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Lu C, Rosentreter R, Delisle M, White M, Parker CE, Premji Z, Wilson SR, Baker ME, Bhatnagar G, Begun J, Bruining DH, Bryant R, Christensen B, Feagan BG, Fletcher JG, Jairath V, Knudsen J, Kucharzik T, Maaser C, Maconi G, Novak K, Rimola J, Taylor SA, Wilkens R, Rieder F. Systematic review: Defining, diagnosing and monitoring small bowel strictures in Crohn's disease on intestinal ultrasound. Aliment Pharmacol Ther 2024; 59:928-940. [PMID: 38436124 DOI: 10.1111/apt.17918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/29/2023] [Accepted: 02/11/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Stricturing Crohn's disease (CD) occurs most commonly in the terminal ileum and poses a clinical problem. Cross-sectional imaging modalities such as intestinal ultrasound (IUS), computed tomography enterography (CTE), and magnetic resonance enterography (MRE) allow for assessment of the entire bowel wall and associated peri-enteric findings. Radiologic definitions of strictures have been developed for CTE and MRE; their reliability and responsiveness are being evaluated in index development programs. A comprehensive assessment strategy for strictures using IUS is needed. AIMS To provide a detailed summary of definitions, diagnosis and monitoring of strictures on IUS as well as technical aspects of image acquisition. METHODS We searched four databases up to 6 January 2024. Two-stage screening was done in duplicate. We assessed risk of bias using QUADAS-2. RESULTS There were 56 studies eligible for inclusion. Definitions for strictures on IUS are heterogeneous, but the overall accuracy for diagnosis of strictures is high. The capability of IUS for characterising inflammation versus fibrosis in strictures is not accurate enough to be used in clinical practice or trials. We summarise definitions for improvement of strictures on IUS, and discuss parameters for image acquisition and standardisation. CONCLUSIONS This systematic review is the first step for a structured program to develop a stricture IUS index for CD.
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Affiliation(s)
- Cathy Lu
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Ryan Rosentreter
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Maxime Delisle
- Department of Medicine, Division of Gastroenterology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mattie White
- Department of Gastroenterology, Hepatology & Nutrition; Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Zahra Premji
- Libraries, University of Victoria, Victoria, British Columbia, Canada
| | - Stephanie R Wilson
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Mark E Baker
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gauraang Bhatnagar
- Centre for Medical Imaging, University College London, London, UK
- Frimley Health NHS Foundation Trust, Surrey, UK
| | - Jakob Begun
- Department of Gastroenterology, Mater Hospital, Brisbane, Queensland, Australia
| | - David H Bruining
- Department of Gastroenterology, Queen Elizabeth Hospital, Adelaide, South Australia
| | - Robert Bryant
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Britt Christensen
- Department of Gastroenterology, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Brian G Feagan
- Alimentiv Inc., London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Joel G Fletcher
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vipul Jairath
- Alimentiv Inc., London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Department of Medicine, Western University, London, Ontario, Canada
| | - John Knudsen
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Torsten Kucharzik
- Department of General Internal Medicine and Gastroenterology, University Teaching Hospital Lüneburg, Lüneburg, Germany
| | - Christian Maaser
- Outpatients' Department of Gastroenterology, University Teaching Hospital Lüneburg, Lüneberg, Germany
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Kerri Novak
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Jordi Rimola
- IBD Unit, Radiology Department, Hospital Clinic Barcelona, IDIBAPS, Barcelona, Spain
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Rune Wilkens
- Digestive Disease Center, Copenhagen University Hospital-Bispebjerg, Copenhagen, Denmark
- Copenhagen Intestinal Ultrasound, Bispebjerg Hospital, Copenhagen, Denmark
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition; Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Cleveland Clinic Center for Global Translational Inflammatory Bowel Diseases, Cleveland, Ohio, USA
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Losurdo G, De Bellis M, Rima R, Palmisano CM, Dell’Aquila P, Iannone A, Ierardi E, Di Leo A, Principi M. Small Intestinal Contrast Ultrasonography (SICUS) in Crohn's Disease: Systematic Review and Meta-Analysis. J Clin Med 2023; 12:7714. [PMID: 38137782 PMCID: PMC10744114 DOI: 10.3390/jcm12247714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/04/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
The diagnosis of Crohn's Disease (CD) is based on a combination of clinical symptoms, laboratory tests, endoscopy, and imaging data. In Small Intestine Contrast Ultrasonography (SICUS), the ingestion of a macrogol solution as an oral contrast medium may optimize image quality. We performed a meta-analysis to evaluate the diagnostic performance of SICUS for CD. A literature search was performed in August 2023. We selected only studies where SICUS was compared to a technique that allows the assessment of the whole gastrointestinal tract, such as an MRE, a CT scan, or a surgical evaluation. We estimated pooled weighted sensitivity, specificity, and likelihood ratio for positive and negative tests (PLR/NLR) of SICUS. Summary receiver operating characteristic curves (SROC) were drawn, and pooled areas under the curve (AUC) were calculated. Five studies with 325 CD patients were included. SICUS showed a pooled sensitivity for the diagnosis of 95% (95% confidence interval CI 89-99%), a specificity = 77% (95% CI 60-90%), and the AUC was 0.94. SICUS demonstrated a pooled sensitivity for strictures of 78% (95% CI 63-88%) and a specificity = 96% (95% CI 85-99%), with AUC = 0.93. For abscesses, SICUS demonstrated a pooled sensitivity of 100% (95% CI 59-100%) and a specificity of 90% (95% CI 74-98%). Fistulae were detected with a pooled sensitivity of 77% (95% CI 46-95%) and a specificity of 92% (95% CI 75-99%). SICUS demonstrated excellent diagnostic performance compared to the gold standard despite some clinical scenarios (stenosis/fistulae) showing suboptimal diagnostic effectiveness.
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Affiliation(s)
- Giuseppe Losurdo
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, 70124 Bari, Italy; (M.D.B.); (P.D.); (A.I.); (E.I.); (A.D.L.); (M.P.)
| | - Margherita De Bellis
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, 70124 Bari, Italy; (M.D.B.); (P.D.); (A.I.); (E.I.); (A.D.L.); (M.P.)
| | - Raffaella Rima
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, 70124 Bari, Italy; (M.D.B.); (P.D.); (A.I.); (E.I.); (A.D.L.); (M.P.)
| | - Chiara Maria Palmisano
- Internal Medicine Unit “C. Frugoni”, Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70124 Bari, Italy;
| | - Paola Dell’Aquila
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, 70124 Bari, Italy; (M.D.B.); (P.D.); (A.I.); (E.I.); (A.D.L.); (M.P.)
| | - Andrea Iannone
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, 70124 Bari, Italy; (M.D.B.); (P.D.); (A.I.); (E.I.); (A.D.L.); (M.P.)
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, 70124 Bari, Italy; (M.D.B.); (P.D.); (A.I.); (E.I.); (A.D.L.); (M.P.)
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, 70124 Bari, Italy; (M.D.B.); (P.D.); (A.I.); (E.I.); (A.D.L.); (M.P.)
| | - Mariabeatrice Principi
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, 70124 Bari, Italy; (M.D.B.); (P.D.); (A.I.); (E.I.); (A.D.L.); (M.P.)
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Hameed M, Taylor SA. Small bowel imaging in inflammatory bowel disease: updates for 2023. Expert Rev Gastroenterol Hepatol 2023; 17:1117-1134. [PMID: 37902040 DOI: 10.1080/17474124.2023.2274926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 10/20/2023] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Cross-sectional imaging techniques including MR and CT enterography and ultrasound are integral to Crohn's disease management, accurate, responsive, and well tolerated. They assess the full thickness of the bowel wall, perienteric environment, and distant complications. As we strive toward tighter disease control, imaging's role will expand further with transmural healing becoming an increasingly important therapeutic target. AREAS COVERED MEDLINE and Web of Science were searched from 2012 to 2023 inclusive. We review the evidence for cross-sectional imaging in assessing disease activity, phenotyping, and therapeutic response assessment. Emerging novel imaging applications such as quantifying enteric motility and fibrosis, prognostication, and potential utility of artificial intelligence will be covered. Recent international consensus statements highlight the need for standardized imaging reporting and definitions of transmural healing and remission. We will discuss how recent advances may be best integrated into patient care and highlight key outstanding research questions. EXPERT OPINION Cross-sectional imaging is established in Crohn's disease management. Research emphasis should be placed on optimal integration of imaging modalities in clinical care pathways, workforce training, definitions, and evidence for use of imaging based therapeutic targets such as transmural healing, better phenotyping of stricturing disease, and developing novel techniques, including integration of artificial intelligence.
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Affiliation(s)
- Maira Hameed
- Centre for Medical Imaging, University College London, United Kingdom
- University College London Hospitals NHS Foundation Trust, University College Hospital, United Kingdom
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, United Kingdom
- University College London Hospitals NHS Foundation Trust, University College Hospital, United Kingdom
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Tavares de Sousa H, Magro F. How to Evaluate Fibrosis in IBD? Diagnostics (Basel) 2023; 13:2188. [PMID: 37443582 DOI: 10.3390/diagnostics13132188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023] Open
Abstract
In this review, we will describe the importance of fibrosis in inflammatory bowel disease (IBD) by discussing its distinct impact on Crohn's disease (CD) and ulcerative colitis (UC) through their translation to histopathology. We will address the existing knowledge on the correlation between inflammation and fibrosis and the still not fully explained inflammation-independent fibrogenesis. Finally, we will compile and discuss the recent advances in the noninvasive assessment of intestinal fibrosis, including imaging and biomarkers. Based on the available data, none of the available cross-sectional imaging (CSI) techniques has proved to be capable of measuring CD fibrosis accurately, with MRE showing the most promising performance along with elastography. Very recent research with radiomics showed encouraging results, but further validation with reliable radiomic biomarkers is warranted. Despite the interesting results with micro-RNAs, further advances on the topic of fibrosis biomarkers depend on the development of robust clinical trials based on solid and validated endpoints. We conclude that it seems very likely that radiomics and AI will participate in the future non-invasive fibrosis assessment by CSI techniques in IBD. However, as of today, surgical pathology remains the gold standard for the diagnosis and quantification of intestinal fibrosis in IBD.
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Affiliation(s)
- Helena Tavares de Sousa
- Gastroenterology Department, Algarve University Hospital Center, 8500-338 Portimão, Portugal
- ABC-Algarve Biomedical Center, University of Algarve, 8005-139 Faro, Portugal
| | - Fernando Magro
- Unit of Pharmacology and Therapeutics, Department of Biomedicine, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
- Department of Gastroenterology, São João University Hospital Center, 4200-319 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
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Solitano V, Dal Buono A, Gabbiadini R, Wozny M, Repici A, Spinelli A, Vetrano S, Armuzzi A. Fibro-Stenosing Crohn's Disease: What Is New and What Is Next? J Clin Med 2023; 12:jcm12093052. [PMID: 37176493 PMCID: PMC10179180 DOI: 10.3390/jcm12093052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/03/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Fibro-stenosing Crohn's disease (CD) is a common disease presentation that leads to impaired quality of life and often requires endoscopic treatments or surgery. From a pathobiology perspective, the conventional view that intestinal fibro-stenosis is an irreversible condition has been disproved. Currently, there are no existing imaging techniques that can accurately quantify the amount of fibrosis within a stricture, and managing patients is challenging, requiring a multidisciplinary team. Novel therapies targeting different molecular components of the fibrotic pathways are increasing regarding other diseases outside the gut. However, a large gap between clinical need and the lack of anti-fibrotic agents in CD remains. This paper reviews the current state of pathobiology behind fibro-stenosing CD, provides an updated diagnostic and therapeutic approach, and finally, focuses on clinical trial endpoints and possible targets of anti-fibrotic therapies.
