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Hoerning A, Jüngert J, Siebenlist G, Knieling F, Regensburger AP. Ultrasound in Pediatric Inflammatory Bowel Disease-A Review of the State of the Art and Future Perspectives. CHILDREN (BASEL, SWITZERLAND) 2024; 11:156. [PMID: 38397268 PMCID: PMC10887069 DOI: 10.3390/children11020156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
Inflammatory bowel disease (IBD) comprises a group of relapsing, chronic diseases of the gastrointestinal tract that, in addition to adults, can affect children and adolescents. To detect relapses of inflammation, these patients require close observation, frequent follow-up, and therapeutic adjustments. While reference standard diagnostics include anamnestic factors, laboratory and stool sample assessment, performing specific imaging in children and adolescents is much more challenging than in adults. Endoscopic and classic cross-sectional imaging modalities may be invasive and often require sedation for younger patients. For this reason, intestinal ultrasound (IUS) is becoming increasingly important for the non-invasive assessment of the intestine and its inflammatory affection. In this review, we would like to shed light on the current state of the art and provide an outlook on developments in this field that could potentially spare these patients more invasive follow-up procedures.
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Affiliation(s)
- André Hoerning
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- German Center Immunotherapy (DZI), University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Jörg Jüngert
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Gregor Siebenlist
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Ferdinand Knieling
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Adrian P Regensburger
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
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De Cristofaro E, Montesano L, Lolli E, Biancone L, Monteleone G, Calabrese E, Zorzi F. Echopattern parameter as an aid to profile Crohn's disease patients. Dig Liver Dis 2023; 55:1652-1657. [PMID: 37258331 DOI: 10.1016/j.dld.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/03/2023] [Accepted: 05/16/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Intestinal ultrasonography (US) allows for the characterization of the intestinal lesions and provides information on transmural inflammation. The aim of the study was to assess the clinical relevance of echopattern and correlation with Crohn's disease (CD) behavior and activity. METHODS We performed a prospective study including CD patients assessed by intestinal US. The echopattern was classified as hypoechoic, hyperechoic and stratified. Color-doppler US was also performed in the thickest segment. RESULTS One hundred CD patients were enrolled. The hypoechoic echopattern was significantly correlated with penetrating behavior (r = 0.44, p<0.0001), active disease (r = 0.21, p = 0.034), C-reactive protein/Fecal Calprotectin (r = 0.31, p = 0.004; r = 0.34, p = 0.031, respectively) and steroids (r = 0.33, p = 0.0008). Hypoechoic echopattern was associated with younger age than stratified (p = 0.046) and hyperechoic (p = 0.018) echopatterns. Bowel wall thickness was greater in the hypoechoic group than in the hyperechoic/stratified groups (p = 0.011 and p<0.0001, respectively). Hypoechoic echopattern was associated with fistulas (r = 0.52, p<0.0001) and increased vascularization (r = 0.32, p = 0.001). The hyperechoic echopattern showed a significant correlation with stricturing disease and an inverse correlation with fistulas. During a follow up period of 6 months, patients with hypoechoic echopattern had an increased risk of biological therapy need or surgery. CONCLUSIONS The characterization of bowel wall echopattern allows for the identification of different CD behaviors.
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Affiliation(s)
- Elena De Cristofaro
- Unità Operativa di Gastroenterologia, Dipartimento di Medicina, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Laura Montesano
- Unità Operativa di Gastroenterologia, Dipartimento di Medicina, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Elisabetta Lolli
- Unità Operativa di Gastroenterologia, Dipartimento di Medicina, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Livia Biancone
- Unità Operativa di Gastroenterologia, Dipartimento di Medicina, Policlinico Universitario Tor Vergata, Rome, Italy; Cattedra di Gastroenterologia, Dipartimento di Medicina dei Sistemi, Università degli studi di Roma Tor Vergata, Italy
| | - Giovanni Monteleone
- Unità Operativa di Gastroenterologia, Dipartimento di Medicina, Policlinico Universitario Tor Vergata, Rome, Italy; Cattedra di Gastroenterologia, Dipartimento di Medicina dei Sistemi, Università degli studi di Roma Tor Vergata, Italy
| | - Emma Calabrese
- Unità Operativa di Gastroenterologia, Dipartimento di Medicina, Policlinico Universitario Tor Vergata, Rome, Italy; Cattedra di Gastroenterologia, Dipartimento di Medicina dei Sistemi, Università degli studi di Roma Tor Vergata, Italy.
| | - Francesca Zorzi
- Unità Operativa di Gastroenterologia, Dipartimento di Medicina, Policlinico Universitario Tor Vergata, Rome, Italy
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Chacon MA, Wilson NA. The Challenge of Small Intestine Length Measurement: A Systematic Review of Imaging Techniques. J Surg Res 2023; 290:71-82. [PMID: 37210758 PMCID: PMC10330168 DOI: 10.1016/j.jss.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/22/2023] [Accepted: 04/15/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Short bowel syndrome is the most common cause of intestinal failure, with morbidity and mortality linked to remanent small intestine length. There is no current standard for noninvasive bowel length measurement. MATERIALS AND METHODS The literature was systematically searched for articles describing measurements of small intestine length from radiographic studies. Inclusion required reporting intestinal length as an outcome and use of diagnostic imaging for length assessment compared to a ground truth. Two reviewers independently screened studies for inclusion, extracted data, and assessed study quality. RESULTS Eleven studies met the inclusion criteria and reported small intestinal length measurement using four imaging modalities: barium follow-through, ultrasound, computed tomography, and magnetic resonance. Five barium follow-through studies reported variable correlations with intraoperative measurements (r = 0.43-0.93); most (3/5) reported underestimation of length. US studies (n = 2) did not correlate with ground truths. Two computed tomography studies reported moderate-to-strong correlations with pathologic (r = 0.76) and intraoperative measurements (r = 0.99). Five studies of magnetic resonance showed moderate-to-strong correlations with intraoperative or postmortem measurements (r = 0.70-0.90). Vascular imaging software was used in two studies, and a segmentation algorithm was used for measurements in one. CONCLUSIONS Noninvasive measurement of small intestine length is challenging. Three-dimensional imaging modalities reduce the risk of length underestimation, which is common with two-dimensional techniques. However, they also require longer times to perform length measurements. Automated segmentation has been trialed for magnetic resonance enterography, but this method does not translate directly to standard diagnostic imaging. While three-dimensional images are most accurate for length measurement, they are limited in their ability to measure intestinal dysmotility, which is an important functional measure in patients with intestinal failure. Future work should validate automated segmentation and measurement software using standard diagnostic imaging protocols.
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Affiliation(s)
- Miranda A Chacon
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Nicole A Wilson
- Division of Pediatric Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York; Department of Biomedical Engineering, University of Rochester, Rochester, New York.
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Castellano MA, Scheeffer V, Petersen V, da Silveira TR. Evaluation of bowel wall flow by color Doppler ultrasound in the assessment of inflammatory bowel disease activity in pediatric patients. Radiol Bras 2023; 56:242-247. [PMID: 38204905 PMCID: PMC10775812 DOI: 10.1590/0100-3984.2023.0039-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/29/2023] [Accepted: 07/27/2023] [Indexed: 01/12/2024] Open
Abstract
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.
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Affiliation(s)
- Marco Aurélio Castellano
- Hospital da Criança Santo Antônio da Santa Casa de
Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
- Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
| | - Vanessa Scheeffer
- Hospital da Criança Santo Antônio da Santa Casa de
Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Vanessa Petersen
- Hospital da Criança Santo Antônio da Santa Casa de
Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
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Statie RC, Iordache S, Florescu LM, Gheonea IA, Sacerdoțianu VM, Ungureanu BS, Rogoveanu I, Gheonea DI, Ciurea T, Florescu DN. Assessment of Ileal Crohn's Disease Activity by Gastrointestinal Ultrasound and MR Enterography: A Pilot Study. Life (Basel) 2023; 13:1754. [PMID: 37629610 PMCID: PMC10455412 DOI: 10.3390/life13081754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/15/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
INTRODUCTION In some cases, there may be a discrepancy between the symptomatology alleged by Crohn's disease (CD) patients and the results of laboratory tests or imaging investigations. Ileocolonoscopy with biopsy is the primary investigation for diagnosing and monitoring CD patients. Cross-sectional imaging techniques such as CT or MR enterography (MRE) and intestinal ultrasonography (IUS) have been proposed as complementary methods to colonoscopy for a complete evaluation of this category of patients. This study aims to identify the role of IUS, contrast-enhanced ultrasound (CEUS) and MRE in evaluating ileal CD activity, using clinical severity scores (Crohn's disease activity index-CDAI, Harvey-Bradshaw index-HBI) and faecal calprotectin or C-reactive protein (CRP) levels as reference methods. MATERIALS AND METHODS A total of 44 adult patients with ileal CD confirmed using an ileocolonoscopy with biopsy and histopathological examination were assessed by IUS, CEUS and MRE. The evaluation of the disease activity based on the results obtained from the cross-sectional imaging tests was carried out by using some severity scores available in the literature. The sensitivity and specificity of IUS + CEUS and MRE for differentiating active from inactive forms of CD were determined using CDAI, HBI, faecal calprotectin and CRP as reference methods. The accuracy of the results was assessed by the receiver operating characteristics method. The Pearson correlation coefficient was used to determine the types of correlation. A p-value less than 0.05 suggested a statistically significant relationship. RESULTS Compared to CDAI, the best correlation was identified for Limberg score (r = 0.667, 95% confidence interval (CI) [0.46, 0.8], p < 0.001), followed by MaRIAs score (r = 0.614, 95% CI [0.39, 0.77], p < 0.001). A sensitivity of 93.33% and a specificity of 71.43% (AUC = 0.98) were demonstrated in the case of Limberg score for differentiating patients with active disease from those in remission and for MaRIAs score a sensitivity of 100.00% and a specificity of 57.14% (AUC = 0.97). Regarding HBI, the best correlation was observed for MaRIAs score (r = 0.594, 95% CI [0.36, 0.76], p < 0.001). Also, faecal calprotectin showed the best correlation with MaRIAs score (r = 0.697, 95% CI [0.46, 0.84], p < 0.001), but in the case of CRP, there was only a weak correlation for all evaluated scores. CONCLUSIONS Although magnetic resonance imaging does not appear to be superior to ultrasonography in terms of accuracy for differentiating active forms of CD from those in remission, the results of our study suggest that MRE associates a better correlation with clinical severity scores and faecal calprotectin levels compared to ultrasonography. More studies are needed to validate these results.
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Affiliation(s)
- Răzvan-Cristian Statie
- Doctoral School, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Sevastița Iordache
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Lucian Mihai Florescu
- Department of Radiology and Medical Imaging, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Ioana-Andreea Gheonea
- Department of Radiology and Medical Imaging, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Victor-Mihai Sacerdoțianu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Bogdan Silviu Ungureanu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Ion Rogoveanu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Dan-Ionuț Gheonea
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Tudorel Ciurea
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Dan Nicolae Florescu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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Wang L, Xu C, Zhang Y, Jiang W, Ma J, Zhang H. External validation and comparison of simple ultrasound activity score and international bowel ultrasound segmental activity score for Crohn's disease. Scand J Gastroenterol 2023; 58:883-889. [PMID: 36825305 DOI: 10.1080/00365521.2023.2181038] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/04/2023] [Accepted: 02/11/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Intestinal ultrasound (IUS) is a non-invasive tool for monitoring Crohn's disease (CD) activity. Recently, sonographic activity scores, including the International Bowel Ultrasound Segmental Activity Score (IBUS-SAS) and Simple Ultrasound Activity Score for CD (SUS-CD), were developed. This study aimed to assess their clinical application value. METHODS This retrospective study enrolled patients with CD from March 2021 to June 2022. The diagnostic performance of the ultrasound scores was evaluated using the simplified endoscopic score for CD (SES-CD). Correlations of ultrasound scores with SES-CD, CD activity index (CDAI), and inflammatory biomarkers were assessed. Inter-rater reliability was compared. RESULTS In total, 140 patients were included. The IBUS-SAS for evaluating disease activity had an area under the curve (AUC) of 0.895, sensitivity of 85.4%, and specificity of 82.4% for the cut-off value of 48.7. The SUS-CD revealed an AUC of 0.835, sensitivity of 92.7%, and specificity of 64.7% for the cut-off value of 2.5. The IBUS-SAS and SUS-CD were positively correlated with SES-CD (r = 0.511 and 0.534, respectively). The scores correlated significantly with the CDAI and inflammatory biomarkers (all p < 0.01). The IBUS-SAS was more strongly correlated with CDAI (r = 0.666 vs 0.486) and C-reactive protein (r = 0.645 vs 0.434) than the SUS-CD. The intraclass correlation coefficient (ICC) of the IBUS-SAS and SUS-CD between the two sonologists was excellent (ICC = 0.96 and 0.78, respectively). CONCLUSION Both the IBUS-SAS and SUS-CD can evaluate disease activity in CD and exhibited a significant correlation with activity indices and inflammatory biomarkers. CLINICAL TRIAL REGISTRATION ChiCTR2200055221.
