoperative assessment of children with inflammatory colitis

BACKGROUND

Accurate diagnosis of Crohn's disease or ulcerative colitis is essential for surgical planning. This study compared the accuracy, safety, and utility of small bowel follow-through (SBFT) and magnetic resonance enterography (MRE) for detecting small bowel (SB) involvement preoperatively.

METHODS

A retrospective review of children who underwent colectomy for inflammatory bowel disease (2000-2014) was performed. Preoperative SBFT and MRE were independently reviewed by two radiologists blinded to clinical data. Gold standard for diagnosis was surgical pathology.

RESULTS

68 patients (36 female) were included. 45 patients had SBFT prior to colectomy, 17 patients had MRE, and 6 both. Interrater reliability for radiologic interpretation was 90% (SBFT) and 91% (MRE). Mean study durations were 190min (SBFT) and 59min (MRE). Median effective dose for SBFT was 1.5mSv, while MRE involved no ionizing radiation. Specificities for diagnosing SB involvement were 87.5% (SBFT) and 94% (MRE). 54 patients underwent subtotal colectomy and ileostomy, 12 restorative proctocolectomy, and 2 colectomy with ileorectal anastomosis. Preoperative imaging correlated with surgical pathology in 83% (SBFT) and 90% (MRE).

CONCLUSION

MRE is at least as effective as SBFT for assessing SB disease in children with colitis prior to colectomy. MRE requires less time and does not expose children to ionizing radiation. Retrospective Case Series, Level 4 Evidence.

Diagnosis and management of inflammatory bowel disease in children

Inflammatory bowel diseases (IBD), including Crohn's disease and ulcerative colitis, are lifelong conditions that often begin in childhood. The implications of IBD are of particular importance in children because of the potential negative effects on growth, development, psychosocial function, and overall wellbeing. The key management strategy is to achieve sustained control of intestinal inflammation and monitor for potential complications of the disease and side effects of therapies. Overall, the evidence on the management of IBD in children is less extensive than in adults, but good quality multicenter studies and various guidelines and society consensus statements are available. This review summarizes the evidence on the pathophysiology, diagnosis, and approaches to management of children and adolescents with IBD.

Radiologic Predictors of Surgery in Newly Diagnosed Pediatric Crohn Disease Patients

OBJECTIVES

The aim of the present study was to assess whether small bowel imaging conducted at the time of diagnosis could be used as a predictor of small bowel surgical intervention in a population of pediatric patients with Crohn disease (CD).

METHODS

A retrospective analysis of small bowel imaging within 30 days of diagnosis of pediatric CD was conducted. Patients were divided into 2 groups based on small bowel imaging: those with no or minor abnormalities (71%) and those with more extensive or obstructive abnormalities (29%). Medical records were reviewed for small bowel surgical intervention and clinic follow-up visits.

RESULTS

A total of 232 patients were included in the study group (average age at diagnosis 11.7 years). Twenty-seven patients (12%) underwent small bowel surgical intervention. The relative risk for small bowel surgical intervention was 2.91 in the group with more extensive imaging abnormalities. The majority of increased surgical risk occurred in the first year after diagnosis, when the normal-minor group had a 2% surgical risk and the more abnormal group had a 17% surgical risk. Both groups had a 2% to 3% surgical risk per year after the first year.

CONCLUSIONS

Small bowel imaging at the time of diagnosis in pediatric CD can help predict the risk of small bowel surgical intervention and should be recommended for all newly diagnosed patients. Nearly one third of our cohort underwent small bowel surgical intervention through 8 years of follow-up. Surgical complications of CD often occur in the small bowel, and counseling families about surgical risk is an integral part of pediatric CD management.

Diffusion-weighted Magnetic Resonance Enterography for Evaluating Bowel Inflammation in Crohn's Disease: A Systematic Review and Meta-analysis

BACKGROUND

To systematically determine the performance of diffusion-weighted imaging magnetic resonance enterography (DWI-MRE) for evaluating bowel inflammation in Crohn's disease and sources of heterogeneity between reported results.

METHODS

We identified research studies that investigated DWI-MRE to diagnose bowel inflammation (present versus absent) or to assess bowel inflammatory severity in Crohn's disease by performing a systematic search of PubMed MEDLINE and EMBASE (until March 31, 2015). Study quality was assessed using QUADAS-2. For studies reporting dichotomous diagnosis of bowel inflammation, study heterogeneity and threshold effect were analyzed, summary sensitivity and specificity were estimated, and meta-regression analysis was performed to further explore study heterogeneity. For studies reporting assessment of inflammatory severity, a qualitative summary was performed.