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Affiliation(s)
- Virginia Solitano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Division of Gastroenterology, Department of Medicine, Western University, London, ON N6A 4V2, Canada
| | - Arianna Dal Buono
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Roberto Gabbiadini
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Marek Wozny
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Department of Endoscopy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Stefania Vetrano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
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Sleiman J, Chirra P, Gandhi NS, Baker ME, Lu C, Gordon IO, Viswanath SE, Rieder F. Crohn's disease related strictures in cross-sectional imaging: More than meets the eye? United European Gastroenterol J 2022; 10:1167-1178. [PMID: 36326993 PMCID: PMC9752301 DOI: 10.1002/ueg2.12326] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 09/17/2022] [Indexed: 11/06/2022] Open
Abstract
Strictures in Crohn's disease (CD) are a hallmark of long-standing intestinal damage, brought about by inflammatory and non-inflammatory pathways. Understanding the complex pathophysiology related to inflammatory infiltrates, extracellular matrix deposition, as well as muscular hyperplasia is crucial to produce high-quality scoring indices for assessing CD strictures. In addition, cross-sectional imaging modalities are the primary tool for diagnosis and follow-up of strictures, especially with the initiation of anti-fibrotic therapy clinical trials. This in turn requires such modalities to both diagnose strictures with high accuracy, as well as be able to delineate the impact of each histomorphologic component on the individual stricture. We discuss the current knowledge on cross-sectional imaging modalities used for stricturing CD, with an emphasis on histomorphologic correlates, novel imaging parameters which may improve segregation between inflammatory, muscular, and fibrotic stricture components, as well as a future outlook on the role of artificial intelligence in this field of gastroenterology.
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Affiliation(s)
- Joseph Sleiman
- Division of Gastroenterology, Hepatology and NutritionUniversity of Pittsburgh School of MedicinePittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Prathyush Chirra
- Department of Biomedical EngineeringCase Western Reserve UniversityClevelandOhioUSA
| | | | - Mark E. Baker
- Imaging InstituteDigestive Diseases and Surgery Institute and Cancer InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Cathy Lu
- Division of Gastroenterology and HepatologyUniversity of CalgaryCalgaryAlbertaCanada
| | - Ilyssa O. Gordon
- Department of PathologyRobert J Tomsich Pathology and Laboratory Medicine InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Satish E. Viswanath
- Department of Biomedical EngineeringCase Western Reserve UniversityClevelandOhioUSA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & NutritionDigestive Diseases and Surgery InstituteCleveland Clinic FoundationClevelandOhioUSA,Department of Inflammation and ImmunityLerner Research InstituteCleveland Clinic FoundationClevelandOhioUSA
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Xu C, Jiang W, Wang L, Mao X, Ye Z, Zhang H. Intestinal Ultrasound for Differentiating Fibrotic or Inflammatory Stenosis in Crohn's Disease: A Systematic Review and Meta-analysis. J Crohns Colitis 2022; 16:1493-1504. [PMID: 35390137 DOI: 10.1093/ecco-jcc/jjac052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Intestinal ultrasound [IUS] has been increasingly reported to distinguish inflammatory or fibrotic intestinal stenosis in Crohn's disease [CD] patients. However, the diagnostic value is unclear. This systematic review and meta-analysis aimed to assess the diagnostic role of different modes of IUS parameters. METHODS We searched PubMed, Embase, Web of Science, and Cochrane Library from inception to August 2021. Regarding effect sizes, weighted mean differences [WMDs] or standardised mean differences [SMDs] were used. We pooled data using a random-effects or fixed-effects model according to heterogeneity. The diagnostic accuracy of IUS for distinguishing fibrosis was pooled. RESULTS A total of 19 studies were retained for qualitative analysis, and 14 were included in the meta-analysis [with 511 total subjects and 635 bowel segments]. In patients with fibrotic stenosis, the pooled WMDs for bowel wall thickness were 1.30 mm (95% confidence interval [CI]: 0.69-1.91) thicker than in patients with inflammatory stenosis, and the pooled SMDs for strain value and strain ratio were 0.80 [95% CI: 0.41-1.20] and 1.08 [95% CI: 0.55-1.60] harder than in patients with inflammatory stenosis, respectively. The percentage of maximal enhancement of fibrotic stenosis was lower than that of inflammatory stenosis [WMD -10.03; 95% CI: -17.91- -2.16]. The diagnostic accuracy of IUS was not performed because only a few studies provided relevant diagnostic indicators, and these studies used different modes and parameters. CONCLUSIONS IUS currently is inaccurate to differentiate fibrotic or inflammatory stenosis in CD patients, and more studies assessing the significance of each parameter and its cut-off value in different modes of IUS are needed to be conducted in the future.
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Affiliation(s)
- Chenjing Xu
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Wenyu Jiang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lu Wang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xiaqiong Mao
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Ziping Ye
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hongjie Zhang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
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Al-Ani AH, Vaughan R, Christensen B, Bryant RV, Novak KL. Treat to transmural healing: how to incorporate intestinal ultrasound into the treatment of inflammatory bowel disease. Br J Radiol 2022; 95:20211174. [PMID: 35766939 PMCID: PMC10996947 DOI: 10.1259/bjr.20211174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Intestinal ultrasound (IUS) is emerging as a key tool to achieving the therapeutic target of transmural healing in inflammatory bowel disease (IBD). IUS is a non-invasive, radiation-free, imaging modality comparable to MRI, CT and ileocolonoscopy (IC). With the appropriate training and equipment, IUS can be an easily repeatable bedside test for IBD diagnosis and disease monitoring, including treatment response. Core to successful high quality IUS employment are appropriate training and expert techniques; however, the training pathway will not be explored in this review. Given the increasing shift towards objective assessment for tight disease control, gastroenterologist-led IUS should be incorporated into the armamentarium of imaging modalities alongside radiologists, to enhance our diagnostic and monitoring toolbox. This comprehensive review aims to outline the current literature around IUS and propose the placement of IUS in a treat-to-target algorithm in IBD. Ultimately, IUS facilitates timely management decisions to optimise patient care with potential to revolutionise patient outcomes, moving towards transmural healing as the holy grail of therapy in IBD.
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Affiliation(s)
- Aysha H Al-Ani
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Gastroenterology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Rose Vaughan
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Gastroenterology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Britt Christensen
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Gastroenterology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Robert V Bryant
- Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville, Australia
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Kerri L Novak
- Department of Gastroenterology, The University of Calgary, Alberta, Australia
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Abstract
Renal and urinary tract complications related to inflammatory bowel disease (IBD) have been relatively understudied in the literature compared with other extraintestinal manifestations. Presentation of these renal manifestations can be subtle, and their detection is complicated by a lack of clarity regarding the optimal screening and routine monitoring of renal function in IBD patients. Urolithiasis is the most common manifestation. Penetrating Crohn's disease involving the genitourinary system as an extraintestinal complication is rare but associated with considerable morbidity. Some biologic agents used to treat IBD have been implicated in progressive renal impairment, although differentiating between drug-related side effects and deteriorating kidney function due to extraintestinal manifestations can be challenging. The most common findings on renal biopsy of IBD patients with renal injury are tubulointerstitial nephritis and IgA nephropathy, the former also being associated with drug-induced nephrotoxicity related to IBD medication. Amyloidosis, albeit rare, must be diagnosed early to reduce the chance of progression to renal failure. In this review, we evaluate the key literature relating to renal and urological involvement in IBD and emphasize the high index of suspicion required for the prompt diagnosis and treatment of these manifestations and complications, considering the potential severity and implications of acute or chronic loss of renal function. We also provide suggestions for future research priorities.
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Affiliation(s)
- Shankar Kumar
- Centre for Medical Imaging, University College London, London, UK
| | - Richard Pollok
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - David Goldsmith
- Renal and Transplantation Department, Guys and St Thomas' Hospitals NHS Foundation Trust, Great Maze Pond, London, UK
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11
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Wilkens R, Liao D, Gregersen H, Glerup H, Peters DA, Buchard C, Tøttrup A, Krogh K. Biomechanical Properties of Strictures in Crohn’s Disease: Can Dynamic Contrast-Enhanced Ultrasonography and Magnetic Resonance Enterography Predict Stiffness? Diagnostics (Basel) 2022; 12:1370. [PMID: 35741180 PMCID: PMC9221822 DOI: 10.3390/diagnostics12061370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/24/2022] [Accepted: 05/31/2022] [Indexed: 11/17/2022] Open
Abstract
Strictures and abdominal pain often complicate Crohn’s disease (CD). The primary aim was to explore whether parameters obtained by preoperative contrast-enhanced (CE) ultrasonography (US) and dynamic CE MR Enterography (DCE-MRE) of strictures associates with biomechanical properties. CD patients undergoing elective small intestinal surgery were preoperatively examined with DCE-MRE and CEUS. The excised intestine was distended utilizing a pressure bag. Luminal and outer bowel wall cross-sectional areas were measured with US. The circumferential stricture stiffness (Young’s modulus E) was computed. Stiffness was associated with the initial slope of enhancement on DCE-MRE (ρ = 0.63, p = 0.007), reflecting active disease, but lacked association with CEUS parameters. For structural imaging parameters, inflammation and stricture stiffness were associated with prestenotic dilatation on US (τb = 0.43, p = 0.02) but not with MRE (τb = 0.01, p = 1.0). Strictures identified by US were stiffer, 16.8 (14.0–20.1) kPa, than those graded as no or uncertain strictures, 12.6 (10.5–15.1) kPa, p = 0.02. MRE global score (activity) was associated with E (ρ = 0.55, p = 0.018). Elastography did not correlate with circumferential stiffness. We conclude that increasing activity defined by the initial slope of enhancement on DCE-MRE and MRE global score were associated with stricture stiffness. Prestenotic dilatation on US could be a potential biomarker of CD small intestinal stricture stiffness.
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12
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Hata J, Imamura H. The Use of Transabdominal Ultrasound in Inflammatory Bowel Disease. Korean J Radiol 2022; 23:308-321. [PMID: 35213095 PMCID: PMC8876649 DOI: 10.3348/kjr.2021.0692] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/11/2021] [Accepted: 12/20/2021] [Indexed: 11/18/2022] Open
Abstract
Transabdominal ultrasound (TAUS) is useful in all aspects of lesion screening, monitoring activity, or treating/diagnosing any related complications of inflammatory bowel disease. Its ability to screen or diagnose complications is almost the same as that of other methods, such as CT or MRI. Moreover, its noninvasiveness makes it a first-line examination method. A TAUS image depicting ulcerative colitis will show large intestinal wall thickening that is continuous from the rectum, which is mainly due to mucosal layer thickening, while for Crohn’s disease, a TAUS image is characterized by a diversity in the areas affected, distribution, and layer structure. Indicators of activity monitoring include wall thickness, wall structure, and vascular tests that use Doppler ultrasound or contrast agents. While all of these have been reported to be useful, at this time, no single parameter has been established as superior to others; therefore, a comprehensive evaluation of these parameters is justified. In addition, evaluating the elasticity of lesions using elastography is particularly useful for distinguishing between fibrous and inflammatory stenoses. However, the lack of objectivity is the biggest drawback of using ultrasound. Standardizing and popularizing the ultrasound process will be necessary, including scanning methods, equipment settings, and image analysis.