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Affiliation(s)
- Lu Wang
- Department of Gastroenterology, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, Jiangsu Province, P.R. China
- Department of Gastroenterology, First Affliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, P.R. China
| | - Chenjing Xu
- Department of Gastroenterology, First Affliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, P.R. China
| | - Yanyan Zhang
- Department of Ultrasonography, First Affliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, P.R. China
| | - Wenyu Jiang
- Department of Gastroenterology, First Affliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, P.R. China
| | - Jingjing Ma
- Department of Gastroenterology, First Affliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, P.R. China
| | - Hongjie Zhang
- Department of Gastroenterology, First Affliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, P.R. China
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Nishida M, Hasegawa Y, Hata J. Basic practices for gastrointestinal ultrasound. J Med Ultrason (2001) 2023; 50:285-310. [PMID: 36087155 PMCID: PMC10354189 DOI: 10.1007/s10396-022-01236-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 06/07/2022] [Indexed: 11/28/2022]
Abstract
The standard diagnostic modalities for gastrointestinal (GI) diseases have long been endoscopy and barium enema. Recently, trans-sectional imaging modalities, such as computed tomography and magnetic resonance imaging, have become increasingly utilized in daily practice. In transabdominal ultrasonography (US), the bowel sometimes interferes with the observation of abdominal organs. Additionally, the thin intestinal walls and internal gas can make structures difficult to identify. However, under optimal US equipment settings, with identification of the sonoanatomy and knowledge of the US findings of GI diseases, US can be used effectively to diagnose GI disorders. Thus, the efficacy of GIUS has been gradually recognized, and GIUS guidelines have been published by the World Federation for Ultrasound in Medicine and Biology and the European Federation of Societies for Ultrasound in Medicine and Biology. Following a systematic scanning method according to the sonoanatomy and precisely estimating the layered wall structures by employing color Doppler make diagnosing disease and evaluating the degree of inflammation possible. This review describes current GIUS practices from an equipment perspective, a procedure for systematic scanning, typical findings of the normal GI tract, and 10 diagnostic items in an attempt to help medical practitioners effectively perform GIUS and promote the use of GIUS globally.
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Affiliation(s)
- Mutsumi Nishida
- Diagnostic Center for Sonography, Hokkaido University Hospital, N14 W5, Kita-ku, Sapporo, 060-8648, Japan.
| | - Yuichi Hasegawa
- Department of Clinical Laboratory, Japanese Red Cross Narita Hospital, Narita, Japan
| | - Jiro Hata
- Department of Laboratory Medicine (Endoscopy and Ultrasound), Kawasaki Medical School Hospital, Okayama, Japan
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Lin WC, Chang CW, Chen MJ, Wang HY. Intestinal Ultrasound in Inflammatory Bowel Disease: A Novel and Increasingly Important Tool. J Med Ultrasound 2023; 31:86-91. [PMID: 37576427 PMCID: PMC10413392 DOI: 10.4103/jmu.jmu_84_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/18/2022] [Accepted: 10/26/2022] [Indexed: 08/15/2023] Open
Abstract
New and efficacious medical therapies have become available that have greatly enhanced clinicians' ability to manage inflammatory bowel diseases (IBDs). IBD activity should be assessed regularly in scheduled examinations as the part of a treat-to-target strategy for IBD care. The gold-standard approach to investigating IBD is colonoscopy, but this is an invasive procedure. Intestinal ultrasound (IUS) has played a crucial role in recent years regarding the assessment of IBD activity because it is noninvasive, safe, reproducible, and inexpensive. IUS findings could inform changes in therapeutic interventions for IBDs; this would necessitate fewer endoscopies and enable faster decision-making processes. Furthermore, patients are accepting and tolerant of IUS examinations. This review outlines the current evidence and gives indication regarding the use of IUS in the management of IBDs.
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Affiliation(s)
- Wei-Chen Lin
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- Mackay Medical College, Taipei, Taiwan
| | - Chen-Wang Chang
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- Mackay Medical College, Taipei, Taiwan
| | - Ming-Jen Chen
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- Mackay Medical College, Taipei, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- Mackay Medical College, Taipei, Taiwan
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Gilja OH, Nylund K. Point-of-care Ultrasound of the Gastrointestinal Tract. J Med Ultrasound 2023; 31:1-7. [PMID: 37180631 PMCID: PMC10173834 DOI: 10.4103/jmu.jmu_5_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 01/31/2023] [Indexed: 05/16/2023] Open
Abstract
The widespread use of portable ultrasound scanners has promoted the concept of point of care ultrasound (POCUS), namely "ultrasound performed bedside and interpreted directly by the clinician." The purpose of this short review is to outline how POCUS can be used in patients with diseases of the gastrointestinal (GI) tract. POCUS is not a replacement for comprehensive ultrasound, but rather allows physicians immediate access to clinical imaging for rapid diagnosis and efficient work-up and treatment of the patients. There are many indications for doing POCUS of the GI tract, including abdominal pain, diarrhea, palpable masses, and to detect fluid or free air in the abdominal cavity. To improve the visibility of deeper parts of the abdomen, the graded compression technique with the scan head is useful. During POCUS, the operator should look for signs of severe pathology including target lesions, the pseudo-kidney sign, the onion sign, dilated bowel loops, gastric retention, free fluid, and free air, depending on the actual clinical problem. We conclude that POCUS of the GI tract is very useful to provide a rapid diagnosis in many clinical scenarios.
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Affiliation(s)
- Odd Helge Gilja
- Department of Medicine, National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Address for correspondence: Prof. Odd Helge Gilja, Department of Medicine, National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, 5021 Bergen, Norway. E-mail:
| | - Kim Nylund
- Department of Medicine, National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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10
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Freitas M, de Castro FD, Macedo Silva V, Arieira C, Cúrdia Gonçalves T, Leite S, Moreira MJ, Cotter J. Ultrasonographic scores for ileal Crohn's disease assessment: Better, worse or the same as contrast-enhanced ultrasound? BMC Gastroenterol 2022; 22:252. [PMID: 35585503 PMCID: PMC9118849 DOI: 10.1186/s12876-022-02326-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intestinal ultrasound (IUS) is an increasingly used non-invasive tool to evaluate Crohn's disease (CD) activity. Recently, two IUS scores that evaluate inflammatory activity have emerged: the Simple Ultrasound Activity Score for CD (SUS-CD) and the International Bowel Ultrasound Segmental Activity Score (IBUS-SAS). We aimed to compare the accuracy of SUS-CD, IBUS-SAS and contrast-enhanced ultrasound (CEUS) in predicting inflammatory activity in the terminal ileum in ileocolonoscopy in CD patients. METHODS Retrospective study including all consecutive CD patients submitted to IUS with CEUS directed to the terminal ileum performed by a single operator between April 2016 and March 2020. Segmental SUS-CD and IBUS-SAS were calculated. A time-intensity curve of the contrast bowel wall enhancement was created with measurement of peak intensity using CEUS. The CD endoscopic activity in ileocolonoscopy was graded by Simple Endoscopic Score for CD (SES-CD) as inactive (SES-CD < 7) or active (SES-CD ≥ 7). RESULTS Fifty patients were included, 54.0% were female, with mean age of 34 ± 12 years, and most had isolated ileal disease (60.0%), and a nonstricturing, nonpenetrating behaviour (44.0%). Most of the patients (60.0%) had active endoscopic disease (SES-CD ≥ 7). SUS-CD and IBUS-SAS were not different between patients with active or inactive endoscopic disease (p = 0.15; 0.57, respectively), having a poor accuracy to correlate endoscopic activity (area under de curve (AUC) 0.62; 0.55, respectively). Peak intensity in CEUS was significantly different in patients with active or inactive endoscopic disease (p = 0.004), having a good accuracy to correlate endoscopic activity (AUC 0.80). CONCLUSION Unlike CEUS, SUS-CD and IBUS-SAS were not able to accurately correlate endoscopic activity in terminal ileum in CD. Therefore, CEUS is a non-invasive emerging method that should be increasingly integrated in the ultrasonographic evaluation of CD patients.
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Affiliation(s)
- M Freitas
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal. .,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal. .,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal.
| | - F Dias de Castro
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - V Macedo Silva
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - C Arieira
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - T Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - S Leite
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - M J Moreira
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - J Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
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11
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Velocity-Encoded Phase-Contrast MRI for Measuring Mesenteric Blood Flow in Patients With Newly Diagnosed Small-Bowel Crohn Disease. AJR Am J Roentgenol 2022; 219:132-141. [PMID: 35195433 DOI: 10.2214/ajr.22.27437] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND. Intestinal inflammation is associated with radiologic and histologic hyperemia. A paucity of studies have used MRI to measure mesenteric blood flow in patients with Crohn disease. OBJECTIVE. The purpose of this study was to evaluate the application of velocity-encoded phase-contrast MRI for measuring mesenteric blood flow in patients with newly diagnosed small-bowel Crohn disease. METHODS. This prospective study included 20 patients with ileal Crohn disease newly diagnosed between December 2018 and October 2021 (eight female participants, 12 male participants; median age, 14.0 years), and 15 healthy control participants (eight female participants, seven male participants; median age, 17.0 years). Patients with Crohn disease underwent investigational MRI and laboratory assessments at diagnosis and at 6 weeks and 6 months after initiating anti-tumor necrosis factor-α medical therapy; control participants underwent a single investigational MRI examination. All MRI examinations included a velocity-encoded phase-contrast acquisition, which was used to measure blood flow in the abdominal aorta, superior mesenteric artery (SMA), and superior mesenteric vein (SMV). Mann-Whitney U test was used to compare blood flow measurements (ratios of SMA and SMV blood flow to aorta blood flow [hereafter, SMA-to-aorta and SMV-to-aorta blood flow, respectively]) between groups; Friedman test was used to evaluate temporal changes in blood flow. Spearman correlation was used to assess relationships between blood flow measurements and laboratory markers of intestinal inflammation. Diagnostic performance was assessed by ROC analysis. RESULTS. At baseline, SMA-to-aorta blood flow in patients versus control participants was 0.44 versus 0.30 (p = .003), and SMV-to-aorta blood flow was 0.36 versus 0.21 (p = .002). At 6 weeks and 6 months, SMA-to-aorta blood flow in patients decreased to 0.30 and 0.27 (p < .001), and SMV-to-aorta blood flow decreased to 0.27 and 0.21 (p = .02), respectively. SMA-to-aorta and SMV-to-aorta blood flow were positively correlated with C-reactive protein (rho, 0.34 [p = .01] and 0.35 [p = .008], respectively) and fecal calprotectin (rho, 0.34 [p = .01] vs 0.47 [p < .001]). AUCs for differentiating patients from controls were 0.79 for SMA-to-aorta (sensitivity, 60%; specificity, 100%) and 0.82 for SMV-to-aorta (sensitivity, 75%; specificity, 87%) blood flow. CONCLUSION. Mesenteric blood flow is quantifiable using velocity-encoded phase-contrast MRI. The measurements differ between patients with ileal Crohn disease and healthy control participants and change in response to medical therapy. CLINICAL IMPACT. MRI-based mesenteric blood flow measurements provide a potential novel marker of intestinal inflammation.