RESULTS

Of 159 articles screened, we found 12 studies (1515 bowel segments) reporting a diagnosis of bowel inflammation and 6 studies (1066 bowel segments) reporting assessment of inflammatory severity. The summary sensitivity and specificity were 92.9% (95% CI, 85.8%-96.6%; I = 87.9%) and 91% (95% CI, 79.7%-96.3%; I = 95.1%), respectively. Sensitivity and false-positive rate were inversely correlated (r = -0.650; P = 0.022). Lack of blinding to contrast-enhanced MRE when interpreting DWI-MRE (P = 0.01) and use of contrast-enhanced MRE as a reference standard (P < 0.01) in some studies were significant factors for study heterogeneity and likely caused overestimation of DWI-MRE accuracy. There was rather clear correlation between diffusion-related parameters and bowel inflammation severity, although the strengths were heterogeneous (correlation coefficient, 0.39-0.98).

CONCLUSIONS

DWI-MRE accuracy was very heterogeneous between studies and was likely overestimated in some studies. Despite rather clear correlation between diffusion-related parameters and bowel inflammatory severity, its strength was variable.

Role of imaging in the evaluation of inflammatory bowel disease: How much is too much?

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.

[Modern MRI of the small bowell]

CLINICAL METHODOLOGICAL ISSUES

The radiological diagnostics of diseases of the small intestine have undergone a great change in the last two decades. Through rapid progress with new treatments and an increasing therapeutic focus on transmural healing, a complete evaluation of the gastrointestinal tract is now crucial.

STANDARD RADIOLOGICAL METHODS

With the introduction of endoscopy, gastrointestinal imaging with a relatively high radiation exposure had only limited applications. The development of cross-sectional imaging allowed a much broader radiological evaluation of abdominal diseases. Due to rapid investigation techniques, excellent soft tissue contrast and the distinct advantage of eliminating exposure to radiation, magnetic resonance imaging (MRI) of the gastrointestinal tract has gained increasing importance. With sufficient filling of the intestinal lumen, simultaneous imaging of all the intestinal wall layers, the perienteric structures and associated abdominal pathologies is now possible.

METHODOLOGICAL INNOVATIONS

New MR sequences, such as diffusion-weighted sequences, dynamic contrast-enhanced sequences and MR fluoroscopy, enable the detection of morphological changes, with additional characterization of affected bowel loops as well as the assessment of functional pathologies with dynamic information about intestinal motility disturbances.

ACHIEVEMENTS

Recent guidelines of European radiological and gastroenterological organizations have confirmed the importance of cross-sectional imaging and particularly of MRI for diagnostics and follow-up in patients with Crohn's disease. Due to the possibility of assessment of all the layers of the intestinal wall and the presence of extramural complications, MRI has a significant impact on further therapeutic treatment in patients with inflammatory bowel disease.

PRACTICAL RECOMMENDATIONS

Especially in patients with inflammatory bowel disease, MR enterography and MR enteroclysis should be the methods of choice for the evaluation of small bowel pathologies because of radiation issues and the great diagnostic value they provide. A variety of MR sequences has enabled not only the detection but also the characterization of pathological changes of the small intestine, which are vital for further treatment of these patients.

Particularities of Crohn's disease in pediatric patients: current status and perspectives regarding imaging modalities

A consensus on the best imaging modality evaluating inflammatory bowel disease in the pediatric population is lacking and it is often unclear which modality to choose in specific clinical circumstances. Children with inflammatory bowel disease are exposed to ionizing radiation from multiple imaging studies performed at initial diagnosis, throughout treatment and during the follow-up period. This paper discusses the value of different imaging techniques in pediatric patients with inflammatory bowel disease and gives a review of the literature. In addition, particular features of inflammatory bowel disease in children including the predilection of affected segments in the gastrointestinal tract are highlighted. Based on current literature knowledge, we encourage an integrative approach to the interpretation of clinical and imaging data for diagnosis and follow-up in daily clinical settings.

High Spatiotemporal Resolution Dynamic Contrast-Enhanced MR Enterography in Crohn Disease Terminal Ileitis Using Continuous Golden-Angle Radial Sampling, Compressed Sensing, and Parallel Imaging

OBJECTIVE

The purpose of this article was to assess the feasibility of golden-angle radial acquisition with compress sensing reconstruction (Golden-angle RAdial Sparse Parallel [GRASP]) for acquiring high temporal resolution data for pharmacokinetic modeling while maintaining high image quality in patients with Crohn disease terminal ileitis.