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Affiliation(s)
- Jiro Hata
- Division of Endoscopy and Ultrasound, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan.
| | - Hiroshi Imamura
- Division of Endoscopy and Ultrasound, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
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13
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Mitselos IV, Fousekis FS, Lamouri C, Katsanos KH, Christodoulou DK. Current noninvasive modalities in Crohn's disease monitoring. Ann Gastroenterol 2021; 34:770-780. [PMID: 34815642 PMCID: PMC8596218 DOI: 10.20524/aog.2021.0648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/16/2021] [Indexed: 12/01/2022] Open
Abstract
Crohn’s disease (CD) is characterized by a remitting and relapsing course. Longstanding active CD may result in accumulating intestinal damage and disease-related complications. In contrast, mucosal healing is associated with significant improvement in the health-related quality of life, longer periods of disease remission and lower risk of disease progression, complications, hospitalizations, intestinal surgeries, as well as a lower risk of developing colorectal cancer. Mucosal healing, the new treatment endpoint in CD, made necessary the development of noninvasive, accurate, objective and reliable tools for the evaluation of CD activity. Ileocolonoscopy with biopsies remains the reference standard method for the evaluation of the colonic and terminal ileal mucosa. However, it is an invasive procedure with a low risk of complications, allowing the investigation of only a small part of the small bowel mucosa without being able to assess transmural inflammation. These disadvantages limit its role in the frequent follow up of CD patients. In this review, we present the currently available biomarkers and imaging modalities for the noninvasive assessment of CD activity.
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Affiliation(s)
- Ioannis V Mitselos
- Department of Gastroenterology, General Hospital of Ioannina (Ioannis V. Mitselos)
| | - Fotios S Fousekis
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina (Fotios S. Fousekis, Charikleia Lamouri, Konstantinos H. Katsanos, Dimitrios K. Christodoulou), Greece
| | - Charikleia Lamouri
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina (Fotios S. Fousekis, Charikleia Lamouri, Konstantinos H. Katsanos, Dimitrios K. Christodoulou), Greece
| | - Konstantinos H Katsanos
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina (Fotios S. Fousekis, Charikleia Lamouri, Konstantinos H. Katsanos, Dimitrios K. Christodoulou), Greece
| | - Dimitrios K Christodoulou
- Department of Gastroenterology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina (Fotios S. Fousekis, Charikleia Lamouri, Konstantinos H. Katsanos, Dimitrios K. Christodoulou), Greece
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14
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Frias-Gomes C, Torres J, Palmela C. Intestinal Ultrasound in Inflammatory Bowel Disease: A Valuable and Increasingly Important Tool. GE Port J Gastroenterol 2021; 29:223-239. [PMID: 35979252 PMCID: PMC9275009 DOI: 10.1159/000520212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022]
Abstract
Background Intestinal ultrasound is emerging as a non-invasive tool for monitoring disease activity in inflammatory bowel disease patients due to its low cost, excellent safety profile, and availability. Herein, we comprehensively review the role of intestinal ultrasound in the management of these patients. Summary Intestinal ultrasound has a good accuracy in the diagnosis of Crohn's disease, as well as in the assessment of disease activity, extent, and evaluating disease-related complications, namely strictures, fistulae, and abscesses. Even though not fully validated, several scores have been developed to assess disease activity using ultrasound. Importantly, intestinal ultrasound can also be used to assess response to treatment. Changes in ultrasonographic parameters are observed as early as 4 weeks after treatment initiation and persist during short- and long-term follow-up. Additionally, Crohn's disease patients with no ultrasound improvement seem to be at a higher risk of therapy intensification, need for steroids, hospitalisation, or even surgery. Similarly to Crohn's disease, intestinal ultrasound has a good performance in the diagnosis, activity, and disease extent assessment in ulcerative colitis patients. In fact, in patients with severe acute colitis, higher bowel wall thickness at admission is associated with the need for salvage therapy and the absence of a significant decrease in this parameter may predict the need for colectomy. Short-term data also evidence the role of intestinal ultrasound in evaluating therapy response, with ultrasound changes observed after 2 weeks of treatment and significant improvement after 12 weeks of follow-up in ulcerative colitis. Key Messages Intestinal ultrasound is a valuable tool to assess disease activity and complications, and to monitor response to therapy. Even though longer prospective data are warranted, intestinal ultrasound may lead to a change in the paradigm of inflammatory bowel disease management as it can be used in a point-of-care setting, enabling earlier intervention if needed.
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Affiliation(s)
- Catarina Frias-Gomes
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Joana Torres
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
- Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Carolina Palmela
- Gastroenterology Division, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
- *Carolina Palmela,
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Golusda L, Kühl AA, Siegmund B, Paclik D. Extracellular Matrix Components as Diagnostic Tools in Inflammatory Bowel Disease. Biology 2021; 10:1024. [PMID: 34681123 PMCID: PMC8533508 DOI: 10.3390/biology10101024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/14/2021] [Accepted: 09/30/2021] [Indexed: 12/20/2022]
Abstract
Simple Summary For decades, the extracellular matrix (ECM) has been defined as a structure component playing a rather neglected role in the human body. In recent years, research has shed light on the role of ECM within cellular processes, including proliferation, migration and differentiation, as well as in inflammation. In inflammation, ECM composition is constantly being remodeled and undergoes dynamic and rapid changes. Tracking these changes could serve as a novel diagnostic tool. Inflammatory bowel disease is accompanied by complications such as fibrosis, stenosis and fistulas. All of these structural complications involve excessive synthesis or degradation of ECM. With this review, we explored whether the analysis of ECM composition can be of support in diagnosing inflammatory bowel disease and whether changes within ECM can help to predict a complicated disease course early on. Abstract Work from the last years indicates that the extracellular matrix (ECM) plays a direct role in various cellular processes, including proliferation, migration and differentiation. Besides homeostatic processes, its regulatory function in inflammation becomes more and more evident. In inflammation, such as inflammatory bowel disease, the ECM composition is constantly remodeled, and this can result in a structuring of fistulizing disease course. Thus, tracking early ECM changes might bear the potential to predict the disease course. In this review, we provide an overview of relevant diagnostic methods, focusing on ECM changes.
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Jauregui-Amezaga A, Rimola J. Role of Intestinal Ultrasound in the Management of Patients with Inflammatory Bowel Disease. Life (Basel) 2021; 11:603. [PMID: 34201630 DOI: 10.3390/life11070603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/13/2021] [Accepted: 06/18/2021] [Indexed: 12/11/2022] Open
Abstract
Intestinal ultrasound (IUS) has gained popularity as a first line technique for the diagnosis and monitoring of patients with inflammatory bowel diseases (IBD) due to its many advantages. It is a non-invasive imaging technique with non-ionizing radiation exposure. It can be easily performed not only by radiologists but also by trained gastroenterologists at outpatient clinics. In addition, the cost of IUS equipment is low when compared with other imaging techniques. IUS is an accurate technique to detect inflammatory lesions and complications in the bowel in patients with suspected or already known Crohn’s disease (CD). Recent evidence indicates that IUS is a convenient and accurate technique to assess extension and activity in the colon in patients with ulcerative colitis (UC), and can be a non-invasive alternative to endoscopy. In patients with IBD, several non-specific pathological ultrasonographic signs can be identified: bowel wall thickening, alteration of the bowel wall echo-pattern, loss of bowel stratification, increased vascularization, decreased bowel peristalsis, fibro-fatty proliferation, enlarged lymph nodes, and/or abdominal free fluid. Considering the transmural CD inflammation, CD complications such as presence of strictures, fistulae, or abscesses can be detected. In patients with UC, where inflammation is limited to mucosa, luminal inflammatory ultrasonographic changes are similar to those of CD. As the technique is related to the operator’s experience, adequate IUS training, performance in daily practice, and a generalized use of standardized parameters will help to increase its reproducibility.
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Ferretti F, Cannatelli R, Ardizzone S, Maier JA, Maconi G. Ultrasonographic Evaluation of Intestinal Fibrosis and Inflammation in Crohn's Disease. The State of the Art. Front Pharmacol 2021; 12:679924. [PMID: 33981246 PMCID: PMC8107820 DOI: 10.3389/fphar.2021.679924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/09/2021] [Indexed: 12/16/2022] Open
Abstract
The evaluation of the degree of inflammation and fibrosis, intrinsic elements in intestinal wall damage of Crohn’s disease, is essential to individuate the extent of the lesions and the presence of strictures. This information will contribute to the choice of the appropriate therapeutic approach, the prediction of the response to therapy and the course of the disease. The accurate evaluation of the extent and severity of inflammation and/or fibrosis in Crohn’s disease currently requires histopathological analysis of the intestinal wall. However, in clinical practice and research, transmural assessment of the intestinal wall with cross sectional imaging is increasingly used for this purpose. The B-mode ultrasonograhic characteristics of the intestinal wall, the assessment of its vascularization by color Doppler and I.V. contrast agents, and the evaluation of the mechanical and elastic properties by sonoelastography, may provide useful and accurate information on the severity and extent of inflammation and intestinal fibrosis in Crohn’s disease. The purpose of this review is to provide an update on current sonographic methods to discriminate inflammation and fibrosis in Crohn’s disease.
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Affiliation(s)
- Francesca Ferretti
- Gastroenterology Unit-ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences (DIBIC) L. Sacco, Università degli Studi di Milano, Milan, Italy
| | - Rosanna Cannatelli
- Gastroenterology Unit-ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences (DIBIC) L. Sacco, Università degli Studi di Milano, Milan, Italy
| | - Sandro Ardizzone
- Gastroenterology Unit-ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences (DIBIC) L. Sacco, Università degli Studi di Milano, Milan, Italy
| | - Jeanette A Maier
- General Pathology-Department of Biomedical and Clinical Sciences (DIBIC) L. Sacco, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Maconi
- Gastroenterology Unit-ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences (DIBIC) L. Sacco, Università degli Studi di Milano, Milan, Italy
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18
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Novak KL, Nylund K, Maaser C, Petersen F, Kucharzik T, Lu C, Allocca M, Maconi G, de Voogd F, Christensen B, Vaughan R, Palmela C, Carter D, Wilkens R. Expert Consensus on Optimal Acquisition and Development of the International Bowel Ultrasound Segmental Activity Score [IBUS-SAS]: A Reliability and Inter-rater Variability Study on Intestinal Ultrasonography in Crohn's Disease. J Crohns Colitis 2021; 15:609-616. [PMID: 33098642 PMCID: PMC8023841 DOI: 10.1093/ecco-jcc/jjaa216] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Intestinal ultrasound [IUS] is an accurate, patient-centreed monitoring tool that objectively evaluates Crohn's disease [CD] activity. However no current, widely accepted, reproducible activity index exists to facilitate consistent IUS identification of inflammatory activity. The aim of this study is to identify key parameters of CD inflammation on IUS, evaluate their reliability, and develop an IUS index reflecting segmental activity. METHODS There were three phases: [1] expert consensus Delphi method to derive measures of IUS activity; [2] an initial, multi-expert case acquisition and expert interpretation of 20 blinded cases, to measure inter-rater reliability for individual measures; [3] refinement of case acquisition and interpretation by 12 international experts, with 30 blinded case reads with reliability assessment and development of a segmental activity score. RESULTS Delphi consensus: 11 experts representing seven countries identified four key parameters including: [1] bowel wall thickness [BWT]; [2] bowel wall stratification; [3] hyperaemia of the wall [colour Doppler imaging]; and [4] inflammatory mesenteric fat. Blind read: each variable exhibited moderate to substantial reliability. Optimal, standardised image and cineloop acquisition were established. Second blind read and score development: intra-class correlation coefficient [ICC] for BWT was almost perfect at 0.96 [0.94-0.98]. All four parameters correlated with the global disease activity assessment and were included in the final International Bowel Ultrasound Segmental Activity Score with almost perfect ICC (0.97 [0.95-0.99, p <0.001]). CONCLUSIONS Using expert consensus and standardised approaches, identification of key activity measurements on IUS has been achieved and a segmental activity score has been proposed, demonstrating excellent reliability.