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12
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Chen WJ, Luo LL, Dong ZX, Wu J, Gu XX, Bian ZL. Application of transabdominal ultrasound in Crohn's disease. Shijie Huaren Xiaohua Zazhi 2022; 30:364-369. [DOI: 10.11569/wcjd.v30.i8.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease (CD), a chronic nonspecific intestinal inflammatory disorder of uncertain origin, is collectively referred to as inflammatory bowel disease with ulcerative colitis. In recent years, with the increasing incidence of CD, a greater demand has been put forward for disease diagnosis and inflammatory activity monitoring. With the development of ultrasound technology, transabdominal ultrasound has become more relevant for the diagnosis and follow-up of CD, providing an effective non-invasive examination tool for patients. This review summarizes several transabdominal ultrasound modalities and associated techniques that are presently being developed and utilized in clinical practice, describes the ultrasound manifestations of CD, and discusses the value and prospect of transabdominal ultrasonography in CD.
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Affiliation(s)
- Wei-Jie Chen
- Nantong University, Nantong 226001, Jiangsu Province, China
| | - Lei-Lei Luo
- Department of Gastroenterology, Affiliated Nantong Third Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Zhi-Xing Dong
- Nantong University, Nantong 226001, Jiangsu Province, China
| | - Jing Wu
- Department of Gastroenterology, Affiliated Nantong Third Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Xing-Xing Gu
- Department of Gastroenterology, Affiliated Nantong Third Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Zhao-Lian Bian
- Department of Gastroenterology, Affiliated Nantong Third Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
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13
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Sævik F, Gilja OH, Nylund K. Gastrointestinal Ultrasound Can Predict Endoscopic Activity in Crohn's Disease. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2022; 43:82-89. [PMID: 32330994 DOI: 10.1055/a-1149-9092] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE To explore the ability of gastrointestinal ultrasound (GIUS) to separate patients in endoscopic remission from patients with active disease in a heterogeneous hospital cohort with Crohn's disease (CD). MATERIALS AND METHODS 145 CD patients scheduled for ileocolonoscopy were prospectively included. The endoscopic disease activity was quantified using the Simple Endoscopic Score for Crohn's disease (SES-CD), and mucosal healing was strictly defined as SES-CD = 0. Ultrasound remission was defined as wall thickness < 3 mm (< 4 mm in the rectum). Additionally, SES-CD was compared to color Doppler, Harvey Bradshaw's index (HBI), C-reactive protein (CRP) and calprotectin. 23 patients were examined by two investigators for interobserver assessment. RESULTS 102 had active disease and 43 patients were in remission. GIUS yielded a sensitivity of 92.2 % and a specificity of 86 % for wall thickness and a sensitivity of 66.7 % and a specificity of 97.7 % for color Doppler. The sensitivity and specificity were 34.3 % and 88.4 %, respectively, for HBI, 35.7 % and 82.9 %, respectively, for CRP and 55.9 % and 82.1 %, respectively, for calprotectin. The interobserver analysis revealed excellent agreement for wall thickness (k = 0.90) and color Doppler (k = 0.91) measurements. CONCLUSION GIUS has a high sensitivity for detecting endoscopic activity. Accordingly, bowel ultrasound has the potential to reduce the number of routine ileocolonoscopies in patients with CD.
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Affiliation(s)
- Fredrik Sævik
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway
| | - Odd Helge Gilja
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway
| | - Kim Nylund
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Norway
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14
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Dolinger MT, Choi JJ, Phan BL, Rosenberg HK, Rowland J, Dubinsky MC. Use of Small Bowel Ultrasound to Predict Response to Infliximab Induction in Pediatric Crohn's Disease. J Clin Gastroenterol 2021; 55:429-432. [PMID: 32453126 DOI: 10.1097/mcg.0000000000001367] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/22/2020] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Michael T Dolinger
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jungwhan J Choi
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY.,Department of Radiology, Boston Children's Hospital, Boston, MA
| | - Becky L Phan
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - John Rowland
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Marla C Dubinsky
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
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15
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Ripollés T, Poza J, Suarez Ferrer C, Martínez-Pérez MJ, Martín-Algíbez A, de Las Heras Paez B. Evaluation of Crohn's Disease Activity: Development of an Ultrasound Score in a Multicenter Study. Inflamm Bowel Dis 2021; 27:145-154. [PMID: 32507880 DOI: 10.1093/ibd/izaa134] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Our goal in this multicentric prospective study was 2-fold: first, to test the diagnostic accuracy of ultrasound, color Doppler imaging (CDI), and contrast-enhanced ultrasound (CEUS) in identifying disease activity in patients with Crohn's disease (CD) compared with endoscopy as the reference standard; and, second, to construct a sonographic score that allows disease activity to be detected. MATERIALS AND METHODS Seventy-two patients with CD from 3 hospitals underwent within a 30-day period both colonoscopy and ultrasound (US), including mural thickness, CDI, and CEUS, prospectively as part of clinical care. A multivariate analysis was carried out to assess the influence of each of the ultrasound variables in predicting endoscopic activity. We then developed a predictive ultrasound score for disease activity, and a receiver operating characteristic (ROC) curve was constructed to determine the area under the ROC curve (AUC) and the best cut-off score value to discriminate between active and inactive disease. RESULTS Sonographic findings that were independent predictors of the presence of active disease at endoscopy were wall thickness, color grade, and contrast parameters. A score based on those variables showed high accuracy in predicting active disease, with an area under the ROC curve of 0.972. A simpler index, without contrast parameters, also showed high accuracy in detecting disease activity (AUC, 0.923). CONCLUSION A score based on wall thickness, color Doppler grade, and contrast parameters showed high accuracy in predicting active disease. A score without including the use of contrast agent had practically similar results and is easier to use in monitoring response to treatment.
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Affiliation(s)
- Tomás Ripollés
- Department of Radiology, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Joaquín Poza
- Department of Gastroenterology, Hospital Universitario La Paz, Madrid, Spain
| | | | | | - Ana Martín-Algíbez
- Department of Gastroenterology, Hospital Universitario 12 Octubre, Madrid, Spain
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16
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Ripollés T, Muñoz F, Martínez-Pérez M, de Miguel E, Poza Cordón J, de la Heras Páez de la Cadena B. Usefulness of intestinal ultrasound in inflammatory bowel disease. RADIOLOGIA 2021. [DOI: 10.1016/j.rxeng.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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17
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Celikyay F, Yuksekkaya R, Yuksekkaya M, Kefeli A. Color Doppler Ultrasound Assessment of Clinical Activity in Inflammatory Bowel Disease. Curr Med Imaging 2020; 17:741-750. [PMID: 33371856 DOI: 10.2174/0929867328666201228124621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 10/03/2020] [Accepted: 10/14/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Ulcerative colitis (UC) and Crohn's disease (CD) are two varieties of inflammatory bowel disease (IBD). Clinicians need a monitoring technique in the IBD. The disease activity can be assessed with endoscopy, activity indexes, and imaging techniques. Color Doppler US (CDUS) is also a non-invasive, radiation, and contrast material free examination which shows the intramural blood flow. OBJECTIVE To evaluate the usefulness of B-mode, CDUS, and a newly developed software Color Quantification (CQ) to determine the activity of the IBD. METHODS The disease activity was assessed by clinical activity indexes. Caecum, terminal ileum, ascending colon, transverse colon, and descending colon were evaluated by B-mode, CDUS, and the CQ. Bowel wall thickness (BWT), loss of bowel stratification, loss of haustration, and the presence of enlarged lymph nodes, mesenteric masses, abscesses, fistula, visual vascular signal patterns of the bowel as "hypo and hyper-flow" and the CQ values were investigated. BWT was compared with laboratory results and clinical activities. Vascular signal patterns and the CQ values were compared with BWT and clinical activity. The diagnostic performances of the CQ were investigated. RESULTS Fifty-two patients with IBD were evaluated. Patients with increased BWT at the transverse colon had an increased frequency of "hyper-flow" pattern. Clinically active patients had an increased incidence of "hyper-flow" pattern at the terminal ileum, ascending colon, and whole segments. They had increased CQ values at the terminal ileum, ascending colon, and descending colon, and whole segments. A cut-off value for the CQ (24.7%) was obtained at the terminal ileum. In the diagnostic performances of CQ, we observed utilities significantly at the ascending colon, descending colon, terminal ileum, and whole segments. There was a positive correlation between the CQ values and BWT at the caecum, ascending colon, transverse colon, and descending colon. CONCLUSION Increased visual vascular signal scores and CQ values might be useful for monitoring the disease activity in patients with IBD.
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Affiliation(s)
- F Celikyay
- Department of Radiology, Gaziosmanpasa University School of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - R Yuksekkaya
- Department of Radiology, Gaziosmanpasa University School of Medicine, Gaziosmanpasa University, Tokat, Turkey
| | - M Yuksekkaya
- Department of Biomedical Engineering, Faculty of Engineering, Baskent University, Ankara, Turkey
| | - A Kefeli
- Department of Gastroentereology, Gaziosmanpasa University School of Medicine, Gaziosmanpasa University, Tokat, Turkey
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18
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Muñoz F, Ripollés T, Poza Cordón J, de Las Heras Páez de la Cadena B, Martínez-Pérez MJ, de Miguel E, Zabana Y, Mañosa Ciria M, Beltrán B, Barreiro-de Acosta M. Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the use of abdominal ultrasound in inflammatory bowel disease. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 44:158-174. [PMID: 33309386 DOI: 10.1016/j.gastrohep.2020.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/22/2020] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Fernando Muñoz
- Servicio de Digestivo. Complejo Asistencial Universitario de Salamanca, España.
| | - Tomás Ripollés
- Servicio Radiodiagnóstico, Hospital Universitario Dr. Peset, Valencia, España
| | - Joaquín Poza Cordón
- Servicio de Aparato Digestivo del Hospital Universitario La Paz, Madrid, España
| | | | | | - Enrique de Miguel
- Servicio de Radiodiagnóstico, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Yamile Zabana
- Servicio de Gastroenterología, Unidad de Enfermedad Inflamatoria Intestinal, Hospital Universitari Mútua de Terrassa, CIBERehd, Barcelona, España
| | - Miriam Mañosa Ciria
- Unidad de EII. Servei d'Aparell digestiu. Hospital Universitari Germans Trias i Pujol, CIBERehd, Barcelona, España
| | - Belén Beltrán
- Servicio de Medicina Digestiva, Hospital Universitario La Fe, CIBERehd, Valencia, España
| | - Manuel Barreiro-de Acosta
- Unidad EII. Servicio de Aparato Digestivo. Hospital Clínico Universitario de Santiago, A Coruña, España
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19
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Ripollés T, Muñoz F, Martínez-Pérez MJ, de Miguel E, Cordón JP, de la Heras Páez de la Cadena B. Usefulness of intestinal ultrasound in inflammatory bowel disease. RADIOLOGIA 2020; 63:89-102. [PMID: 33189372 DOI: 10.1016/j.rx.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/30/2020] [Accepted: 10/02/2020] [Indexed: 02/07/2023]
Abstract
Imaging techniques play a fundamental role in the initial diagnosis and follow-up of inflammatory bowel disease. Intestinal ultrasound has high sensitivity and specificity in patients with suspected Crohn's disease and in the detection of inflammatory activity. This technique enables the early diagnosis of intra-abdominal complications such as stenosis, fistulas, and abscesses. It has also proven useful in monitoring the response to treatment and in detecting postsurgical recurrence. Technical improvements in ultrasound scanners, technological advances such as ultrasound contrast agents and elastography, and above all increased experience have increased the role of ultrasound in the evaluation of the gastrointestinal tract. The features that make ultrasound especially attractive include its wide availability, its noninvasiveness and lack of ionizing radiation, its low cost, and its good reproducibility, which is important because it is easy to repeat the study and the study is well tolerated during follow-up. This review summarizes the role of intestinal ultrasound in the detection and follow-up of inflammatory bowel disease.
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Affiliation(s)
- T Ripollés
- Servicio de Radiología, Hospital Dr. Peset, Valencia, España.
| | - F Muñoz
- Servicio de Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca, España
| | | | - E de Miguel
- Servicio de Radiología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J Poza Cordón
- Servicio de Digestivo, Hospital Universitario La Paz, Madrid, España
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20
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Arndt H, Hauenstein C, Weber MA, Däbritz J, Bierwirth C. [Imaging of chronic inflammatory bowel diseases in childhood and adolescence : Repetitorium]. Radiologe 2020; 60:1085-1096. [PMID: 33048221 DOI: 10.1007/s00117-020-00755-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Chronic inflammatory bowel diseases can already occur in childhood and in contrast to affected adults, are more frequently manifested as unspecific symptoms. Therefore, at the time of diagnosis the gastrointestinal tract may already be severely affected. Both the diagnostic methods and the treatment concept, which is ideally carried out by pediatric gastroenterologists, differ from those used in adults. The primary diagnostics mainly include sonography and hydro-magnetic resonance imaging (MRI), whereby each modality offers certain advantages depending on the patient and the examiner but is also subject to limitations in terms of feasibility and evaluation. Imaging diagnostics contribute not only to finding the diagnosis but also to assessing the extent of the disease. They also serve to monitor the course of the disease in terms of treatment response or failure, to assess the activity and to detect and quantify possible complications, such as fistulas or abscesses.