MATERIALS AND METHODS

Fourteen patients with biopsy-proven Crohn terminal ileitis were scanned using both contrast-enhanced GRASP and Cartesian breath-hold (volume-interpolated breath-hold examination [VIBE]) acquisitions. GRASP data were reconstructed with 2.4-second temporal resolution and fitted to the generalized kinetic model using an individualized arterial input function to derive the volume transfer coefficient (K(trans)) and interstitial volume (v(e)). Reconstructions, including data from the entire GRASP acquisition and Cartesian VIBE acquisitions, were rated for image quality, artifact, and detection of typical Crohn ileitis features.

RESULTS

Inflamed loops of ileum had significantly higher K(trans) (3.36 ± 2.49 vs 0.86 ± 0.49 min(-1), p < 0.005) and v(e) (0.53 ± 0.15 vs 0.20 ± 0.11, p < 0.005) compared with normal bowel loops. There were no significant differences between GRASP and Cartesian VIBE for overall image quality (p = 0.180) or detection of Crohn ileitis features, although streak artifact was worse with the GRASP acquisition (p = 0.001).

CONCLUSION

High temporal resolution data for pharmacokinetic modeling and high spatial resolution data for morphologic image analysis can be achieved in the same acquisition using GRASP.

Use of Imaging Techniques in Inflammatory Bowel Diseases That Minimize Radiation Exposure

The use of imaging in the management of inflammatory bowel disease (IBD) has grown exponentially in the last few years. This has raised concerns about the risk of high cumulative level of radiation exposure from medical imaging in IBD patients during their lifetime, especially when the disease begins in pediatric age. Physicians caring for IBD children should be aware of the malignant potential of ionizing radiation and of the availability of alternative radiation-free techniques such as magnetic resonance imaging (MRI) and ultrasonography (US), in order to use them whenever possible. This review will focus on the value of US and MRI in pediatric IBD.

Outcome measures for clinical trials in paediatric IBD: an evidence-based, expert-driven practical statement paper of the paediatric ECCO committee

OBJECTIVE

Although paediatric-onset IBD is becoming more common, few medications have a registered paediatric indication. There are multiple hurdles to performing clinical trials in children, emphasising the importance of choosing an appropriate outcome measure, which can facilitate enrolment, and thereby also drug approval. The aim of this consensus statement is to highlight paediatric specific issues and key factors critical for the optimal conduct of paediatric IBD trials.

DESIGN

The Paediatric European Crohn's and Colitis Organisation (ECCO) committee has established an international expert panel to determine the best outcome measures in paediatric IBD, following a literature search and a modified Delphi process. All recommendations were endorsed by at least 80% agreement.

RESULTS

Recognising the importance of mucosal healing (MH), the panel defined steroid-free MH as primary outcome measure for all drugs of new category with one or two postintervention endoscopies per trial (at 8-12 weeks and/or 54 weeks). Since endoscopic evaluation is a barrier for recruitment in children, trials with medications already shown to induce MH in children or adults, could use paediatric-specific disease activity scores as primary outcome, including a modified Paediatric Crohn's Disease Activity Index in Crohn's disease and the Paediatric Ulcerative Colitis Activity Index in UC. Secondary outcomes should include safety issues, MR enterography-based damage and inflammatory scores (in Crohn's disease), faecal calprotectin, quality of life scales, and a patient-reported outcome.

CONCLUSIONS

It is crucial to perform paediatric trials early in the development of new drugs in order to reduce off-label use of IBD medication in children. The thoughtful choice of feasible and standardised outcome measures can help move us towards this goal.

Magnetic resonance enterography, small-intestine contrast US, and capsule endoscopy to evaluate the small bowel in pediatric Crohn's disease: a prospective, blinded, comparison study

BACKGROUND

Small-bowel (SB) disease is a severe clinical entity among the phenotypes of Crohn's disease (CD).

OBJECTIVE

To assess sensitivity, specificity, and accuracy of magnetic resonance enterography (MRE), small-intestine contrast US (SICUS), and capsule endoscopy (CE) in the diagnosis of pediatric SB-CD.

DESIGN

Prospective, blinded, comparison study.

SETTING

Tertiary center for pediatric inflammatory bowel disease.

PATIENTS

Children with known or suspected CD. Diagnosis of SB obstruction at SICUS or MRE excluded patients from the study.