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Affiliation(s)
- Kerri L Novak
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, AB, Canada
| | - Kim Nylund
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
- Institute of Clinical Medicine, University in Bergen, Klinisk institutt 1, Bergen, Norway
| | - Christian Maaser
- Outpatient Department of Gastroenterology, Department of Geriatric Medicine, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Frauke Petersen
- Department of Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Torsten Kucharzik
- Department of Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Cathy Lu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, AB, Canada
| | - Mariangela Allocca
- Humanitas Clinical and Research Centre, Rozzano, Italy
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences. FBF- L.Sacco University Hospital, Milan. Italy
| | - Floris de Voogd
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Britt Christensen
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, VIC Australia
| | - Rose Vaughan
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville, VIC Australia
| | - Carolina Palmela
- Division of Gastroenterology, Department of General Surgery, Hospital Beatriz Ângelo, Loures, Portugal
| | - Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Centre, Tel Hashomer, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rune Wilkens
- Gastrounit, Division of Medicine, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
- Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents and Adults, University of Copenhagen, Hvidovre Hospital, Copenhagen, Denmark
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Jing J, Wu Y, Zhang H, Zhang Y, Mu J, Luo Y, Zhuang H. The establishment of a regression model from four modes of ultrasound to predict the activity of Crohn's disease. Sci Rep 2021; 11:77. [PMID: 33420168 DOI: 10.1038/s41598-020-79944-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 11/26/2020] [Indexed: 02/05/2023] Open
Abstract
To establish a multi-parametric regression model from four modes of ultrasound to predict the activity of Crohn's disease (CD) noninvasively. Score of 150 of the Crohn’s Disease Activity Index (CDAI) was taken as the cut-off value to divide the involved bowel segments of 51 patients into the active and inactive group. Eleven parameters from four modes of ultrasound (B-mode ultrasonography, color Doppler flow imaging, contrast-enhanced ultrasonography and shear wave elastography) were compared between the two groups to investigate the relationship between multimodal ultrasonic features and CD activity. P < 0.05 was considered statistically significant. Parameters with AUC larger than 0.5 was selected to establish the prediction model of CDAI. Totally seven ultrasound parameters (bowel wall thickness, mesenteric fat thickness, peristalsis, texture of enhancement, Limberg grade, bowel wall perforation and bowel wall stratification) were significantly different between active and inactive group. A regression model was established based on the seven parameters as followed: CDAI = 211.325 + 3.186BWT − 53.003BWS + 6.280BWP + 0.392MFT + 22.239PS + 79.012LG + 72.793TE. (R2 = 0.72, P = 0.037). The multimodal ultrasound parametric regression model was designed to predict CDAI score invasively. The model has the potential to provide an alternative method for quantifying the CD activity.
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20
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Bhatnagar G, Rodriguez-Justo M, Higginson A, Bassett P, Windsor A, Cohen R, Halligan S, Taylor SA. Inflammation and fibrosis in Crohn's disease: location-matched histological correlation of small bowel ultrasound features. Abdom Radiol (NY) 2021; 46:144-155. [PMID: 32564208 PMCID: PMC7864849 DOI: 10.1007/s00261-020-02603-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate the utility of mural and extramural sonographic features of Crohn's Disease as potential imaging biomarkers of inflammation and fibrosis against whole-mount histological sections. METHODS Twelve Crohn's disease patients (Mean age 35(25-69), 7 males) underwent small bowel ultrasound prior to small bowel resection. Two radiologists in consensus graded multiple parameters including mural, mucosal and submucosal thickness, submucosal/mesenteric echogenicity and clarity and mural Doppler signal in 50 selected bowel cross-sections. Matching with histological sampling sites was facilitated via scanning of the resected specimen. A histopathologist scored acute and chronic inflammation, and fibrosis (using histological scoring systems) following analysis of whole mount block sections. The association between sonographic observations and histopathological scores was examined via univariable and multivariable analysis. RESULTS In univariate analyses, bowel wall thickness (regression co-efficient and 95% CI 0.8 (0.3, 1.3) p = 0.001), mesenteric fat echogenicity (8.7(3.0, 14.5) p = 0.005), submucosal layer thickness (7.4(1.2, 13.5) p = 0.02), submucosal layer clarity (4.4(0.6, 8.2) p = 0.02) and mucosal layer thickness (4.6(1.8, 7.4) p = 0.001) were all significantly associated with acute inflammation. Mesenteric fat echogenicity (674(8.67, 52404) p = 0.009), submucosal layer thickness (79.9(2.16, 2951) p = 0.02) and mucosal layer thickness (13.6(1.54, 121) p = 0.02) were significantly associated with chronic inflammation. Submucosal layer echogenicity (p = 0.03), clarity (25.0(1.76, 356) p = 0.02) and mucosal layer thickness (53.8(3.19, 908) p = 0.006) were significantly associated with fibrosis. In multivariate analyses, wall and mucosal thickness remained significantly associated with acute inflammation (p = 0.02), mesenteric fat echogenicity with chronic inflammation (p = 0.009) and mucosal thickness (p = 0.006) with fibrosis. CONCLUSION Multiple sonographic parameters are associated with histological phenotypes in Crohn's disease although there is overlap between ultrasonic stigmata of acute inflammation, chronic inflammation and fibrosis.
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Affiliation(s)
- Gauraang Bhatnagar
- grid.83440.3b0000000121901201Centre for Medical Imaging, University College London, 2nd Floor Charles Bell House, 43-45 Foley Street, London, W1W 7TS UK
| | - Manuel Rodriguez-Justo
- grid.439749.40000 0004 0612 2754Department of Histology, University College Hospitals, London, UK
| | - Antony Higginson
- grid.415470.30000 0004 0392 0072Department of Radiology, Queen Alexandra Hospital, Portsmouth, UK
| | | | - Alastair Windsor
- grid.439749.40000 0004 0612 2754Department of Colorectal Surgery, University College Hospitals, London, UK
| | - Richard Cohen
- grid.439749.40000 0004 0612 2754Department of Colorectal Surgery, University College Hospitals, London, UK
| | - Steve Halligan
- grid.83440.3b0000000121901201Centre for Medical Imaging, University College London, 2nd Floor Charles Bell House, 43-45 Foley Street, London, W1W 7TS UK
| | - Stuart A. Taylor
- grid.83440.3b0000000121901201Centre for Medical Imaging, University College London, 2nd Floor Charles Bell House, 43-45 Foley Street, London, W1W 7TS UK
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21
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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. Radiología (English Edition) 2021. [DOI: 10.1016/j.rxeng.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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22
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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. Gastroenterol Hepatol 2020; 44:158-174. [PMID: 33309386 DOI: 10.1016/j.gastrohep.2020.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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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 (Engl Ed) 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kamel S, Sakr M, Hamed W, Eltabbakh M, Askar S, Bassuny A, Hussein R, Elbaz A. Comparative study between bowel ultrasound and magnetic resonance enterography among Egyptian inflammatory bowel disease patients. World J Gastroenterol 2020; 26:5884-5895. [PMID: 33132642 PMCID: PMC7579751 DOI: 10.3748/wjg.v26.i38.5884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/11/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Bowel ultrasound and magnetic resonance enterography (MRE) are decisive medical imaging modalities for diagnosing and locating bowel lesions with its extramural extent and complications. They assess the degree of activity, help clinicians to identify patients in need of surgery, and can be used for patient follow-up.
AIM To compare the role of MRE and bowel ultrasound in diagnosis and follow-up of inflammatory bowel disease (IBD) patients in Egypt.
METHODS The study was conducted on 40 patients with IBD. All patients were subjected to clinical assessment, laboratory investigations, bowel ultrasound, MRE, and colonoscopy up to the terminal ileum with biopsies for histopathological examination.
RESULTS This study was conducted on 14 patients (35%) with ulcerative colitis and 26 patients (65%) with Crohn's disease; 34 (85%) of these patients had active disease. Bowel ultrasound detected different bowel lesions with the following accuracies: ileum (85%), large bowel (70%), fistula (95%), stricture and proximal dilatation (95%) and abscesses (100%). Also, it showed that statistically significance of bowel ultrasound in differentiation between remission and activity of IBD in comparison to MRE and colonoscopy.
CONCLUSION In comparison to MRE, bowel ultrasound is a useful, non-invasive, and feasible bedside imaging tool for the detection of inflammation, detection of complications, and follow-up of IBD patients when performed by the attending physician.