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Affiliation(s)
- H Arndt
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland.
| | - C Hauenstein
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
| | - M-A Weber
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
| | - J Däbritz
- Kinder- und Jugendklinik, Universitätsmedizin Rostock, Rostock, Deutschland
| | - C Bierwirth
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
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21
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Kakkadasam Ramaswamy P, Vizhi N K, Yelsangikar A, Krishnamurthy AN, Bhat V, Bhat N. Utility of bowel ultrasound in assessing disease activity in Crohn's disease. Indian J Gastroenterol 2020; 39:495-502. [PMID: 33201441 DOI: 10.1007/s12664-020-01019-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/04/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Gastrointestinal ultrasound (GIUS) has been used increasingly for monitoring inflammatory bowel disease (IBD) patients. The aim of this study was to assess the utility of GIUS in assessing disease activity in Crohn's disease (CD). METHODS Consecutive patients with CD (diagnosis established for at least 6 months) between July 2017 and July 2018 requiring assessment of disease activity were prospectively assessed by magnetic resonance enterography, colonoscopy (CS), and GIUS within a 2-week period and without any change in ongoing treatment. Features on GIUS which correlated with disease activity were assessed. Sensitivity and specificity of the GIUS in assessing disease activity and localization were calculated. RESULTS Thirty-five patients were enrolled in the study. Bowel wall thickness (BWT) ≥ 3 mm and Doppler activity ≥ 2 had the highest sensitivity (100% and 95.6%, respectively) for detecting active disease on CS. BWT ≥ 3 mm had sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 83.3%, 92%, and 100%, respectively for assessing active disease. Combination of median BWT, Doppler activity, and loss of bowel wall stratification correlated with simplified endoscopic score (SES) for CD (r = 0.8, p 0.009) and Harvey-Bradshaw index (HBI, r = 0.76, p 0.04). For localizing active disease in the ileum, GIUS had a sensitivity of 93.7%, 80% for lesions in the right colon, 100% for transverse colon, and 89% for the left colon. Specificity was 100% for ileal and colonic lesions. CONCLUSION Loss of stratification, BWT, and Doppler activity in the bowel wall correlate with endoscopic and clinical disease activity in CD. GIUS is a sensitive modality in assessing disease activity in CD.
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Affiliation(s)
- Pradeep Kakkadasam Ramaswamy
- Department of Gastroenterology, Liver Diseases and Clinical Nutrition, Aster CMI Hospital, #43/2, International Airport Road, Sahakar Nagar, Bangalore, 560 092, India.
| | - Kayal Vizhi N
- Department of Gastroenterology, Liver Diseases and Clinical Nutrition, Aster CMI Hospital, #43/2, International Airport Road, Sahakar Nagar, Bangalore, 560 092, India
| | - Amit Yelsangikar
- Department of Gastroenterology, Liver Diseases and Clinical Nutrition, Aster CMI Hospital, #43/2, International Airport Road, Sahakar Nagar, Bangalore, 560 092, India
| | - Anupama Nagar Krishnamurthy
- Department of Gastroenterology, Liver Diseases and Clinical Nutrition, Aster CMI Hospital, #43/2, International Airport Road, Sahakar Nagar, Bangalore, 560 092, India
| | - Vinay Bhat
- Department of Surgery and Allied Sciences, Aster CMI Hospital, Bangalore 560 092, India
| | - Naresh Bhat
- Department of Gastroenterology, Liver Diseases and Clinical Nutrition, Aster CMI Hospital, #43/2, International Airport Road, Sahakar Nagar, Bangalore, 560 092, India
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Ferreira-Duarte M, Sousa JB, Diniz C, Sousa T, Duarte-Araújo M, Morato M. Experimental and Clinical Evidence of Endothelial Dysfunction in Inflammatory Bowel Disease. Curr Pharm Des 2020; 26:3733-3747. [PMID: 32611296 DOI: 10.2174/1381612826666200701212414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/04/2020] [Indexed: 02/07/2023]
Abstract
The endothelium has a crucial role in proper hemodynamics. Inflammatory bowel disease (IBD) is mainly a chronic inflammatory condition of the gastrointestinal tract. However, considerable evidence points to high cardiovascular risk in patients with IBD. This review positions the basic mechanisms of endothelial dysfunction in the IBD setting (both clinical and experimental). Furthermore, we review the main effects of drugs used to treat IBD in endothelial (dys)function. Moreover, we leave challenging points for enlarging the therapeutic arsenal for IBD with new or repurposed drugs that target endothelial dysfunction besides inflammation.
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Affiliation(s)
| | | | - Carmen Diniz
- LAQV@REQUIMTE, University of Porto, Porto, Portugal
| | - Teresa Sousa
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
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Sævik F, Eriksen R, Eide GE, Gilja OH, Nylund K. Development and Validation of a Simple Ultrasound Activity Score for Crohn's Disease. J Crohns Colitis 2020; 15:115-124. [PMID: 32504533 PMCID: PMC7805799 DOI: 10.1093/ecco-jcc/jjaa112] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS To improve management of patients with Crohn's disease, objective measurements of disease activity are needed. Ileocolonoscopy is the current reference standard but has limitations that restrict repeated use. Ultrasonography is potentially useful for activity monitoring, but no validated sonographic activity index is currently in widespread use. Thus, we aimed to construct and validate a simple ultrasound score for Crohn's disease. METHODS Forty patients were prospectively examined with ultrasound and endoscopy in the development phase. The Simple Endoscopic Score for Crohn's Disease [SES-CD] was used as a reference standard. Seven ultrasound variables [bowel wall thickness, length, colour Doppler, stenosis, fistula, stratification and fatty wrapping] were initially included, and multiple linear regression was used to select the variables that should be included in the final score. Second, the ultrasound data from each patient were re-examined for interobserver assessment using weighted kappa and intraclass correlation. Finally, the activity index was validated in a new cohort of 124 patients. RESULTS Length, fistula and stenosis were excluded. The combination of the remaining variables provided a multiple correlation coefficient of r = 0.78. Interobserver analysis revealed poor agreement for stratification and fatty wrapping and these were thus excluded. There was excellent interobserver agreement for the remaining score consisting of wall thickness and colour Doppler. In both patient cohorts, the ultrasound score correlated well with SES-CD [Development cohort: rho = 0.83, p < 0.001, Validation cohort: rho = 0.78, p < 0.001]. A receiver operating characteristic curve analysis revealed an area under the curve of 0.92 and 0.88 for detecting endoscopic activity and moderate endoscopic activity, respectively. CONCLUSIONS A simple ultrasound activity index for Crohn's disease consisting of bowel wall thickness and colour Doppler was constructed and validated and correlated well with endoscopic disease activity.ClinicalTrials. gov ID: NCT03481751.
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Affiliation(s)
- Fredrik Sævik
- Department of Clinical Medicine, University of Bergen, Bergen, Norway,National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway,Corresponding author: Fredrik Sævik, MD, Department of Clinical Medicine, University of Bergen, Haukeland University Hospital, Jonas Lies vei, N-5021 Bergen, Norway. Tel: +47 40 01 39 10; Fax: + 47 55 97 29 50;
| | - Ragnar Eriksen
- Department of Medicine, Ålesund Hospital, Ålesund, Norway
| | - Geir Egil Eide
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway,Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Odd Helge Gilja
- Department of Clinical Medicine, University of Bergen, Bergen, Norway,National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - Kim Nylund
- Department of Clinical Medicine, University of Bergen, Bergen, Norway,National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
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Radiologische Diagnostik chronisch-entzündlicher Darmerkrankungen bei Kindern und Jugendlichen. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-00854-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ZusammenfassungDank der technischen Fortschritte nehmen bildgebende Methoden eine immer wichtigere Rolle sowohl in der Diagnostik als auch im klinischen Management chronisch-entzündlicher Darmerkrankungen (CED), insbesondere in der Pädiatrie, ein. Dieser Beitrag fokussiert charakteristische Erscheinungsformen der CED und jeweils relevante bildgebende Verfahren (Ultraschall und MRT). Außerdem werden Forschungstrends und aktueller Wissensstand zu verschiedenen bildgebenden Modalitäten dargestellt.
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van Wassenaer EA, de Voogd FAE, van Rijn RR, van der Lee JH, Tabbers MM, van Etten-Jamaludin FS, Gecse KB, Kindermann A, de Meij TGJ, D’Haens GR, Benninga MA, Koot BGP. Diagnostic Accuracy of Transabdominal Ultrasound in Detecting Intestinal Inflammation in Paediatric IBD Patients-a Systematic Review. J Crohns Colitis 2019; 13:1501-1509. [PMID: 31329839 PMCID: PMC7142400 DOI: 10.1093/ecco-jcc/jjz085] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Elsa A van Wassenaer
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands,Corresponding author: Elsa A. van Wassenaer, MD, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands.
| | - Floris A E de Voogd
- Amsterdam UMC, University of Amsterdam, Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | - Rick R van Rijn
- Amsterdam UMC, University of Amsterdam, Radiology, Amsterdam, The Netherlands
| | - Johanna H van der Lee
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Clinical Research Office, Amsterdam, The Netherlands
| | - Merit M Tabbers
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | | | - Krisztina B Gecse
- Amsterdam UMC, University of Amsterdam, Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | - Angelika Kindermann
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Tim G J de Meij
- Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Geert R D’Haens
- Amsterdam UMC, University of Amsterdam, Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | - Marc A Benninga
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Bart G P Koot
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
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Sarno A, Varello S, Debani P, Bonenti G, Robotti D. Intestinal ultrasonography in adults with Crohn's disease: a 2020 update. MINERVA GASTROENTERO 2019; 65:335-345. [PMID: 31760739 DOI: 10.23736/s1121-421x.19.02638-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the last years intestinal ultrasonography (IUS) has increased its role in the management of inflammatory bowel diseases (IBD), that include Crohn's disease (CD) and ulcerative colitis. This is due to the fact that IUS is a non-invasive, inexpensive, and well-tolerated examination technique. Furthermore, it allows a real-time diagnosis with no radiation exposure. Usually, convex and linear probes with frequency between 3.5 and 12 MHz are used, also with the Color- Power Doppler. Focusing on CD, the IUS images of clinical interest are: bowel wall thickening (greater than 3 mm), pseudostratification and the wall vascularization. Moreover, IUS demonstrates inflammatory mass, loss of colonic haustration and the complications of the disease, such as stenosis, abscesses, and fistulas as well as other extraintestinal manifestations, such as lymph node enlargement and changes in the appearance of the mesenteric adipose tissue (creeping fat). Oral and intravenous contrast are used to obtain a better visualization of the bowel wall and to increase the diagnostic accuracy of IUS. In particular, intravenous contrast, administered during the procedure, allows to differentiate between active disease (bowel wall enhancement) and the fibrostenotic complications. Contrast-enhanced ultrasonography (CEUS) was proven to be useful in the follow-up and the disease recurrence detection. Beyond the support in the initial diagnosis, IUS has an important role in the follow-up of patients with CD, to monitor the response to the medical therapy and to detect possible complications. Furthermore, it can predict the recurrences after surgery, with more accuracy if Color-Doppler is used.