INTERVENTION

Patients underwent ileocolonoscopy, MRE, SICUS, and CE over a 7-day period. For the imaging evaluation, SB was divided into 3 segments: jejunum, proximal and mid ileum, and terminal ileum.

MAIN OUTCOME MEASUREMENTS

The performance of each method was compared to a consensus reference standard for upper SB and to ileocolonoscopy for the terminal ileum.

RESULTS

Twenty-five patients completed the study. In the jejunum, the sensitivity of SICUS and CE was 92%, which was not significantly higher than MRE (75%); the specificity of CE (61%) was significantly lower than that of MRE (P = .04). In the proximal and mid ileum, MRE and CE did not have significantly higher sensitivity (100%) than SICUS (80%), but CE was less specific (P > .05). At the terminal ileum, SICUS and MRE were slightly more sensitive than CE (94% vs. 81%); however, the latter was more specific.

LIMITATIONS

Use of the consensus reference standard for upper SB. Small number of patients.

CONCLUSION

SICUS, MRE, and CE are all effective options for imaging SB. An integrated use of different tools should be suggested to achieve a complete assessment of the SB in children with suspected or confirmed CD.

Magnetic resonance enterography of Crohn's disease

Magnetic resonance enterography (MRE) has been reported to be a useful modality for the evaluation of luminal inflammation and extraintestinal complications in Crohn's disease (CD). A recent study indicated that the diagnostic ability of MRE was comparable to the diagnostic ability of other devices, such as ileocolonoscopy. MRE can be performed repeatedly because there is no radiation exposure. Therefore, MRE is useful as a method of follow-up for younger patients with established CD. It is useful for evaluating the efficacy of medical treatments, such as biologics. MRE can detect small intestinal lesions even if the endoscope does not pass through the stenosis. The concerns of availability of expertise and the costs associated with MRE should be addressed so MRE can be widely used for CD patients in the near future.

Systematic review with meta-analysis: magnetic resonance enterography signs for the detection of inflammation and intestinal damage in Crohn's disease

BACKGROUND

In the treatment of Crohn's disease (CD), mucosal healing has become a major goal, with the hope of avoiding intestinal damage from chronic inflammation. Magnetic resonance enterography (MRE) has emerged as a non-invasive means of monitoring inflammation and damage.

AIMS

As part of the development of MRE-based multi-item measures of inflammation and damage for paediatric studies, we carried out a systematic review and meta-analysis to identify MRE variables used to describe these two distinct concepts.

METHODS

2501 studies of MRI and CD were identified. Studies written in any language reporting individual MRE signs for patients diagnosed with CD were included. Two-hundred-and-forty-four studies were fully reviewed and 62 were included (inflammation, n = 51; damage, n = 24). Sensitivity, specificity and associated confidence intervals were calculated, and hierarchical summary ROC curves were constructed for each MRE sign.

RESULTS

A total of 22 MRE signs were used to reflect inflammation, and 9 to reflect damage. Diagnostic accuracy of MRE signs of inflammation and damage was heterogeneous; however, wall enhancement, mucosal lesions and wall T2 hyperintensity were the most consistently useful for inflammation (most sensitivities >80% and specificities >90%), and detection of abscess and fistula were most consistently useful for damage (most sensitivities >90%, specificities >95%).

CONCLUSIONS

Identifying the best MRE variables to reflect inflammation and damage will maximise the utility of this rapidly emerging technique and is the first stage of constructing MRE-based indices for evaluating inflammation and intestinal damage.

Inflammatory bowel disease-the role of cross-sectional imaging techniques in the investigation of the small bowel

Abstract

Background: The diagnosis of inflammatory bowel disease (IBD) in children and adolescents is based on the integration of clinical, biological, endoscopic, histological and radiological data. Methods: The most important part of the diagnosis is the histology, which is acquired by endoscopy. Imaging of the small bowel has changed in recent years, but the imaging goals are primarily to determine the extent of small bowel involvement, assess complications and define candidates for surgery. Imaging techniques are divided into conventional and cross-sectional ones. Results: The spectrum of imaging findings of cross-sectional techniques is discussed, emphasising the advantages and limitations of each technique, acknowledging the specificities of the paediatric population. Cross-sectional techniques have advanced the ability to diagnose and monitor inflammatory disease of the small bowel. Conclusion: MR enterography is the technique of choice in children with known IBD, for the investigation of the small bowel and the whole GI tract. US should be the first choice examination in children with suspected IBD, while CT should be reserved for cases in which MRI is contraindicated or in acute emergency situations when US is inadequate.

Teaching Points

• Cross-sectional imaging of the small bowel is essential in paediatric IBD.