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Affiliation(s)
- Shimaa Kamel
- Department of Tropical Medicine, Gastroenterology and Hepatology, Ain Shams University, Cairo 11566, Egypt
| | - Mohamed Sakr
- Department of Tropical Medicine, Gastroenterology and Hepatology, Ain Shams University, Cairo 11566, Egypt
| | - Waleed Hamed
- Department of Tropical Medicine, Gastroenterology and Hepatology, Ain Shams University, Cairo 11566, Egypt
| | - Mohamed Eltabbakh
- Department of Tropical Medicine, Gastroenterology and Hepatology, Ain Shams University, Cairo 11566, Egypt
| | - Safaa Askar
- Department of Tropical Medicine, Gastroenterology and Hepatology, Ain Shams University, Cairo 11566, Egypt
| | - Ahmed Bassuny
- Department of Tropical Medicine, Gastroenterology and Hepatology, Ain Shams University, Cairo 11566, Egypt
| | - Rasha Hussein
- Department of Radiology, Ain Shams University and MR Unit of Misr Radiology Center, Cairo 11566, Egypt
| | - Ahmed Elbaz
- Department of Tropical Medicine, Gastroenterology and Hepatology, Ain Shams University, Cairo 11566, Egypt
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Taylor SA, Mallett S, Bhatnagar G, Morris S, Quinn L, Tomini F, Miles A, Baldwin-Cleland R, Bloom S, Gupta A, Hamlin PJ, Hart AL, Higginson A, Jacobs I, McCartney S, Murray CD, Plumb AA, Pollok RC, Rodriguez-Justo M, Shabir Z, Slater A, Tolan D, Travis S, Windsor A, Wylie P, Zealley I, Halligan S. Magnetic resonance enterography compared with ultrasonography in newly diagnosed and relapsing Crohn's disease patients: the METRIC diagnostic accuracy study. Health Technol Assess 2020; 23:1-162. [PMID: 31432777 DOI: 10.3310/hta23420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Magnetic resonance enterography and enteric ultrasonography are used to image Crohn's disease patients. Their diagnostic accuracy for presence, extent and activity of enteric Crohn's disease was compared. OBJECTIVE To compare diagnostic accuracy, observer variability, acceptability, diagnostic impact and cost-effectiveness of magnetic resonance enterography and ultrasonography in newly diagnosed or relapsing Crohn's disease. DESIGN Prospective multicentre cohort study. SETTING Eight NHS hospitals. PARTICIPANTS Consecutive participants aged ≥ 16 years, newly diagnosed with Crohn's disease or with established Crohn's disease and suspected relapse. INTERVENTIONS Magnetic resonance enterography and ultrasonography. MAIN OUTCOME MEASURES The primary outcome was per-participant sensitivity difference between magnetic resonance enterography and ultrasonography for small bowel Crohn's disease extent. Secondary outcomes included sensitivity and specificity for small bowel Crohn's disease and colonic Crohn's disease extent, and sensitivity and specificity for small bowel Crohn's disease and colonic Crohn's disease presence; identification of active disease; interobserver variation; participant acceptability; diagnostic impact; and cost-effectiveness. RESULTS Out of the 518 participants assessed, 335 entered the trial, with 51 excluded, giving a final cohort of 284 (133 and 151 in new diagnosis and suspected relapse cohorts, respectively). Across the whole cohort, for small bowel Crohn's disease extent, magnetic resonance enterography sensitivity [80%, 95% confidence interval (CI) 72% to 86%] was significantly greater than ultrasonography sensitivity (70%, 95% CI 62% to 78%), with a 10% difference (95% CI 1% to 18%; p = 0.027). For small bowel Crohn's disease extent, magnetic resonance enterography specificity (95%, 95% CI 85% to 98%) was significantly greater than ultrasonography specificity (81%, 95% CI 64% to 91%), with a 14% difference (95% CI 1% to 27%). For small bowel Crohn's disease presence, magnetic resonance enterography sensitivity (97%, 95% CI 91% to 99%) was significantly greater than ultrasonography sensitivity (92%, 95% CI 84% to 96%), with a 5% difference (95% CI 1% to 9%). For small bowel Crohn's disease presence, magnetic resonance enterography specificity was 96% (95% CI 86% to 99%) and ultrasonography specificity was 84% (95% CI 65% to 94%), with a 12% difference (95% CI 0% to 25%). Test sensitivities for small bowel Crohn's disease presence and extent were similar in the two cohorts. For colonic Crohn's disease presence in newly diagnosed participants, ultrasonography sensitivity (67%, 95% CI 49% to 81%) was significantly greater than magnetic resonance enterography sensitivity (47%, 95% CI 31% to 64%), with a 20% difference (95% CI 1% to 39%). For active small bowel Crohn's disease, magnetic resonance enterography sensitivity (96%, 95% CI 92% to 99%) was significantly greater than ultrasonography sensitivity (90%, 95% CI 82% to 95%), with a 6% difference (95% CI 2% to 11%). There was some disagreement between readers for both tests. A total of 88% of participants rated magnetic resonance enterography as very or fairly acceptable, which is significantly lower than the percentage (99%) of participants who did so for ultrasonography. Therapeutic decisions based on magnetic resonance enterography alone and ultrasonography alone agreed with the final decision in 122 out of 158 (77%) cases and 124 out of 158 (78%) cases, respectively. There were no differences in costs or quality-adjusted life-years between tests. LIMITATIONS Magnetic resonance enterography and ultrasonography scans were interpreted by practitioners blinded to clinical data (but not participant cohort), which does not reflect use in clinical practice. CONCLUSIONS Magnetic resonance enterography has higher accuracy for detecting the presence, extent and activity of small bowel Crohn's disease than ultrasonography does. Both tests have variable interobserver agreement and are broadly acceptable to participants, although ultrasonography produces less participant burden. Diagnostic impact and cost-effectiveness are similar. Recommendations for future work include investigation of the comparative utility of magnetic resonance enterography and ultrasonography for treatment response assessment and investigation of non-specific abdominal symptoms to confirm or refute Crohn's disease. TRIAL REGISTRATION Current Controlled Trials ISRCTN03982913. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 42. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Sue Mallett
- Institute of Applied Health Research, National Institute for Health Research Birmingham Biomedical Research Centre, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Stephen Morris
- Applied Health Research, University College London, London, UK
| | - Laura Quinn
- Institute of Applied Health Research, National Institute for Health Research Birmingham Biomedical Research Centre, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Florian Tomini
- Applied Health Research, University College London, London, UK
| | - Anne Miles
- Department of Psychological Sciences, Birkbeck, University of London, London, UK
| | - Rachel Baldwin-Cleland
- Intestinal Imaging Centre, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Stuart Bloom
- Department of Gastroenterology, University College Hospital, London, UK
| | - Arun Gupta
- Intestinal Imaging Centre, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Peter John Hamlin
- Department of Gastroenterology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ailsa L Hart
- Inflammatory Bowel Disease Unit, St Mark's Hospital, London North West University Healthcare NHS Trust, Harrow, UK
| | - Antony Higginson
- Department of Radiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Ilan Jacobs
- Independent patient representative, c/o Centre for Medical Imaging, University College London, London, UK
| | - Sara McCartney
- Department of Gastroenterology, University College Hospital, London, UK
| | - Charles D Murray
- Department of Gastroenterology and Endoscopy, Royal Free London NHS Foundation Trust, London, UK
| | - Andrew Ao Plumb
- Centre for Medical Imaging, University College London, London, UK
| | - Richard C Pollok
- Department of Gastroenterology, St George's Hospital, London, UK
| | | | - Zainib Shabir
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Andrew Slater
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Damian Tolan
- Department of Radiology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Simon Travis
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Peter Wylie
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Ian Zealley
- Department of Radiology, Ninewells Hospital, Dundee, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
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Zorzi F, Ghosh S, Chiaramonte C, Lolli E, Ventura M, Onali S, De Cristofaro E, Fantini MC, Biancone L, Monteleone G, Calabrese E. Response Assessed by Ultrasonography as Target of Biological Treatment for Crohn's Disease. Clin Gastroenterol Hepatol 2020; 18:2030-2037. [PMID: 31866561 DOI: 10.1016/j.cgh.2019.10.042] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/15/2019] [Accepted: 10/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Mucosal healing, determined by ileocolonoscopy, is a goal for treatment of Crohn's disease (CD), but this is an invasive assessment procedure. We investigated whether response to tumor necrosis factor (TNF) antagonists, determined by small-intestine contrast ultrasonography, associates with long-term outcomes. METHODS We performed observational study of 80 patients with CD treated with anti-TNF agents for at least 1 year who underwent serial small intestine contrast ultrasonography (SICUS) at the University of Rome, in Italy. SICUS was used to evaluate disease site (based on bowel wall thickness), extent of lesions, and presence of complications. Inclusion criteria required pre-therapy SICUS with follow-up SICUS after 18 months. At second SICUS, patients were assigned to categories of complete or partial responder or non-responder. CD-related outcomes (corticosteroid need, hospitalization, and surgery) were assessed at 1 year from the second SICUS, using multivariate models, and were analyzed after long term follow up (5 years) using Kaplan-Meier survival analysis. RESULTS Based on SICUS, after a median of 18 months, 36 patients (51%) were complete responders, 30 were partial responders (34%), and 13 were non-responders (15%). At 1 year from the second SICUS, no patients with a complete response, based on ultrasonography, underwent surgery, in comparison to partial responders (P = .0003) or non-responders (P = .001). Complete responders used smaller amounts of corticosteroids than partial responders (P = .0001) or non-responders (P < .0001). Complete responders required fewer hospitalizations than non-responders (P = .001). Kaplan-Meier survival analysis of long-term follow up data demonstrated a lower cumulative probability of need for surgery, hospitalization, and need for steroids among SICUS-categorized complete responders (P < .0001, P = .003 and P = .0001 respectively) than SICUS-categorized non-responders. CONCLUSIONS In patients with CD, response to anti-TNF agents, determined by SICUS, is associated with better long-term outcomes than partial or no response. Ultrasonographic assessment therefore provides a relatively non-invasive method for monitoring response to treatment in patients with CD.
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Affiliation(s)
- Francesca Zorzi
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Subrata Ghosh
- NIHR Biomedical Research Centre Birmingham, University of Birmingham, Birmingham, United Kingdom
| | - Carlo Chiaramonte
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Elisabetta Lolli
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Martina Ventura
- Department of Epidemiology, Lazio Regional Health Service, Rome Italy
| | - Sara Onali
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Elena De Cristofaro
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Massimo C Fantini
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Livia Biancone
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giovanni Monteleone
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Emma Calabrese
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
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Nachand D, Gandhi NS. Imaging of bowel in patients requiring surgery for Crohn's disease. Seminars in Colon and Rectal Surgery 2020. [DOI: 10.1016/j.scrs.2020.100741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Wu S, Zhuang H, Zhao JY, Wang YF. Gastrocolic fistula in Crohn’s disease detected by oral agent contrast-enhanced ultrasound: A case report of a novel ultrasound modality. World J Gastroenterol 2020; 26:2119-2125. [PMID: 32536779 PMCID: PMC7267691 DOI: 10.3748/wjg.v26.i17.2119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/31/2020] [Accepted: 04/09/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Fistulas are common complications of Crohn’s disease (CD). Gastrocolic fistulas (GFs) are rare, occult and potentially life-threatening complications. Few cases of GFs have been reported. Oral agent contrast-enhanced ultrasound (OA-CEUS) is a novel technique of ultrasound (US) for gut. Contrast agent made by Chinese yam is taken orally to dilate the lumen of the upper gastrointestinal tract. Thus, the impediment of gas inside gastrointestinal tract is removed and a good acoustic window is provided for gastroin-testinal tract scanning. This paper describes a case of GF secondary to CD detected by OA-CEUS when it was missed by endoscopy and computed tomography (CT). To our knowledge, this is the first report of GF secondary to CD detected by OA-CEUS up to date.
CASE SUMMARY A 29-year-old woman with a 6-year history of CD was admitted to our hospital for abdominal pain and diarrhea for 5 months without obvious predisposing causes. Initial gastroscopy failed to show any evidence of lesions. Colonoscopy revealed multiple erosions, mucosal nodularity, linear ulcers and a cobblestone appearance. A CT scan of her abdomen showed a complex multilocular structure adherent to the greater curvature of the stomach in her left lower abdomen, with fluid, gas and significant surrounding inflammation. CT also demonstrated an abdominal abscess, which was later treated with US-guided drainage. Colonoscopy, gastroscopy and CT missed the presence of a GF. OA-CEUS was performed. A contrast agent made from Chinese yam was taken orally to dilate the lumen of the gastrointestinal tract. A good acoustic window was provided for gastrointestinal tract scanning and the impediment of gas inside the gastrointestinal tract was removed. With the aid of the “window”, a canal with hypoechoic wall was identified connecting the greater curvature of stomach to the splenic colon flexure in free sections. We also observed the hyperechoic gas flowing dynamically inside the canal. Thus, a GF was suspected. US is the first imaging modality taking GF into account. At the same time, OA-CEUS identified the site of the fistula and its two orifices. Gastroscopy was performed again, revealing a small ulcer approximately 5 mm in diameter, which was considered as an orifice. On the basis of OA-CEUS and other examinations, the patient was diagnosed with a GF secondary to CD. Then, laparoscopic exploration, partial stomach resection, transverse colostomy and abdominal abscess drainage were performed. The patient recovered uneventfully.