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Affiliation(s)
- Antonino Sarno
- Unit of Radiodiagnostics 2, AOU Città della Salute e della Scienza di Torino, Turin, Italy -
| | - Sara Varello
- Unit of Radiodiagnostics 2, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Paola Debani
- Unit of Radiodiagnostics 2, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Giovanni Bonenti
- Unit of Radiodiagnostics 2, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Daniela Robotti
- Unit of Radiodiagnostics 2, AOU Città della Salute e della Scienza di Torino, Turin, Italy
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Goyal P, Shah J, Gupta S, Gupta P, Sharma V. Imaging in discriminating intestinal tuberculosis and Crohn's disease: past, present and the future. Expert Rev Gastroenterol Hepatol 2019; 13:995-1007. [PMID: 31559871 DOI: 10.1080/17474124.2019.1673730] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Intestinal tuberculosis (ITB) and Crohn's disease (CD) have similar clinical presentation, but require different treatment approaches. Despite advances in various endoscopic, imaging, microbiological, and histological techniques, the differentiation of these two entities is often difficult. Newer radiological and image acquisition modalities have now become indispensable tools for evaluation of these two diseases.Areas covered: This review summarizes the currently available literature on various radiological investigations to differentiate ITB from CD. This review also enumerates the newer modalities in image acquisition techniques and their potential role for differentiating these two diseases. At present abdominal computed tomography (CT) scan is used as a first line investigation for differentiating ITB from CD. Magnetic resonance imaging (MRI) is preferred in pediatric patients and for follow-up studies.Expert opinion: Role of newer modalities like contrast enhanced abdominal ultrasound, perfusion CT, advanced MRI and positron emission tomography (PET) is evolving and requires further exploration. Till further robust studies are available, differentiation between ITB and CD requires use of a combination of clinical, endoscopic, serological, histological, and radiological parameters rather than relying on a single test.
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Affiliation(s)
- Pradeep Goyal
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sonali Gupta
- Department of Medicine, St. Vincent's Medical Center, Bridgeport, CT, USA.,Department of Medicine, The Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, CT, USA
| | - Pankaj Gupta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Dynamic gut microbiome changes following regional intestinal lymphatic obstruction in primates. ACTA ACUST UNITED AC 2019; 26:253-261. [PMID: 31301989 DOI: 10.1016/j.pathophys.2019.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/24/2019] [Accepted: 06/26/2019] [Indexed: 12/15/2022]
Abstract
The pathogenesis of inflammatory bowel disease (IBD) has been linked with lymphostasis, but whether and how lymphatic obstruction might disturb the intestinal microbiome in the setting of Crohn's Disease (CD) is currently unknown. We employed a new model of CD in African Green monkeys, termed 'ATLAS' (African green monkey truncation of lymphatics with obstruction and sclerosis), to evaluate how gut lymphatic obstruction alters the intestinal microbiome at 7, 21 and 61 days. Remarkable changes in several microbial sub- groupings within the gut microbiome were observed at 7 days post-ATLAS compared to controls including increased abundance of Prevotellaceae and Bacteroidetes-Prevotella-Porphyromonas (BPP), which may contribute to disease activity in this model of gut injury. To the best of our knowledge, these findings represent the first report linking lymphatic structural/gut functional changes with alterations in the gut microbiome as they may relate to the pathophysiology of CD.
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Intravenous Contrast-Enhanced Ultrasound for Assessing and Grading Postoperative Recurrence of Crohn's Disease. Dig Dis Sci 2019; 64:1640-1650. [PMID: 30604372 DOI: 10.1007/s10620-018-5432-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 12/12/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE The aim was to investigate the contribution of contrast-enhanced ultrasound (CEUS) to improve the results of US in the evaluation of recurrence in postsurgical Crohn's disease (CD) and establish its role in the assessment of the severity. METHODS Anastomotic site was assessed in 108 postsurgical CD patients with B-mode, color Doppler and CEUS. Bowel wall thickness (WT), transmural complications or stenosis, color Doppler grade, and bowel wall contrast enhancement (BWCE)-using time-intensity curves-were correlated with endoscopic Rutgeerts score. A receiver operating characteristic (ROC) curve was built to establish the best cutoff to predict recurrence and the severity. A US scoring system was elaborated in order to determine the grade of recurrence. RESULTS Ileocolonoscopy detected recurrence in 90 (83.3%) subjects and severe recurrence in 62. WT ≥ 3 mm had an accuracy of 90.7% in the detection of endoscopic recurrence. The combination of parameters-WT ≥ 3 mm and BWCE (≥ 46%)-demonstrated similar accuracy (90.7%). A WT ≥ 5 mm showed the best specificity (100%) for the diagnosis of recurrence and a WT ≥ 6 mm the best specificity (95.7%) for the detection of severe recurrence. The combination of sonographic parameters-WT ≥ 6 mm or WT between 5 and 6 mm with BWCE ≥ 70%, or complications-obtained the best results grading the recurrence (sensitivity, specificity, and accuracy of 90.3%, 87%, and 88.9%, respectively). CONCLUSIONS US shows high sensitivity and specificity for the diagnosis of postsurgical recurrence. When combined with CEUS, it can improve the detection of severe recurrence.
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Ripollés T, Martínez-Pérez MJ, Paredes JM, Vizuete J, Martin G. The Role of Intravenous Contrast Agent in the Sonographic Assessment of Crohn's Disease Activity: Is Contrast Agent Injection Necessary? J Crohns Colitis 2019; 13:585-592. [PMID: 30535070 DOI: 10.1093/ecco-jcc/jjy204] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Contrast-enhanced ultrasound [CEUS] is reported to be superior to wall thickness or colour Doppler imaging [CDI] in predicting disease activity using endoscopy as the reference standard. Our aims were to determine in patients with Crohn's disease [CD] whether the evaluation of wall thickness or CDI before CEUS examination could help to decide when the injection of contrast agent is justified as a means for detecting disease activity as determined at endoscopy, without reducing the accuracy of ultrasound. METHODS In total, 180 patients with CD underwent both colonoscopy and ultrasound, including mural thickness, CDI and CEUS evaluation, prospectively as part of clinical care. A receiver operating characteristic curve was constructed to determine the area under the curve and the best cutoff of wall thickness and ultrasound enhancement value to discriminate between endoscopically active and inactive disease. Several analyses were carried out to determine which parameter or combination of parameters best detected endoscopic activity. RESULTS Comparative evaluation of the different analysis showed that wall thickness alone classified 76.6% of patients correctly, CDI alone 72.7%, and thickness plus CDI 72.2%. The use of CEUS significantly improved the diagnosis of active disease: CEUS alone correctly classified 164 of 180 patients [91.1%], combined analysis of CDI and CEUS 165 of 180 [91.7%], and combined analysis of thickness, CDI and CEUS 164 of 180 [91.1%], without significant differences. Patients with CDI grade 2 or 3 showed a predictive positive value of 97% to detect disease activity, similar to CEUS [100%]. CONCLUSION CEUS is the most reliable ultrasound criterion for endoscopic disease activity. However, the use of a contrast agent is probably not justified to assess disease activity for patients with CDI grade 2/3.
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Affiliation(s)
- Tomás Ripollés
- Department of Radiology, Hospital Universitario Dr. Peset, Valencia, Spain
| | | | - José María Paredes
- Department of Gastroenterology, Hospital Universitario Dr. Peset, Valencia, Spain
| | - José Vizuete
- Department of Radiology, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Gregorio Martin
- Department of Radiology, Hospital Universitario Dr. Peset, Valencia, Spain
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Jimbo K, Ohtsuka Y, Kono T, Arai N, Kyoudo R, Hosoi K, Aoyagi Y, Kudo T, Asai N, Shimizu T. Ultrasonographic study of intestinal Doppler blood flow in infantile non-IgE-mediated gastrointestinal food allergy. Allergol Int 2019; 68:199-206. [PMID: 30249378 DOI: 10.1016/j.alit.2018.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/06/2018] [Accepted: 08/28/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although non-IgE-mediated gastrointestinal food allergy has increased rapidly in Japan, a small number of reports has evaluated B-mode and Doppler ultrasonographic findings in the acute phase of infantile gastrointestinal milk allergy. The aim of the present study was to compare the diagnostic utility of ultrasonographic findings and laboratory allergic data in non-IgE-mediated infantile gastrointestinal milk allergy. METHODS Sixteen cases of active non-IgE-mediated infantile gastrointestinal milk allergy, diagnosed by food elimination tests and oral food challenge tests (OFCTs) (group A), 15 cases of acute viral gastroenteritis (AGE) (group B), and 15 controls (group C) were enrolled. 1) B-mode abdominal ultrasound findings, 2) laboratory allergic data including eosinophil counts (Eos), serum IgE, and the antigen-specific lymphocyte proliferation test (ALPT) against milk protein, and 3) vessel density (VD) indirectly quantified by gastrointestinal Doppler flow at jejunum, ileum, and sigmoid colonic mucosae were evaluated and compared among the groups. RESULTS In the small intestine, wall thickening, dilation, mesenteric thickening, and poor peristalsis were found in 100%, 62.5%, 93.7%, and 100%, respectively, in group A. Eos, IgE, ALPT, and VD were positive in 25.0%, 0%, 87.5%, and 100%, respectively, in group A. Small intestinal VD was significantly greater in group A than in groups B (jejunum p < .001; ileum p < .001) and C (jejunum p < .001; ileum p < .001), with no significant differences between groups B and C (jejunum: p = .74; ileum: p = .73). CONCLUSIONS Abdominal Doppler ultrasonography and small intestinal VD at symptomatic state can support the diagnosis and evaluation of non-IgE-mediated infantile gastrointestinal milk allergy with symptoms of vomiting, diarrhea, and failure to thrive.
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Wilkens R, Wilson A, Burns PN, Ghosh S, Wilson SR. Persistent Enhancement on Contrast-Enhanced Ultrasound Studies of Severe Crohn's Disease: Stuck Bubbles? ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:2189-2198. [PMID: 30076030 DOI: 10.1016/j.ultrasmedbio.2018.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/16/2018] [Accepted: 06/25/2018] [Indexed: 06/08/2023]
Abstract
A small population of patients with severe Crohn's disease (CD) exhibit atypical lack of intensity decline on intestinal contrast-enhanced ultrasound. From a retrospective CD cohort examined with contrast-enhanced ultrasound, 104 patients were identified. Twenty study patients with severe active disease exhibited high peak enhancement (>23 dB) and minimal decline. From the same cohort, 84 control patients also exhibited high peak enhancement >23dB, but with typical intensity decline. Patient outcomes were assessed. Time-intensity curve analysis revealed a significantly higher (p < 0.0001) area under the curve (44.7 ± 1.5 dB·s), washout time and intensities at 60s and 120s in the study population compared with controls (40.0 ± 1.1 dB·s). Study patients had a worse overall outcome with surgery in 30% versus 10% (p = 0.027) during follow-up. Heightened enhancement with lack of decline on contrast-enhanced ultrasound suggests microbubbles are stuck within the inflamed bowel wall for an extended period. This observation occurs in patients with severe disease and a bad outcome.
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Affiliation(s)
- Rune Wilkens
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra Wilson
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter N Burns
- Department of Medical Imaging Research, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Subrata Ghosh
- Department of Medicine, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Stephanie R Wilson
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada.
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Paediatric bowel ultrasound in inflammatory bowel disease. Eur J Radiol 2018; 108:21-27. [DOI: 10.1016/j.ejrad.2018.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 08/30/2018] [Accepted: 09/03/2018] [Indexed: 01/10/2023]
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Gauci J, Sammut L, Sciberras M, Piscopo N, Micallef K, Cortis K, Ellul P. Small bowel imaging in Crohn's disease patients. Ann Gastroenterol 2018; 31:395-405. [PMID: 29991884 PMCID: PMC6033758 DOI: 10.20524/aog.2018.0268] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 02/27/2018] [Indexed: 12/15/2022] Open
Abstract
Crohn’s disease (CD) is a lifelong, chronic inflammatory bowel disorder. The small bowel (SB) is involved to varying extents, and the clinical course may vary from an inflammatory type to a more complicated one with stricture, fistula, and abscess formation. Esophagogastroduodenoscopy and ileocolonoscopy with biopsies are the conventional endoscopic techniques that usually establish the diagnosis. On the other hand, CD may affect SB segments that cannot be reached through these procedures. Video capsule endoscopy and enteroscopy are additional endoscopic techniques that may allow further SB evaluation in such circumstances. Computed tomographic enterography, magnetic resonance enterography, and ultrasonography are radiologic techniques that serve as a crucial adjunct to endoscopic assessment. They enable the assessment of parts of the bowel that may be difficult to reach with conventional endoscopy; this allows for the detection of active inflammation, penetrating or stricturing disease, and the appreciation of extraintestinal complications. Both endoscopic and radiologic modalities play a role in establishing the diagnosis of CD, as well as determining the disease extent, activity and response to therapy. This review is intended to evaluate these modalities in terms of specificity, sensitivity, potential side-effects, and limiting factors. This should serve as a guide to the clinician for establishing the most appropriate and reliable test within a particular clinical context.