• Endoscopy is unable to assess extramural disease and examine the entire small bowel.

• US should be the first choice examination in children with suspected IBD.

• MR enterography is the technique of choice in children with known IBD.

• There are still controversies regarding the prediction of disease activity or fibrosis.

Magnetic resonance enterography in the evaluation of Crohn's disease: a primer for the gastroenterologist

The assessment of disease location, severity, and complications is critical in guiding the choice of Crohn's disease therapy. Cross-sectional imaging studies have therefore had a paramount role in accurately staging Crohn's disease. Traditionally, computed tomography was the test of choice in confirming/excluding strictures, fistulae, and abscesses. Magnetic resonance imaging is now replacing computed tomography because it eliminates radiation risks. This review provides a primer for the gastroenterologist on magnetic resonance enterography in Crohn's disease.

Advancing magnetic resonance imaging in Crohn's disease

Crohn's disease (CD) is a lifelong chronic inflammatory bowel disease associated with diarrhea, abdominal pain, bloody stool and often perianal fistulae. Inflammation in CD involves the entire gastrointestinal tract, especially including the small and large bowels, causing irreversible bowel damage. Frequent imaging examinations are necessary to monitor disease activity and to evaluate response to therapeutic interventions, and, furthermore, to predict recurrence in order to provide appropriate treatment. The suitable imaging modality should be reproducible, well tolerated, safe and free of ionizing radiation. In recent years, imaging used in CD has dramatically changed. Cross-sectional imaging techniques such as computed tomography and magnetic resonance imaging (MRI) are used to investigate not only extraluminal abnormalities, but also intraluminal changes. Recently, new techniques such as MR enteroclysis, enterography, colonography and enterocolonography have been developed. These recent advances enable the use of MRI to assess bowel disorders with high sensitivity, specificity and accuracy. MRI can evaluate simultaneously the bowel surface, bowel wall, abdominal abscesses and perianal lesions, such as perianal fistulae and perianal abscesses, without the problem of overlapping bowel loops. Therefore, MRI has the potential for evaluation of the overall disease activity of CD without radiation exposure. We believe that MRI is a suitable first choice imaging modality in the assessment of CD.

Comprehensive magnetic resonance enterography of Crohn's disease in the pediatric population: technique, interpretation, and management

Magnetic resonance enterography (MRE) plays a critical role in the management of Crohn's disease in the pediatric population. The ability to provide dynamic assessment of disease burden, complications, and therapeutic response without ionizing radiation makes it an ideal tool for younger patients requiring frequent follow-up. With a growing array of available treatment options, a sound understanding of MRE is critical in directing management aimed at curbing the physical and emotional morbidity associated with the lifelong condition. The goal of this article is to provide a practical overview of MRE in the pediatric population. This includes a review of our technique, approach to interpretation, pictorial collection of findings, and discussion of the role MRE plays in management.

ESPGHAN revised porto criteria for the diagnosis of inflammatory bowel disease in children and adolescents

BACKGROUND

The diagnosis of pediatric-onset inflammatory bowel disease (PIBD) can be challenging in choosing the most informative diagnostic tests and correctly classifying PIBD into its different subtypes. Recent advances in our understanding of the natural history and phenotype of PIBD, increasing availability of serological and fecal biomarkers, and the emergence of novel endoscopic and imaging technologies taken together have made the previous Porto criteria for the diagnosis of PIBD obsolete.

METHODS

We aimed to revise the original Porto criteria using an evidence-based approach and consensus process to yield specific practice recommendations for the diagnosis of PIBD. These revised criteria are based on the Paris classification of PIBD and the original Porto criteria while incorporating novel data, such as for serum and fecal biomarkers. A consensus of at least 80% of participants was achieved for all recommendations and the summary algorithm.

RESULTS

The revised criteria depart from existing criteria by defining 2 categories of ulcerative colitis (UC, typical and atypical); atypical phenotypes of UC should be treated as UC. A novel approach based on multiple criteria for diagnosing IBD-unclassified (IBD-U) is proposed. Specifically, these revised criteria recommend upper gastrointestinal endoscopy and ileocolonscopy for all suspected patients with PIBD, with small bowel imaging (unless typical UC after endoscopy and histology) by magnetic resonance enterography or wireless capsule endoscopy.

CONCLUSIONS

These revised Porto criteria for the diagnosis of PIBD have been developed to meet present challenges and developments in PIBD and provide up-to-date guidelines for the definition and diagnosis of the IBD spectrum.