CONCLUSION GFs are rare, occult and potentially life-threatening complications in CD. US is one of the first-line modalities to evaluate CD and its complications. OA-CEUS, a novel technique of US for gut, may be helpful in reducing the possibility of a missed diagnosis of GF.
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Affiliation(s)
- Shuang Wu
- Department of Diagnostic Ultrasound, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hua Zhuang
- Department of Diagnostic Ultrasound, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jie-Ying Zhao
- Department of Diagnostic Ultrasound, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yu-Fang Wang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Abstract
The use of biologic agents including anti-tumor necrosis factor monoclonal antibodies followed by anti-integrins and anti-interleukins has drastically changed the treatment paradigm of Crohn’s disease (CD) by improving clinical symptoms and mucosal healing. However, up to 70% of CD patients still eventually undergo surgery mainly due to fibrostenotic strictures. There are no specific anti-fibrotic drugs yet. This review comprehensively addresses the mechanism, prediction, diagnosis and treatment of the fibrostenotic strictures in CD. We also introduce promising anti-fibrotic agents which may be available in the near future and summarize challenges in developing novel therapies to treat fibrostenotic strictures in CD.
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Affiliation(s)
- Jun Hwan Yoo
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Stefan Holubar
- Department of Colorectal Surgery, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Hakim A, Alexakis C, Pilcher J, Tzias D, Mitton S, Paul T, Saxena S, Pollok R, Kumar S. Comparison of small intestinal contrast ultrasound with magnetic resonance enterography in pediatric Crohn's disease. JGH Open 2019; 4:126-131. [PMID: 32280754 PMCID: PMC7144762 DOI: 10.1002/jgh3.12228] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 05/29/2019] [Accepted: 06/30/2019] [Indexed: 12/23/2022]
Abstract
Aim To compare the diagnostic yield of small intestinal contrast ultrasonography (SICUS) with magnetic resonance enterography (MRE) in routine clinical practice in a cohort of pediatric patients investigated for Crohn's disease (CD) attending a UK tertiary center. Methods and Results Patients with suspected or established CD who underwent SICUS were identified retrospectively. SICUS was compared to conventional transabdominal ultrasound (TUS), ileocolonoscopy (IC), and MRE. The accuracy and agreement of SICUS in detecting small bowel lesions and CD-related complications were assessed using kappa (κ) coefficient statistics. A total of 93 patients (median age 15 years, range 2-17, 49 male) underwent SICUS; 58 had suspected and 35 had established CD. In suspected CD, sensitivity and specificity of SICUS in detecting CD small bowel lesions were 81.8 and 100% and for TUS 85.7 and 87.5%, respectively. In established CD, sensitivity and specificity of SICUS were 98.7 and 100% and TUS 80 and 100%, respectively. Agreement between SICUS and IC was substantial for the presence of lesions (κ = 0.73) but fair in TUS (κ = 0.31). Agreement between SICUS and IC was almost perfect for detecting strictures (κ = 0.84), with a sensitivity of 100% and specificity of 97.6%. When comparing SICUS and TUS with MRE, agreement for the presence of lesions was substantial (κ = 0.63) and moderate (κ = 0.53), respectively. Agreement between SICUS and MRE was substantial for detecting strictures (κ = 0.77) and dilatation (κ = 0.68). Conclusions SICUS offers a radiation-free alternative for assessing pediatric small bowel CD, with diagnostic accuracy that is comparable to MRE and IC, supporting its wider use in routine practice.
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Affiliation(s)
| | - Christopher Alexakis
- Department of Gastroenterology St George's University Hospitals NHS Foundation Trust London UK
| | - James Pilcher
- Department of Radiology St George's University Hospitals NHS Foundation Trust London UK
| | - Demitrios Tzias
- Department of Radiology St George's University Hospitals NHS Foundation Trust London UK
| | - Sally Mitton
- Department of Paediatric Gastroenterology St George's University Hospitals NHS Foundation Trust London UK
| | - Thankam Paul
- Department of Paediatric Gastroenterology St George's University Hospitals NHS Foundation Trust London UK
| | - Sonia Saxena
- Child Health Unit, School of Public Health Imperial College London London UK
| | - Richard Pollok
- Medical School St George's Hospital London UK.,Department of Gastroenterology St George's University Hospitals NHS Foundation Trust London UK
| | - Shankar Kumar
- Centre for Medical Imaging University College London London UK
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Bollegala N, Griller N, Bannerman H, Habal M, Nguyen GC. Ultrasound vs Endoscopy, Surgery, or Pathology for the Diagnosis of Small Bowel Crohn's Disease and its Complications. Inflamm Bowel Dis 2019; 25:1313-1338. [PMID: 30883639 DOI: 10.1093/ibd/izy392] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND In patients with inflammatory bowel disease, we strive to achieve mucosal healing, as this has been shown to decrease the risk of disease flares, hospitalization, and surgery. For this reason, we must use objective measures of mucosal healing to inform our clinical decision-making and can no longer rely on patient symptoms alone. Assessment of small bowel Crohn's disease (SBCD) is particularly challenging given its lack of accessibility via standard endoscopic techniques. Ultrasound (US) represents a readily available, cost-effective, minimally invasive, radiation-free alternative for the assessment of small bowel disease. In this study, we performed a systematic review to determine the accuracy of ultrasound in diagnosing SBCD and its complications as compared with endoscopic visualization, surgery, and/or pathology. METHODS We searched MEDLINE, EMBASE, and CENTRAL. Prospective cohort studies published up to March 2017 were reviewed. References meeting all eligibility criteria were assessed at the full-text level by 2 independent reviewers. Sensitivity and specificity were collected where available. RESULTS A total of 2817 unique references were identified. Twenty-two studies were included. All studies were at low-moderate risk of bias based on the Quality Assessment of Diagnostic Accuracy Studies criteria. Transabdominal US (TAUS) yielded moderately high sensitivity and specificity for the diagnosis of SBCD and its postoperative recurrence. Detection was more accurate for severe postoperative recurrence. The diagnostic accuracy of US in stricture and abscess detection was high. Contrast enhancement improved the detection of abscess. Diagnostic detection of fistulas was of moderate accuracy. Entero-enteric fistulization and entero-mesenteric fistulization were most clearly identified. CONCLUSIONS Ultrasound can be used to diagnose SBCD in those with known or suspected Crohn's disease. It can be used to detect postoperative recurrence and can accurately identify abscesses and fistulas, especially with the aid of contrast enhancement.
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Affiliation(s)
- Natasha Bollegala
- Division of Gastroenterology, Department of Medicine, Women's College Hospital, Toronto, Canada
| | - Nadia Griller
- Division of Gastroenterology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Heather Bannerman
- Internal Medicine Residency Training Program, McMaster University, Hamilton, Canada
| | - Mohammed Habal
- Internal Medicine Residency Training Program, University of Toronto, Toronto, Canada
| | - Geoffrey C Nguyen
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, Toronto, Canada
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Bettenworth D, Bokemeyer A, Baker M, Mao R, Parker CE, Nguyen T, Ma C, Panés J, Rimola J, Fletcher JG, Jairath V, Feagan BG, Rieder F. Assessment of Crohn's disease-associated small bowel strictures and fibrosis on cross-sectional imaging: a systematic review. Gut 2019; 68:1115-1126. [PMID: 30944110 PMCID: PMC6580870 DOI: 10.1136/gutjnl-2018-318081] [Citation(s) in RCA: 163] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 12/12/2022]
Abstract
Patients with Crohn's disease commonly develop ileal and less commonly colonic strictures, containing various degrees of inflammation and fibrosis. While predominantly inflammatory strictures may benefit from a medical anti-inflammatory treatment, predominantly fibrotic strictures currently require endoscopic balloon dilation or surgery. Therefore, differentiation of the main components of a stricturing lesion is key for defining the therapeutic management. The role of endoscopy to diagnose the nature of strictures is limited by the superficial inspection of the intestinal mucosa, the lack of depth of mucosal biopsies and by the risk of sampling error due to a heterogeneous distribution of inflammation and fibrosis within a stricturing lesion. These limitations may be in part overcome by cross-sectional imaging techniques such as ultrasound, CT and MRI, allowing for a full thickness evaluation of the bowel wall and associated abnormalities. This systematic literature review provides a comprehensive summary of currently used radiologic definitions of strictures. It discusses, by assessing only manuscripts with histopathology as a gold standard, the accuracy for diagnosis of the respective modalities as well as their capability to characterise strictures in terms of inflammation and fibrosis. Definitions for strictures on cross-sectional imaging are heterogeneous; however, accuracy for stricture diagnosis is very high. Although conventional cross-sectional imaging techniques have been reported to distinguish inflammation from fibrosis and grade their severity, they are not sufficiently accurate for use in routine clinical practice. Finally, we present recent consensus recommendations and highlight experimental techniques that may overcome the limitations of current technologies.
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Affiliation(s)
- Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University of Münster, Münster, North Rhine-Westphalia, Germany
| | - Arne Bokemeyer
- Department of Medicine B, Gastroenterology and Hepatology, University of Münster, Münster, North Rhine-Westphalia, Germany
| | - Mark Baker
- Section of Abdominal Imaging, Imaging Institute, Digestive Disease Institute and Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Tran Nguyen
- Robarts Clinical Trials, London, Ontario, Canada
| | - Christopher Ma
- Robarts Clinical Trials, London, Ontario, Canada,Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Julián Panés
- Department of Gastroenterology, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic de Barcelona, Institut d’investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Joel G Fletcher
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vipul Jairath
- Robarts Clinical Trials, London, Ontario, Canada,Department of Medicine, Western University, London, Ontario, Canada,Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - Brian G Feagan
- Robarts Clinical Trials, London, Ontario, Canada,Department of Medicine, Western University, London, Ontario, Canada,Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - Florian Rieder
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA,Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Manetta R, Capretti I, Belleggia N, Marsecano C, Viscido A, Bruno F, Arrigoni F, Ma L, Guglielmi G, Splendiani A, Di Cesare E, Masciocchi C, Barile A. Magnetic resonance enterography (MRE) and ultrasonography (US) in the study of the small bowel in Crohn's disease: state of the art and review of the literature. Acta Biomed 2019; 90:38-50. [PMID: 31085972 PMCID: PMC6625566 DOI: 10.23750/abm.v90i5-s.8337] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Indexed: 02/06/2023]
Abstract
Crohn’s disease (CD) is a chronic idiopathic disease and its diagnosis is based on a combination of clinical symptoms, laboratory tests and imaging data. There isn’t a diagnostic gold standard: the ileocolonoscopy with mucosal biopsies represents the standard for luminal disease, while cross-sectional imaging such as Ultrasound (US), Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) can show transmural alterations and extraintestinal manifestations. CD is usually diagnosed in the young age and after baseline diagnosis, the patients have to undergo to variable follow-up depending on remission or active disease. The aim of our review is to compare Magnetic Resonance Enterography (MRE) to Ultrasonography (US) in the follow-up of CD. (www.actabiomedica.it)
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Affiliation(s)
- Rosa Manetta
- Division of Radiology, S. Salvatore Hospital, L'Aquila, Italy.