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Affiliation(s)
- James Gauci
- Division of Gastroenterology (James Gauci, Martina Sciberras, Naomi Piscopo, Pierre Ellul), Mater Dei Hospital, Malta
| | - Lara Sammut
- Department of Medical Imaging (Lara Sammut, Kristian Micallef, Kelvin Cortis), Mater Dei Hospital, Malta
| | - Martina Sciberras
- Division of Gastroenterology (James Gauci, Martina Sciberras, Naomi Piscopo, Pierre Ellul), Mater Dei Hospital, Malta
| | - Naomi Piscopo
- Division of Gastroenterology (James Gauci, Martina Sciberras, Naomi Piscopo, Pierre Ellul), Mater Dei Hospital, Malta
| | - Kristian Micallef
- Department of Medical Imaging (Lara Sammut, Kristian Micallef, Kelvin Cortis), Mater Dei Hospital, Malta
| | - Kelvin Cortis
- Department of Medical Imaging (Lara Sammut, Kristian Micallef, Kelvin Cortis), Mater Dei Hospital, Malta
| | - Pierre Ellul
- Division of Gastroenterology (James Gauci, Martina Sciberras, Naomi Piscopo, Pierre Ellul), Mater Dei Hospital, Malta
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Radmard AR, Eftekhar Vaghefi R, Montazeri SA, Naybandi Atashi S, Hashemi Taheri AP, Haghighi S, Salehnia A, Dadgostar M, Malekzadeh R. Mesenteric lymph nodes in MR enterography: are they reliable followers of bowel in active Crohn's disease? Eur Radiol 2018; 28:4429-4437. [PMID: 29696432 DOI: 10.1007/s00330-018-5441-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To demonstrate magnetic resonance enterography (MRE) features of mesenteric lymph nodes (LN) in patients with Crohn's disease (CD) and investigate whether they follow enhancement or apparent diffusion coefficient (ADC) parameters of bowel. METHODS This study was approved by the institutional review board. A total of 788 MREs from patients with CD were retrospectively reviewed. Eighty-eight patients, aged 16-66 years, including 59 active cases, were enrolled based on inclusion criteria. In each MRE, two segments (normal and abnormal) and two LNs (regional and non-regional) were independently suggested, consensually chosen, and analyzed by two radiologists. Signal-to-noise (SNR) and contrast-to-noise (CNR) ratios were calculated to assess signal intensities (SI) at 30, 60 and 180 s after contrast administration, as well as slope of enhancement (SOE). Enhancement parameters and ADC values were compared. RESULTS Regional LNs showed significantly higher SI30, SI60 and SI180 (CNR&SNR) and lower ADC values in active vs. inactive groups (all p<0.05) without significant difference in number or size. Strong correlations were demonstrated between abnormal segments and regional LNs in active group in terms of SI30, SI60, SI180, SOE0-30 and ADC values (r = 0.679 to 0.774, all p<0.001). SI180, SOE60-180 and ADC values were moderately correlated between abnormal segments and regional LNs in inactive group (r = 0.448 to 0.595, all p<0.05). In logistic regression analyses, SOE0-30 and ADC value of regional LNs independently predicted active CD. CONCLUSION Mesenteric LNs follow quantitative enhancement and diffusion parameters of bowel in active CD. SOE0-30 and ADC value of LN could predict disease activity. KEY POINTS • Mesenteric LNs may strongly follow enhancement pattern of bowel in active CD. • DWI parameters of LNs and bowel were strongly correlated in active CD. • SI180 was moderately correlated between bowel and LNs in inactive CD. • DWI parameters were moderately correlated between LNs and bowel in inactive CD. • SOE0-30 and ADC value of mesenteric LN could predict disease activity.
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Affiliation(s)
- Amir Reza Radmard
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, North Kargar St., Tehran, 14117, Iran.
| | - Rana Eftekhar Vaghefi
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, North Kargar St., Tehran, 14117, Iran
| | - Seyed Ali Montazeri
- Digestive Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Naybandi Atashi
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, North Kargar St., Tehran, 14117, Iran
| | - Amir Pejman Hashemi Taheri
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, North Kargar St., Tehran, 14117, Iran
| | - Sepehr Haghighi
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, North Kargar St., Tehran, 14117, Iran
| | - Aneseh Salehnia
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, North Kargar St., Tehran, 14117, Iran
| | - Mehrdad Dadgostar
- Department of Electrical Engineering, Central Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Reza Malekzadeh
- Digestive Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
Contrast-enhanced ultrasound (CEUS) of the gastrointestinal tract provides vascular information helpful for characterizing masses and other pathologies in and around the bowel, similar to contrast applications in other solid organs. However, the use of microbubble contrast agents for the bowel provides additional unique contributions as it gives both subjective and objective information about mural and mesenteric blood flow, invaluable for the determination of disease activity in those many patients affected by inflammatory bowel disease (IBD). IBD is a lifelong chronic disease and has its peak age of onset in adolescence or young adult life. Today, we have moved away from treating patient’s symptoms and strive instead to alter the course of disease by obtaining mucosal healing. Expensive and aggressive biologic therapies and lack of agreement of patient’s symptoms with their disease activity and complications necessitate frequent imaging surveillance, which must be safe, readily available, inexpensive, and effective. Ultrasound with the benefit of contrast enhancement meets these requirements and is shown in meta-analysis to be equivalent to CT and MRI scans for these indications.
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Salem HA, Wadie W. Effect of Niacin on Inflammation and Angiogenesis in a Murine Model of Ulcerative Colitis. Sci Rep 2017; 7:7139. [PMID: 28769047 PMCID: PMC5541000 DOI: 10.1038/s41598-017-07280-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 06/19/2017] [Indexed: 12/18/2022] Open
Abstract
Butyrate and niacin are produced by gut microbiota, however butyrate has received most attention for its effects on colonic health. The present study aimed at exploring the effect of niacin on experimental colitis as well as throwing some light on the ability of niacin to modulate angiogenesis which plays a crucial role of in the pathogenesis of inflammatory bowel disease. Rats were given niacin for 2 weeks. On day 8, colitis was induced by intrarectal administration of iodoacetamide. Rats were sacrificed on day 15 and colonic damage was assessed macroscopically and histologically. Colonic myeloperoxidase (MPO), tumour necrosis factor (TNF)-α, interleukin (IL)-10, vascular endothelial growth factor (VEGF), angiostatin and endostatin levels were determined. Niacin attenuated the severity of colitis as demonstrated by a decrease in weight loss, colonic wet weight and MPO activity. Iodoacetamide-induced rise in the colonic levels of TNF-α, VEGF, angiostatin and endostatin was reversed by niacin. Moreover, niacin normalized IL-10 level in colon. Mepenzolate bromide, a GPR109A receptor blocker, abolished the beneficial effects of niacin on body weight, colon wet weight as well as colonic levels of MPO and VEGF. Therefore, niacin was effective against iodoacetamide-induced colitis through ameliorating pathologic angiogenesis and inflammatory changes in a GPR109A-dependent manner.
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Affiliation(s)
- Hesham Aly Salem
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Walaa Wadie
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Cairo University, Cairo, Egypt.
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Dillman JR, Dehkordy SF, Smith EA, DiPietro MA, Sanchez R, DeMatos-Maillard V, Adler J, Zhang B, Trout AT. Defining the ultrasound longitudinal natural history of newly diagnosed pediatric small bowel Crohn disease treated with infliximab and infliximab-azathioprine combination therapy. Pediatr Radiol 2017; 47:924-934. [PMID: 28421251 PMCID: PMC5511547 DOI: 10.1007/s00247-017-3848-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/07/2017] [Accepted: 03/22/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Little is known about changes in the imaging appearances of the bowel and mesentery over time in either pediatric or adult patients with newly diagnosed small bowel Crohn disease treated with anti-tumor necrosis factor-alpha (anti-TNF-α) therapy. OBJECTIVE To define how bowel ultrasound findings change over time and correlate with laboratory inflammatory markers in children who have been newly diagnosed with pediatric small bowel Crohn disease and treated with infliximab. MATERIALS AND METHODS We included 28 pediatric patients treated with infliximab for newly diagnosed ileal Crohn disease who underwent bowel sonography prior to medical therapy and at approximately 2 weeks, 1 month, 3 months and 6 months after treatment initiation; these patients also had laboratory testing at baseline, 1 month and 6 months. We used linear mixed models to compare mean results between visits and evaluate whether ultrasound measurements changed over time. We used Spearman rank correlation to assess bivariate relationships. RESULTS Mean subject age was 15.3±2.2 years; 11 subjects were girls (39%). We observed decreases in mean length of disease involvement (12.0±5.4 vs. 9.1±5.3 cm, P=0.02), maximum bowel wall thickness (5.6±1.8 vs. 4.7±1.7 mm, P=0.02), bowel wall color Doppler signal (1.7±0.9 vs. 1.2±0.8, P=0.002) and mesenteric color Doppler signal (1.1±0.9 vs. 0.6±0.6, P=0.005) at approximately 2 weeks following the initiation of infliximab compared to baseline. All laboratory inflammatory markers decreased at 1 month (P-values<0.0001). There was strong correlation between bowel wall color Doppler signal and fecal calprotectin (ρ=0.710; P<0.0001). Linear mixed models confirmed that maximum bowel wall thickness (P=0.04), length of disease involvement (P=0.0002) and bowel wall color Doppler signal (P<0.0001) change over time in response to infliximab, when adjusted for age, sex, azathioprine therapy, scanning radiologist and baseline short pediatric Crohn's disease activity index score. CONCLUSION The ultrasound appearance of the bowel changes as early as 2 weeks after the initiation of infliximab therapy. There is strong correlation between bowel wall color Doppler signal and fecal calprotectin.
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Affiliation(s)
- Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., ML5031, Cincinnati, OH, 45229-3039, USA.
| | - Soudabeh Fazeli Dehkordy
- Department of Radiology, Section of Pediatric Radiology, C. S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ethan A Smith
- Department of Radiology, Section of Pediatric Radiology, C. S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael A DiPietro
- Department of Radiology, Section of Pediatric Radiology, C. S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ramon Sanchez
- Department of Radiology, Section of Pediatric Radiology, C. S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Vera DeMatos-Maillard
- Department of Pediatrics, Division of Gastroenterology, C. S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jeremy Adler
- Department of Pediatrics, Division of Gastroenterology, C. S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., ML5031, Cincinnati, OH, 45229-3039, USA
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Rosenbaum DG, Conrad MA, Biko DM, Ruchelli ED, Kelsen JR, Anupindi SA. Ultrasound and MRI predictors of surgical bowel resection in pediatric Crohn disease. Pediatr Radiol 2017; 47:55-64. [PMID: 27687769 DOI: 10.1007/s00247-016-3704-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 08/06/2016] [Accepted: 09/02/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Imaging predictors for surgery in children with Crohn disease are lacking. OBJECTIVE To identify imaging features of the terminal ileum on short-interval bowel ultrasound (US) and MR enterography (MRE) in children with Crohn disease requiring surgical bowel resection and those managed by medical therapy alone. MATERIALS AND METHODS This retrospective study evaluated patients 18 years and younger with Crohn disease undergoing short-interval bowel US and MRE (within 2 months of one another), as well as subsequent ileocecectomy or endoscopy within 3 months of imaging. Appearance of the terminal ileum on both modalities was compared between surgical patients and those managed with medical therapy, with the following parameters assessed: bowel wall thickness, mural stratification, vascularity, fibrofatty proliferation, abscess, fistula and stricture on bowel US; bowel wall thickness, T2 ratio, enhancement pattern, mesenteric edema, fibrofatty proliferation, abscess, fistula and stricture on MRE. A two-sided t-test was used to compare means, a Mann-Whitney U analysis was used for non-parametric parameter scores, and a chi-square or two-sided Fisher exact test compared categorical variables. Imaging findings in surgical patients were correlated with location-matched histopathological scores of inflammation and fibrosis using a scoring system adapted from the Simple Endoscopic Score for Crohn Disease, and a Spearman rank correlation coefficient was used to compare inflammation and fibrosis on histopathology. RESULTS Twenty-two surgical patients (mean age: 16.5 years; male/female: 13/9) and 20 nonsurgical patients (mean age: 14.8; M/F: 8/12) were included in the final analysis. On US, the surgical group demonstrated significantly increased mean bowel wall thickness (6.1 mm vs. 4.7 mm for the nonsurgical group; P = 0.01), loss of mural stratification (odds ratio [OR] = 6.3; 95% confidence interval [CI]: 1.4-28.4; P = 0.02) and increased fibrofatty proliferation (P = 0.04). On MRE, the surgical group showed increased mean bowel wall thickness (9.1 mm vs. 7.2 mm for the nonsurgical group; P = 0.02), increased mean T2 ratio (4.6 vs. 3.6 for the nonsurgical group; P = 0.03), different enhancement patterns (P = 0.03), increased mesenteric edema (P = 0.001) and increased stricture formation (OR = 8.2; 95% CI: 1.8-36.4; P = 0.005). Nineteen of 22 ileocecectomy specimens showed severe inflammation and 21/22 showed severe fibrosis, with significant correlation between inflammation and fibrosis scores (ρ = 0.55; P = 0.008); however, correlation with imaging findings was limited by the uniformity of findings on histopathology. CONCLUSION Children with terminal ileal Crohn disease requiring surgical bowel resection demonstrate more severe manifestations of imaging features traditionally associated with both active inflammation and chronic fibrosis than those managed medically on US and MRE, findings that are corroborated by histopathology. These features may potentially serve as imaging biomarkers indicating the necessity for surgical intervention.
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Affiliation(s)
- Daniel G Rosenbaum
- Division of Pediatric Radiology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, 525 E. 68th St., New York, NY, 10065, USA.
| | - Maire A Conrad
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David M Biko
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Eduardo D Ruchelli
- Division of Anatomic Pathology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Judith R Kelsen
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sudha A Anupindi
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Chen M, Remer EM, Liu X, Lopez R, Shen B. Identification of the distinguishing features of Crohn's disease and ischemic colitis using computed tomographic enterography. Gastroenterol Rep (Oxf) 2016; 5:219-225. [PMID: 28852526 PMCID: PMC5554382 DOI: 10.1093/gastro/gow037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 09/25/2016] [Accepted: 10/04/2016] [Indexed: 01/27/2023] Open
Abstract
Background and aims: The differential diagnosis between Crohn’s disease (CD) and ischemic colitis (ISC) is important as their clinical management is different. ISC can easily be misdiagnosed as CD, especially in elderly populations. The distinctive radiographic features of the two disease entities have not been investigated. The aim of this study is to assess the utility of computed tomographic enterography (CTE) in the differential diagnosis between CD and ISC. Methods: Patients with confirmed CD and ISC were identified through an electronic medical record search of the Cleveland Clinic Foundation. Patients who had undergone CTE, with or without concurrent colonoscopy and histopathological specimens, were included in this study. CTE images were blindly re-reviewed by an expert gastrointestinal radiologist. The sensitivities, specificities, accuracies and positive and negative predictive values for each of the CTE findings in differentiating CD from ISC were estimated. Kappa coefficients (κ) were calculated to measure diagnosis agreement between CTE and the reference standard. Results: A total of 34 eligible patients were included in this study with 17 having CD and 17 having ISC. In differentiating CD from ISC, the presence of mucosal hyperenhancement and absence of the “target sign” on CTE showed a sensitivity of 100% each for CD, while the two radiographic features yielded a low specificity of 35.3% and 76.5%, respectively. The presence of stricture had a lower sensitivity of 64.7% for the detection of CD but had a high specificity of 100%. In distinguishing CD from ISC, the accuracy of presence of mucosal hyperenhancement, stricture and absence of target sign were 67.7%, 82.4% and 88.2%, respectively. The combination of the presence of mucosal hyperenhancement and the absence of the target sign achieved an accuracy of 100% for distinguishing CD from ISC. There was a good correlation between CTE and the reference standard for distinguishing CD from ISC (κ = 0.882). Conclusions: CTE appeared to be clinically useful in distinguishing CD from ISC.
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Affiliation(s)
- Min Chen
- Department of Gastroenterology/Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA.,Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Erick M Remer
- Department of Gastroenterology/Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA.,Section of Abdominal Imaging, Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Xiuli Liu
- Department of Gastroenterology/Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rocio Lopez
- Department of Gastroenterology/Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bo Shen
- Department of Gastroenterology/Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA
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Bhatnagar G, Von Stempel C, Halligan S, Taylor SA. Utility of MR enterography and ultrasound for the investigation of small bowel Crohn's disease. J Magn Reson Imaging 2016; 45:1573-1588. [PMID: 27943484 DOI: 10.1002/jmri.25569] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/11/2016] [Indexed: 12/18/2022] Open
Abstract
Cross sectional Imaging plays an increasingly important role the diagnosis and management of Crohn's disease. Particular emphasis is placed on MRI and Ultrasound as they do not impart ionising radiation. Both modalities have reported high sensitivity for disease detection, activity assessment and evaluation of extra-luminal complications, and have positive effects on clinical decision making. International Guidelines now recommend MRI and Ultrasound in the routine management of Crohn's disease patients. This article reviews the current evidence base supporting both modalities with an emphasis on the key clinical questions. We describe current protocols, basic imaging findings and highlight areas in need of further research. LEVEL OF EVIDENCE 5 Technical Efficacy: Stage 4 J. MAGN. RESON. IMAGING 2017;45:1573-1588.
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Affiliation(s)
- Gauraang Bhatnagar
- Frimley Park Hospital NHS Foundation Trust, London, UK.,Centre for Medical Imaging, University College London, London, UK
| | | | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
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Kljucevsek D, Vidmar D, Urlep D, Dezman R. Dynamic contrast-enhanced ultrasound of the bowel wall with quantitative assessment of Crohn's disease activity in childhood. Radiol Oncol 2016; 50:347-354. [PMID: 27904441 PMCID: PMC5120573 DOI: 10.1515/raon-2015-0042] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 06/11/2015] [Indexed: 02/06/2023] Open
Abstract
Background Contrast-enhanced ultrasound (CEUS) has become an established non-invasive, patient-friendly imaging technique which improves the characterization of lesions. In addition, dynamic contrast-enhanced ultrasound (DCE-US) provides valuable information concerning perfusion of examined organs. This review addresses current applications of CEUS in children, focused on DCE-US of the bowel wall in patients with Crohn disease, which enables realtime assessment of the bowel wall vascularity with semi-quantitative and quantitative assessment of disease activity and response to medical treatment. Conclusions Crohn’s disease is a chronic inflammatory relapsing disease. Frequent imaging re-evaluation is necessary. Therefore, imaging should be as little invasive as possible, children friendly with high diagnostic accuracy. US with wide varieties of techniques, including CEUS/DCE-US, can provide an important contribution for diagnosing and monitoring a disease activity. Even if the use of US contrast agent is off-label in children, it is welcome and widely accepted for intravesical use, and a little less for intravenous use, manly in evaluation of parenchymal lesions. To our knowledge this is the first time that the use of DCE-US in the evaluation of activity of small bowel Crohn disease with quantitative assessment of kinetic parameters is being described in children. Even if the results of the value and accuracy of different quantitative kinetic parameters in published studies in adult population often contradict one another there is a great potential of DCE-US to become a part of the entire sonographic evaluation not only in adults, but also in children. Further control studies should be performed.
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Affiliation(s)
- Damjana Kljucevsek
- Radiology Unit, Children's Hospital, University Medical Centre Ljubljana, Slovenia
| | - Dubravka Vidmar
- Institute of Radiology, University Medical Centre Ljubljana, Slovenia
| | - Darja Urlep
- Department of Gastroenterology, Hepatology and Nutrition, Children's Hospital, University Medical Centre Ljubljana, Slovenia
| | - Rok Dezman
- Institute of Radiology, University Medical Centre Ljubljana, Slovenia
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Schreiber-Dietrich D, Chiorean L, Cui XW, Braden B, Kucharzik T, Jüngert J, Kosiak W, Stenzel M, Dietrich CF. Particularities of Crohn's disease in pediatric patients: current status and perspectives regarding imaging modalities. Expert Rev Gastroenterol Hepatol 2016; 9:1313-25. [PMID: 26377445 DOI: 10.1586/17474124.2015.1083420] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
| | - Liliana Chiorean
- a 1 Medical Department, Caritas-Krankenhaus, Uhlandstr. 7, D-97980 Bad Mergentheim, Germany.,b 2 Département d'imagerie médicale, Clinique des Cévennes 07100 Annonay, France
| | - Xin-Wu Cui
- a 1 Medical Department, Caritas-Krankenhaus, Uhlandstr. 7, D-97980 Bad Mergentheim, Germany.,c 3 Sino-German Research Center of Ultrasound in Medicine, The First Affiliated Hospital of Zhengzhou University, China
| | - Barbara Braden
- d 4 Barbara Braden, Translational Gastroenterology Unit, Oxford University Hospitals, Oxford OX3 9DU, UK
| | - Torsten Kucharzik
- e 5 Klinikum Lüneburg, Department of Gastroenterology, Lueneburg, Germany
| | - Jörg Jüngert
- f 6 Department of Pediatrics, University of Erlangen, Germany
| | - Wojciech Kosiak
- g 7 Department of Pediatric, Hematology & Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Martin Stenzel
- h 8 Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Christoph F Dietrich
- a 1 Medical Department, Caritas-Krankenhaus, Uhlandstr. 7, D-97980 Bad Mergentheim, Germany
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Park EK, Han NY, Park BJ, Sung DJ, Cho SB, Jeen YT, Keum B, Kim MJ. Value of Computerized Tomography Enterography in Predicting Crohn's Disease Activity: Correlation with Crohn's Disease Activity Index and C-Reactive Protein. IRANIAN JOURNAL OF RADIOLOGY 2016; 13:e34301. [PMID: 27895873 PMCID: PMC5116772 DOI: 10.5812/iranjradiol.34301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 12/14/2015] [Accepted: 12/22/2015] [Indexed: 12/14/2022]
Abstract
Background The accurate evaluation of Crohn’s disease activity is important for the treatment of the disease and for monitoring the response. Computerized tomography (CT) enterography is a useful imaging modality that reflects enteric inflammation, as well as extramural complications. Objectives The aim of this study was to evaluate the correlation between CT enterographic (CTE) findings of active Crohn’s disease and the Crohn’s disease activity index (CDAI) and C-reactive protein (CRP). Patients and Methods Fifty CT enterographies of 39 patients with Crohn’s disease in the small bowel were used in our study. The CDAI was assessed through clinical and laboratory variables. Multiple CT parameters, including mural hyperenhancement, mural thickness, mural stratification, comb sign, and mesenteric fat attenuation, were evaluated with a four-point scale. The presence or absence of enhanced lymph nodes, fibrofatty proliferation, sinus or fistula, abscess, and stricture were also assessed. Two gastrointestinal radiologists independently reviewed all CT images, and inter-observer agreement was examined. Correlations between CT findings, CRP, and CDAI were assessed using Spearman’s rank correlation and logistic regression analysis. To assess the predictive accuracy of the model, a receiver-operating characteristic curve analysis for the sum of CT enterographic scores was used. Results Mural hyperenhancement, mural thickness, comb sign, mesenteric fat density, and fibrofatty proliferation were significantly correlated with CDAI and CRP (P < 0.05). The binary logistic regression model demonstrated that mesenteric fat density, mural stratification, and the presence of enhanced lymph nodes (P < 0.05) had an influence on CDAI severity. The area under the receiver operating characteristic curve (AUROC) of the CTE index for predicting disease activity was 0.85. Using a cut-off value of 8, the sensitivity and negative predictive values were 95% and 94%, respectively. Conclusion Most CTE findings correlated with CDAI and CRP in patients with active Crohn’s disease.