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Maaser C, Sturm A, Vavricka SR, Kucharzik T, Fiorino G, Annese V, Calabrese E, Baumgart DC, Bettenworth D, Borralho Nunes P, Burisch J, Castiglione F, Eliakim R, Ellul P, González-Lama Y, Gordon H, Halligan S, Katsanos K, Kopylov U, Kotze PG, Krustinš E, Laghi A, Limdi JK, Rieder F, Rimola J, Taylor SA, Tolan D, van Rheenen P, Verstockt B, Stoker J. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis 2019; 13:144-164. [PMID: 30137275 DOI: 10.1093/ecco-jcc/jjy113] [Citation(s) in RCA: 817] [Impact Index Per Article: 163.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Andreas Sturm
- Department of Gastroenterology, DRK Kliniken Berlin I Westend, Berlin, Germany
| | | | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Gionata Fiorino
- Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic & American Hospital, Dubai, UAE
| | - Emma Calabrese
- Department of Systems Medicine, University of Rome, Tor Vergata, Italy
| | - Daniel C Baumgart
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, Münster, Germany
| | - Paula Borralho Nunes
- Department of Anatomic Pathology, Hospital Cuf Descobertas; Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital; Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Fabiana Castiglione
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Pierre Ellul
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Yago González-Lama
- Department of Gastroenterology, University Hospital Puerta De Hierro, Majadahonda [Madrid], Spain
| | - Hannah Gordon
- Department of Gastroenterology, Royal London Hospital, London, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Paraná [PUCPR], Curitiba, Brazil
| | - Eduards Krustinš
- Department of of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Andrea Laghi
- Department of Clinical and Surgical Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester; Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Damian Tolan
- Clinical Radiology, St James's University Hospital, Leeds, UK
| | - Patrick van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, Groningen, The Netherlands
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven and CHROMETA - Translational Research in Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Center [AMC], University of Amsterdam, Amsterdam, The Netherlands
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Pallotta N, Vincoli G, Pezzotti P, Giovannone M, Gigliozzi A, Badiali D, Vernia P, Corazziari ES. A risk score system to timely manage treatment in Crohn's disease: a cohort study. BMC Gastroenterol 2018; 18:164. [PMID: 30400823 PMCID: PMC6219027 DOI: 10.1186/s12876-018-0889-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 10/17/2018] [Indexed: 12/23/2022] Open
Abstract
Background Clinical severity and intestinal lesions of Crohn’s disease (CD) usually progress over time and require a step up adjustment of the therapy either to prevent or to treat complications. The aim of the study was to develop a simple risk scoring system to assess in individual CD patients the risk of disease progression and the need for more intensive treatment and monitoring. Methods Prospective cohort study (January 2002–September 2014) including 160 CD patients (93 female, median age 31 years; disease behavior (B)1 25%, B2 55.6%, B3 19.4%; location (L)1 61%, L3 31.9%, L2 6%; L4 0.6%; perianal disease 28.8%) seen at 6–12-month interval. Median follow-up 7.9 years (IQR: 4.3–10.5 years). Poisson models were used to evaluate predictors, at each clinical assessment, of having the following outcomes at the subsequent clinical assessment a) use of steroids; b) start of azathioprine; c) start of anti-TNF-α drugs; d) need of surgery. For each outcome 32 variables, including demographic and clinical characteristics of patients and assessment of CD intestinal lesions and complications, were evaluated as potential predictors. The predictors included in the model were chosen by a backward selection. Risk scores were calculated taking for each predictor the integer part of the Poisson model parameter. Results Considering 1464 clinical assessments 12 independent risk factors were identified, CD lesions, age at diagnosis < 40 years, stricturing behavior (B2), specific intestinal symptoms, female gender, BMI < 21, CDAI> 50, presence of inflammatory markers, no previous surgery or presence of termino-terminal anastomosis, current use of corticosteroid, no corticosteroid at first flare-up. Six of these predicted steroids use (score 0–9), three to start azathioprine (score 0–4); three to start anti-TNF-α drugs (score 0–4); six need of surgery (score 0–11). The predicted percentage risk to be treated with surgery within one year since the referral assessment varied from 1 to 28%; with azathioprine from 3 to 13%; with anti-TNF-α drugs from 2 to 15%. Conclusions These scores may provide a useful clinical tool for clinicians in the prognostic assessment and treatment adjustment of Crohn’s disease in any individual patient.
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Affiliation(s)
- Nadia Pallotta
- Dipartimento di Medicina Interna e Specialità Mediche, Università "Sapienza", Policlinico "Umberto I", V.le del Policlinico, 155, 00161, Rome, Italy.
| | - Giuseppina Vincoli
- Dipartimento di Medicina Interna e Specialità Mediche, Università "Sapienza", Policlinico "Umberto I", V.le del Policlinico, 155, 00161, Rome, Italy
| | - Patrizio Pezzotti
- Dipartimento di Malattie Infettive, Istituto Superiore di Sanità, Rome, Italy
| | | | | | - Danilo Badiali
- Dipartimento di Medicina Interna e Specialità Mediche, Università "Sapienza", Policlinico "Umberto I", V.le del Policlinico, 155, 00161, Rome, Italy
| | - Piero Vernia
- Dipartimento di Medicina Interna e Specialità Mediche, Università "Sapienza", Policlinico "Umberto I", V.le del Policlinico, 155, 00161, Rome, Italy
| | - Enrico Stefano Corazziari
- Dipartimento di Medicina Interna e Specialità Mediche, Università "Sapienza", Policlinico "Umberto I", V.le del Policlinico, 155, 00161, Rome, Italy
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37
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Bots S, Nylund K, Löwenberg M, Gecse K, Gilja OH, D'Haens G. Ultrasound for Assessing Disease Activity in IBD Patients: A Systematic Review of Activity Scores. J Crohns Colitis 2018; 12:920-929. [PMID: 29684200 DOI: 10.1093/ecco-jcc/jjy048] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/16/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Ultrasound [US] indices for assessing disease activity in IBD patients have never been critically reviewed. We aimed to systematically review the quality and reliability of available ultrasound [US] indices compared with reference standards for grading disease activity in IBD patients. METHODS Pubmed, Embase and Medline were searched for relevant literature published within the period 1990 to June 2017. Relevant publications were identified through full text review after initial screening by two investigators. Data on methodology and index characteristics were collected. Study quality was assessed using a modified version of the Quadas-2 tool for risk of bias assessment. RESULTS Of 20 studies with an US index, 11 studies met the inclusion criteria. Out of these 11 studies, 7 and 4 studied Crohn's disease [CD] and ulcerative colitis [UC0 activity indices, respectively. Parameters that were used in these indices included bowel wall thickness [BWT], Doppler signal [DS], wall layer stratification [WLS], compressibility, peristalsis, haustrations, fatty wrapping, contrast enhancement [CE], and strain pattern. Study quality was graded high in 5 studies, moderate in 3 studies and low in 3 studies. Ileocolonoscopy was used as the reference standard in 9 studies. In 1 study a combined index of ileocolonoscopy and barium contrast radiography and in 1 study histology was used as the reference standard. Only 5 studies used an established endoscopic index for comparison with US. CONCLUSIONS Several US indices for assessing disease activity in IBD are available; however, the methodology for development was suboptimal in most studies. For the development of future indices, stringent methodological design is required.
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Affiliation(s)
- S Bots
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - K Nylund
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - M Löwenberg
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - K Gecse
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - O H Gilja
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - G D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Bryant RV, Friedman AB, Wright EK, Taylor KM, Begun J, Maconi G, Maaser C, Novak KL, Kucharzik T, Atkinson NSS, Asthana A, Gibson PR. Gastrointestinal ultrasound in inflammatory bowel disease: an underused resource with potential paradigm-changing application. Gut 2018; 67:973-985. [PMID: 29437914 DOI: 10.1136/gutjnl-2017-315655] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 12/13/2017] [Accepted: 12/14/2017] [Indexed: 12/20/2022]
Abstract
Evolution of treatment targets in IBD has increased the need for objective monitoring of disease activity to guide therapeutic strategy. Although mucosal healing is the current target of therapy in IBD, endoscopy is invasive, expensive and unappealing to patients. GI ultrasound (GIUS) represents a non-invasive modality to assess disease activity in IBD. It is accurate, cost-effective and reproducible. GIUS can be performed at the point of care without specific patient preparation so as to facilitate clinical decision-making. As compared with ileocolonoscopy and other imaging modalities (CT and MRI), GIUS is accurate in diagnosing IBD, detecting complications of disease including fistulae, strictures and abscesses, monitoring disease activity and detecting postoperative disease recurrence. International groups increasingly recognise GIUS as a valuable tool with paradigm-changing application in the management of IBD; however, uptake outside parts of continental Europe has been slow and GIUS is underused in many countries. The aim of this review is to present a pragmatic guide to the positioning of GIUS in IBD clinical practice, providing evidence for use, algorithms for integration into practice, training pathways and a strategic implementation framework.
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Affiliation(s)
- Robert Venning Bryant
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, Australia.,Faculty of Health Sciences, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Antony B Friedman
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Emily Kate Wright
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
| | - Kirstin M Taylor
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Jakob Begun
- Department of Gastroenterology, Mater Hospital, Brisbane, Australia.,Mater Research Institute, University of Queensland, Brisbane, Australia
| | - Giovanni Maconi
- Department of Gastroenterology, Luigi Sacco University Hospital, Milan, Italy
| | - Christian Maaser
- Department of General Internal Medicine and Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Kerri L Novak
- Division of Gastroenterology, University of Calgary, Calgary, Canada
| | - Torsten Kucharzik
- Department of General Internal Medicine and Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | | | - Anil Asthana
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
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Yusuf GT, Fang C, Huang DY, Sellars ME, Deganello A, Sidhu PS. Endocavitary contrast enhanced ultrasound (CEUS): a novel problem solving technique. Insights Imaging 2018; 9:303-311. [PMID: 29594851 PMCID: PMC5991005 DOI: 10.1007/s13244-018-0601-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 01/12/2018] [Accepted: 01/19/2018] [Indexed: 12/13/2022] Open
Abstract
Abstract Contrast-enhanced ultrasound (CEUS) is a technique that has developed as an adjunct to conventional ultrasound. CEUS offers a number of benefits over conventional axial imaging with computerised tomography and magnetic resonance imaging, primarily as a “beside” test, without ionising radiation or the safety concerns associated with iodinated/gadolinium-based contrast agents. Intravascular use of ultrasound contrast agents (UCAs) is widespread with extensive evidence for effective use. Despite this, the potential utility of UCAs in physiological and non-physiological cavities has not been fully explored. The possibilities for endocavitary uses of CEUS are described in this review based on a single-centre experience including CEUS technique and utility in confirming drain placement, as well as within the biliary system, urinary system, gastrointestinal tract and intravascular catheters. Teaching Points • CEUS offers an excellent safety profile, spatial resolution and is radiation free. • Endocavitary CEUS provides real-time imaging similar to fluoroscopy in a portable setting. • Endocavitary CEUS can define internal architecture of physiological cavities. • Endocavitary CEUS can confirm drain position in physiological and non-physiological cavities.
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Affiliation(s)
- G T Yusuf
- Department of Radiology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - C Fang
- Department of Radiology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - D Y Huang
- Department of Radiology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - M E Sellars
- Department of Radiology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - A Deganello
- Department of Radiology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - P S Sidhu
- Department of Radiology, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
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Abstract
Crohn's disease (CD) leads to the development of complications through progressive uncontrolled inflammation and the transmural involvement of the bowel wall. Most of the available literature on penetrating CD focuses on the perianal phenotype. The management of nonperianal penetrating complications poses its own set of challenges and can result in significant morbidity and an increased risk of mortality. Few controlled trials have been published evaluating this subgroup of patients for clinicians to use for guidance. Utilizing the available evidence, we review the epidemiology, presentation, and modalities used to diagnosis and assess intestinal fistulas, phlegmons, and abscesses. The literature regarding the medical, endoscopic, and surgical management options are reviewed providing physicians with a therapeutic framework to comprehensively treat these nonperianal penetrating complications. Through a multidisciplinary evidence-based approach to the complex sequela of CD outcomes can be improved and patient's quality of life enhanced.10.1093/ibd/izx108_video1izx108_Video5754037501001.