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Affiliation(s)
- Eun Kyung Park
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Na Yeon Han
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Beom Jin Park
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Deuk Jae Sung
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sung Beom Cho
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yoon Tae Jeen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Bora Keum
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min Ju Kim
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
- Corresponding author: Min Ju Kim, Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea. Tel: +82-29205578, Fax: +82-29293796, E-mail:
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Li Y, Zhu W, Zuo L, Shen B. The Role of the Mesentery in Crohn's Disease: The Contributions of Nerves, Vessels, Lymphatics, and Fat to the Pathogenesis and Disease Course. Inflamm Bowel Dis 2016; 22:1483-95. [PMID: 27167572 DOI: 10.1097/mib.0000000000000791] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Crohn's disease (CD) is a complex gastrointestinal disorder involving multiple levels of cross talk between the immunological, neural, vascular, and endocrine systems. The current dominant theory in CD is based on the unidirectional axis of dysbiosis-innate immunity-adaptive immunity-mesentery-body system. Emerging clinical evidence strongly suggests that the axis be bidirectional. The morphologic and/or functional abnormalities in the mesenteric structures likely contribute to the disease progression of CD, to a less extent the disease initiation. In addition to adipocytes, mesentery contains nerves, blood vessels, lymphatics, stromal cells, and fibroblasts. By the secretion of adipokines that have endocrine functions, the mesenteric fat tissue exerts its activity in immunomodulation mainly through response to afferent signals, neuropeptides, and functional cytokines. Mesenteric nerves are involved in the pathogenesis and prognosis of CD mainly through neuropeptides. In addition to angiogenesis observed in CD, lymphatic obstruction, remodeling, and impaired contraction maybe a cause and consequence of CD. Lymphangiogenesis and angiogenesis play a concomitant role in the progress of chronic intestinal inflammation. Finally, the interaction between neuropeptides, adipokines, and vascular and lymphatic endothelia leads to adipose tissue remodeling, which makes the mesentery an active participator, not a bystander, in the disease initiation and precipitation CD. The identification of the role of mesentery, including the structure and function of mesenteric nerves, vessels, lymphatics, and fat, in the intestinal inflammation in CD has important implications in understanding its pathogenesis and clinical management.
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Affiliation(s)
- Yi Li
- *Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China; and †Center for Inflammatory Bowel Disease, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
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Quantitative Contrast-Enhanced Ultrasound Parameters in Crohn Disease: Their Role in Disease Activity Determination With Ultrasound. AJR Am J Roentgenol 2016; 206:64-73. [PMID: 26700336 DOI: 10.2214/ajr.15.14506] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The primary objective of our study was to examine the association between contrast-enhanced ultrasound (CEUS) parameters and established gray-scale ultrasound with color Doppler imaging (CDI) for the determination of disease activity in patients with Crohn disease. Our secondary objective was to develop quantitative time-signal intensity curve thresholds for disease activity. MATERIALS AND METHODS One hundred twenty-seven patients with Crohn disease underwent ultrasound with CDI and CEUS. Reviewers graded wall thickness, inflammatory fat, and mural blood flow as showing remission or inflammation (mild, moderate, or severe). If both gray-scale ultrasound and CDI predicted equal levels of disease activity, the studies were considered concordant. If ultrasound images suggested active disease not supported by CDI findings, the ultrasound results for disease activity were indeterminate. Time-signal intensity curves from CEUS were acquired with calculation of peak enhancement (PE), and AUCs. Interobserver variation and associations between PE and ultrasound parameters were examined. Multiclass ROC analysis was used to develop CEUS thresholds for activity. RESULTS Ninety-six (76%) studies were concordant, 19 of which showed severe disease, and 31 (24%) studies were indeterminate. Kappa analyses revealed good interobserver agreement on grades for CDI (κ = 0.76) and ultrasound (κ = 0.80) assessments. PE values on CEUS and wall thickness showed good association with the Spearman rank correlation coefficient for the entire population (ρ = 0.62, p < 0.01) and for the concordant group (ρ = 0.70, p < 0.01). Multiclass ROC analyses of the concordant group using wall thickness alone as the reference standard showed cutoff points of 18.2 dB for differentiating mild versus moderate activity (sensitivity, 89.0% and specificity, 87.0%) and 23.0 dB for differentiating moderate versus severe (sensitivity, 90% and specificity, 86.8%). Almost identical cutoff points were observed when using ultrasound global assessment as the reference standard: using 18.2 dB to differentiate mild versus moderate activity yielded sensitivity of 89.2% and specificity of 90.9% and using 22.9 dB to differentiate moderate versus severe activity yielded sensitivity of 89.5% and specificity of 83.1%. CONCLUSION Quantitative CEUS parameters integrated into inflammatory assessments with ultrasound reduce indeterminate results and improve disease activity level determinations.
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Medical Imaging in Small Bowel Crohn's Disease-Computer Tomography Enterography, Magnetic Resonance Enterography, and Ultrasound: "Which One Is the Best for What?". Inflamm Bowel Dis 2016; 22:1246-61. [PMID: 27070909 DOI: 10.1097/mib.0000000000000727] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Small bowel imaging in Crohn's disease (CD) is an important adjunct to endoscopy for the diagnosis, assessment of postoperative recurrence, and detection of complications. The best imaging modality for such indications though remains unclear. This systematic review aims to identify the imaging modality of choice considering the use of ultrasound (US), computed tomography enterography (CTE), and magnetic resonance enterography (MRE). METHODS Databases were systematically searched for studies pertaining to the performance of US, CTE, and MRE, as compared with a predefined reference standard in the assessment of small bowel CD. RESULTS Thirty-three studies, from a total of 1427 studies, were included in the final analysis. A comparable performance was demonstrated for MRE, CTE, and US for the diagnosis of small CD. Ultrasound was found to have the highest accuracy in the differentiation of inflammation and fibrosis. Postoperative recurrence detection was feasible with the use of MRE and US. All 3 modalities were shown to have a role in the detection of small bowel CD complications. The radiation exposure associated with CTE can be minimized by using lower radiation protocols. CONCLUSIONS Ultrasound, CTE, and MRE all play an important role in the diagnosis and management of small bowel CD, with preference for a particular modality being influenced by specific indication, institution resources, and patient preference.
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Bowel Ultrasonography in the Management of Crohn's Disease. A Review with Recommendations of an International Panel of Experts. Inflamm Bowel Dis 2016; 22:1168-83. [PMID: 26958988 DOI: 10.1097/mib.0000000000000706] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Bowel ultrasonography (US) is considered a useful technique for assessing mural inflammation and complications in Crohn's disease (CD). The aim of this review is to appraise the evidence on the accuracy of bowel US for CD. In addition, we aim to provide recommendations for its optimal use. METHODS Publications were identified by literature search from 1992 to 2014 and selected based on predefined criteria: 15 or more patients; bowel US for diagnosing CD, complications, postoperative recurrence, activity; adequate reference standards; prospective study design; data reported to allow calculation of sensitivity, specificity, agreement, or correlation values; articles published in English. RESULTS The search yielded 655 articles, of which 63 were found to be eligible and retrieved as full-text articles for analysis. Bowel US showed 79.7% sensitivity and 96.7% specificity for the diagnosis of suspected CD, and 89% sensitivity and 94.3% specificity for initial assessment in established patients with CD. Bowel US identified ileal CD with 92.7% sensitivity, 88.2% specificity, and colon CD with 81.8% sensitivity, 95.3% specificity, with lower accuracy for detecting proximal lesions. The oral contrast agent improves the sensitivity and specificity in determining CD lesions and in assessing sites and extent. CONCLUSIONS Bowel US is a tool for evaluation of CD lesions in terms of complications, postoperative recurrence, and monitoring response to medical therapy; it reliably detects postoperative recurrence and complications, as well as offers the possibility of monitoring disease progression.
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Prospective cohort study of ultrasound-ultrasound and ultrasound-MR enterography agreement in the evaluation of pediatric small bowel Crohn disease. Pediatr Radiol 2016; 46:490-7. [PMID: 26718197 DOI: 10.1007/s00247-015-3517-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 10/07/2015] [Accepted: 11/19/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is a paucity of published literature describing ultrasound (US)-US and US-MR enterography (MRE) inter-radiologist agreement in pediatric small bowel Crohn disease. OBJECTIVE To prospectively assess US-US and US-MRE inter-radiologist agreement in pediatric small bowel Crohn disease. MATERIALS AND METHODS Institutional Review Board approval and informed consent/assent were obtained for this HIPAA-compliant prospective cohort study of children with newly diagnosed distal small bowel Crohn disease (July 2012 to December 2014). Enrolled subjects (n = 29) underwent two small bowel US examinations performed by blinded independent radiologists both before and at multiple time points after initiation of medical therapy (231 unique US examinations, in total); 134 US examinations were associated with concurrent MRE. The MRE examination was interpreted by a third blinded radiologist. The following was documented on each examination: involved length of ileum (cm); maximum bowel wall thickness (mm); amount of bowel wall and mesenteric Doppler signal, and presence of stricture, penetrating disease and/or abscess. Inter-radiologist agreement was assessed with single-measure, three-way, mixed-model intra-class correlation coefficients (ICC) and prevalence-adjusted, bias-adjusted kappa statistics (κ). Numbers in brackets are 95% confidence intervals. RESULTS Ultrasound-US agreement was moderate for involved length (ICC: 0.41 [0.35-0.49]); substantial for maximum bowel wall thickness (ICC: 0.67 [0.64-0.70]); moderate for bowel wall Doppler signal (ICC: 0.53 [0.48-0.59]); slight for mesenteric Doppler signal (ICC: 0.25 [0.18-0.42]), and moderate to almost perfect for stricture (κ: 0.54), penetrating disease (κ: 0.80), and abscess (κ: 0.96). US-MRE agreement was moderate for involved length (ICC: 0.42 [0.37-0.49]); substantial for maximum bowel wall thickness (ICC: 0.66 [0.65-0.69]), and substantial to almost perfect for stricture (κ: 0.61), penetrating disease (κ: 0.72) and abscess (κ: 0.88). CONCLUSION Ultrasound-US agreement was similar to US-MRE agreement for assessing pediatric small bowel Crohn disease. Discrepancies in US-US and US-MRE reporting question the utility of US as an accurate, reproducible radiologic biomarker for assessing response to medical therapy and disease-related complications.
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Knod JL, Crawford K, Dusing M, Collins MH, Chernoguz A, Frischer JS. Angiogenesis and Vascular Endothelial Growth Factor-A Expression Associated with Inflammation in Pediatric Crohn's Disease. J Gastrointest Surg 2016; 20:624-30. [PMID: 26530519 DOI: 10.1007/s11605-015-3002-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/18/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIMS Angiogenesis is a component of chronic inflammatory diseases including inflammatory bowel disease. Some studies describe increased angiogenesis associated with acute disease in adult Crohn's disease and ulcerative colitis, while animal models aid investigations of mechanism and pathophysiology of angiogenesis. We aim to explore the role of angiogenesis and its pathways in pediatric Crohn's disease. METHODS Surgical specimens were obtained from pediatric Crohn's disease (both inflamed and non-inflamed regions of ileum) and control patients. Samples were examined for inflammation, microvessel density, and molecular expression of vascular endothelial growth factor-A, platelet-derived growth factor-β, angiopoietin-1, and angiopoietin-2. RESULTS Angiogenesis and inflammation were increased in parallel in Crohn's disease compared to controls. We also discovered increased angiogenesis in Crohn's disease tissue that was relatively free of inflammatory disease. Vascular endothelial growth factor-A gene expression (P = 0.034) was elevated in Crohn's disease over controls, while gene expression of platelet-derived growth factor-β (P = 0.069), angiopoietin-1 (P = 0.206), and angiopoietin-2 (P = 0.082) was not significantly elevated. CONCLUSIONS We confirm that inflammation-associated angiogenesis is upregulated in pediatric Crohn's disease. This population also exhibits elevated mucosal angiogenesis at the surgical margin with limited inflammation. This suggests that angiogenesis is an additional pathologic characteristic to potentially identify normal mucosa and margins of surgical resection that are uninvolved with disease and, furthermore, may have implications for monitoring complete disease remission. We further identify the vascular endothelial growth factor-A pathway involvement in the disease process, which may serve as a future molecular target for anti-angiogenic therapy in inflammatory bowel disease.
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Affiliation(s)
- J Leslie Knod
- Division of Pediatric General & Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kelly Crawford
- Division of Pediatric General & Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mary Dusing
- Division of Pediatric General & Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Margaret H Collins
- Division of Pediatric Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Artur Chernoguz
- Division of Pediatric General & Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jason S Frischer
- Division of Pediatric General & Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Director, Colorectal Center for Children, Division of Pediatric General & Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, MLC-2023, Cincinnati, OH, 45229, USA.
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