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Affiliation(s)
- Robert P Hirten
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Shailja Shah
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David B Sachar
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Pita I, Magro F. Advanced imaging techniques for small bowel Crohn's disease: what does the future hold? Therap Adv Gastroenterol 2018; 11:1756283X18757185. [PMID: 29467827 PMCID: PMC5813850 DOI: 10.1177/1756283x18757185] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/03/2018] [Indexed: 02/04/2023] Open
Abstract
Treatment of Crohn's disease (CD) is intrinsically reliant on imaging techniques, due to the preponderance of small bowel disease and its transmural pattern of inflammation. Ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) are the most widely employed imaging methods and have excellent diagnostic accuracy in most instances. Some limitations persist, perhaps the most clinically relevant being the distinction between inflammatory and fibrotic strictures. In this regard, several methodologies have recently been tested in animal models and human patients, namely US strain elastography, shear wave elastography, contrast-enhanced US, magnetization transfer MRI and contrast dynamics in standard MRI. Technical advances in each of the imaging methods may expand their indications. The addition of oral contrast to abdominal US appears to substantially improve its diagnostic capabilities compared to standard US. Ionizing dose-reduction methods in CT can decrease concern about cumulative radiation exposure in CD patients and diffusion-weighted MRI may reduce the need for gadolinium contrast. Clinical indexes of disease activity and severity are also increasingly relying on imaging scores, such as the recently developed Lémann Index. In this review we summarize some of the recent advances in small bowel CD imaging and how they might affect clinical practice in the near future.
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Affiliation(s)
- Inês Pita
- Department of Gastroenterology, Portuguese Institute of Oncology, Porto, Portugal
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Mocci G, Migaleddu V, Cabras F, Sirigu D, Scanu D, Virgilio G, Marzo M. SICUS and CEUS imaging in Crohn's disease: an update. J Ultrasound 2017; 20:1-9. [PMID: 28298939 DOI: 10.1007/s40477-016-0230-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 11/07/2016] [Indexed: 12/21/2022] Open
Abstract
Endoscopy remains the main technique in the diagnosis and treatment of Crohn's disease (CD); nevertheless, the recent development of innovative and non-invasive imaging techniques has led to a new tool in the exploration of small bowel in CD patients. This paper reviews the available data on ultrasound imaging used for the evaluation of CD, highlighting the role of small intestine contrast-enhanced ultrasonography with the use of oral and intravenous contrast agents.
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Affiliation(s)
| | - Vincenzo Migaleddu
- Sardinian Mediterranean Imaging Research Group, SMIRG No-profit Foundation, Via Gorizia 11, 07100 Sassari, Italy
| | | | - Danilo Sirigu
- Sardinian Mediterranean Imaging Research Group, SMIRG No-profit Foundation, Via Gorizia 11, 07100 Sassari, Italy
| | - Domenico Scanu
- Sardinian Mediterranean Imaging Research Group, SMIRG No-profit Foundation, Via Gorizia 11, 07100 Sassari, Italy
| | - Giuseppe Virgilio
- Sardinian Mediterranean Imaging Research Group, SMIRG No-profit Foundation, Via Gorizia 11, 07100 Sassari, Italy
| | - Manuela Marzo
- Sardinian Mediterranean Imaging Research Group, SMIRG No-profit Foundation, Via Gorizia 11, 07100 Sassari, Italy
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Abstract
The high frequency of intestinal strictures in patients with Crohn's disease and the different treatment approaches specific for each type of stenosis make the differentiation between fibrotic and inflammatory strictures crucial in management of the disease. However, there is no standardized approach to evaluate and discriminate intestinal strictures, and until now, there was no established cross-sectional imaging modality to detect fibrosis. New techniques, such as contrast-enhanced ultrasound and sonoelastography allow the assessment of vascularization and mechanical properties of stenotic bowel tissue, respectively. These techniques have shown great potential to characterize strictures in Crohn's disease. The aim of this review is to sum up the current knowledge on bowel ultrasound tools to discriminate inflammatory from fibrotic stenosis in Crohn's disease considering the most recent published studies in the field.
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Civitelli F, Nuti F, Oliva S, Messina L, La Torre G, Viola F, Cucchiara S, Aloi M. Looking Beyond Mucosal Healing: Effect of Biologic Therapy on Transmural Healing in Pediatric Crohn's Disease. Inflamm Bowel Dis 2016; 22:2418-24. [PMID: 27598739 DOI: 10.1097/MIB.0000000000000897] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Crohn's disease is a chronic inflammatory disease characterized by a progressive transmural bowel damage leading to complications. Anti-TNFα therapy is effective in achieving mucosal healing (MH), but its efficacy on transmural inflammation has been poorly investigated. The aim of this study is to evaluate, in pediatric Crohn's disease, the efficacy of anti-tumor necrosis factor α agents in inducing transmural healing (TH) as assessed by ultrasonography (US). METHODS Children with Crohn's disease requiring anti-tumor necrosis factor α therapy were prospectively enrolled. Clinical activity, laboratory tests, endoscopic activity, and transmural disease assessed by small intestine contrast US (SICUS) were evaluated at baseline (T0) and then after 9 to 12 months of therapy (T1). We evaluated US quantitative and qualitative parameters: disease extension (centimeters), bowel wall (BW) thickness >3 mm, BW vascularity and stratification strictures, and prestenotic dilatation. TH was defined as a BW thickness <3 mm and normalization of all US parameters at T1. RESULTS Thirty-two patients were included. Patients with mucosal healing (MH) showed a significant decrease of BW thickness and disease extension at T1 (4.3 ± 1.4 mm and 8 ± 6.3 cm versus 6.1 ± 2.3 mm and 13 ± 5 cm at baseline, respectively) (P < 0.001). Increased vascularity of the BW was found in 80% of patients at T0 and in 18% at T1 (P < 0.001). These parameters did not change in patients without MH, despite clinical and laboratory remission. The presence of stenosis and prestenotic dilatation did not modify in any group. A complete TH was achieved in 14% of patients, all of them showing complete MH. CONCLUSIONS Biologics induce clinical and laboratory remission and MH in pediatric CD. Although caution is needed due to the small sample size, our data suggest that transmural inflammation also improves during therapy, but a complete TH is achieved only in a small percentage of patients.
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Abstract
BACKGROUND Crohn disease (CD) is a chronic relapsing disease. Imaging modalities are essential for the diagnosis and assessment of CD. Small intestine contrast ultrasonography (SICUS) is a well-tolerated, noninvasive and radiation-free modality and has shown potential in CD assessment. We aimed at evaluating the diagnostic accuracy of SICUS in the detection and assessment of small-bowel lesions and complications in CD. METHODS We searched PubMed database for relevant studies published before April 24, 2016. We integrated the true positive, false positive, false negative, and true negative into the pooled estimates of sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio. Forest plots were to represent the pooled results of all studies. RESULTS Thirteen articles were finally considered eligible. The pooled sensitivity and specificity of SICUS in detecting small-bowel lesions were 0.883 (95% confidence interval (CI) 0.847-0.913) and 0.861 (95% CI 0.828-0.890), respectively. The pooled diagnostic odds ratio was 39.123 (95% CI 20.014-76.476) and the area under the curve of summary receiver operating characteristic was 0.9273 (standard error: 0.0152). In subgroup analyses, SICUS represented fine sensitivity and specificity in proximal and distal small intestine lesion, as well as in CD-related complications such as stricture, dilation, abscess, and fistula. CONCLUSION SICUS is accurate enough to make a complete assessment about the location, extent, number, and almost all kinds of complications in CD small-bowel lesions.
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Affiliation(s)
- Chenjing Zhu
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital
| | - Xuelei Ma
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital
- Correspondence: Xuelei Ma, West China Hospital, No. 37, Guoxue Alley, 610041 Chengdu, P.R. China (e-mail: )
| | - Luqi Xue
- West China School of Medicine, Sichuan University, Chengdu
| | - Jing Xu
- West China School of Medicine, Sichuan University, Chengdu
| | - Qingfang Li
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital
| | - Yun Wang
- Gansu Province Wuwei Cancer Hospital, P.R. China
| | - Jing Zhang
- West China School of Medicine, Sichuan University, Chengdu
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Greenup AJ, Bressler B, Rosenfeld G. 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] [What about the content of this article? (0)] [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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Calabrese E, Maaser C, Zorzi F, Kannengiesser K, Hanauer SB, Bruining DH, Iacucci M, Maconi G, Novak KL, Panaccione R, Strobel D, Wilson SR, Watanabe M, Pallone F, Ghosh S. 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: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Dillman JR, Smith EA, Sanchez R, DiPietro MA, Dehkordy SF, Adler J, DeMatos-Maillard V, Khalatbari S, Davenport MS. 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] [What about the content of this article? (0)] [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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Abstract
Bowel ultrasound is cheap, relatively quick, allows dynamic evaluation of the bowel, has no radiation burden, is well tolerated by patients, and allows repeat imaging. Bowel ultrasound requires a systematic assessment of the entire bowel using high-frequency probes. In addition, hydrosonography and contrast-enhanced ultrasound may be performed. We present the normal sonographic appearances of large and small bowel and the sonographic appearances of acute appendicitis, Crohn's disease, celiac disease, intussusception, infectious enteritis, intestinal tuberculosis, small bowel ileus and obstruction, small bowel ischemia, and malignant tumors.
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Affiliation(s)
- Anita Wale
- Department of Radiology, St Georges Hospital, London, UK.
| | - James Pilcher
- Department of Radiology, St Georges Hospital, London, UK
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Haas K, Rubesova E, Bass D. Role of imaging in the evaluation of inflammatory bowel disease: How much is too much? World J Radiol 2016; 8:124-131. [PMID: 26981221 PMCID: PMC4770174 DOI: 10.4329/wjr.v8.i2.124] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 11/24/2015] [Accepted: 01/07/2016] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a lifelong condition with waxing and waning disease course that requires reassessment of disease status as well as screening for complications throughout a patient’s lifetime. Laboratory testing, endoscopic assessment, and fecal biomarkers are often used in the initial diagnosis and ongoing monitoring of a patient with IBD. Imaging plays an integral role in the diagnosis and evaluation of IBD. Different imaging modalities can be used over the course of a patient’s lifetime, from the initial screening and diagnosis of IBD, to determining the extent of intestinal involvement, monitoring for disease activity, and evaluating for complications of uncontrolled IBD. The various imaging modalities available to the provider each have a unique set of risks and benefits when considering cost, radiation exposure, need for anesthesia, and image quality. In this article we review the imaging techniques available for the evaluation of IBD including fluoroscopic small bowel follow-through, computed tomography enterography, magnetic resonance enterography, and transabdominal ultrasound with particular focus on the judicious use of imaging and the risks and benefits of each option. We also review the risks of ionizing radiation, strategies to reduce exposure to ionizing radiation, and current imaging guidelines among pediatric and adult patient with IBD.
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