Machine Learning Diagnosis of Small-Bowel Crohn Disease Using T2-Weighted MRI Radiomic and Clinical Data

BACKGROUND. Radiologists have variable diagnostic performance and considerable interreader variability when interpreting MR enterography (MRE) examinations for suspected Crohn disease (CD). OBJECTIVE. The purposes of this study were to develop a machine learning method for predicting ileal CD by use of radiomic features of ileal wall and mesenteric fat from noncontrast T2-weighted MRI and to compare the performance of the method with that of expert radiologists. METHODS. This single-institution study included retrospectively identified patients who underwent MRE for suspected ileal CD from January 1, 2020, to January 31, 2021, and prospectively enrolled participants (patients with newly diagnosed ileal CD or healthy control participants) from December 2018 to October 2021. Using axial T2-weighted SSFSE images, a radiologist selected two slices showing greatest terminal ileal wall thickening. Four ROIs were segmented, and radiomic features were extracted from each ROI. After feature selection, support-vector machine models were trained to classify the presence of ileal CD. Three fellowship-trained pediatric abdominal radiologists independently classified the presence of ileal CD on SSFSE images. The reference standard was clinical diagnosis of ileal CD based on endoscopy and biopsy results. Radiomic-only, clinical-only, and radiomic-clinical ensemble models were trained and evaluated by nested cross-validation. RESULTS. The study included 135 participants (67 female, 68 male; mean age, 15.2 ± 3.2 years); 70 were diagnosed with ileal CD. The three radiologists had accuracies of 83.7% (113/135), 88.1% (119/135), and 86.7% (117/135) for diagnosing CD; consensus accuracy was 88.1%. Interradiologist agreement was substantial (κ = 0.78). The best-performing ROI was bowel core (AUC, 0.95; accuracy, 89.6%); other ROIs had worse performance (whole-bowel AUC, 0.86; fat-core AUC, 0.70; whole-fat AUC, 0.73). For the clinical-only model, AUC was 0.85 and accuracy was 80.0%. The ensemble model combining bowel-core radiomic and clinical models had AUC of 0.98 and accuracy of 93.5%. The bowel-core radiomic-only model had significantly greater accuracy than radiologist 1 (p = .009) and radiologist 2 (p = .02) but not radiologist 3 (p > .99) or the radiologists in consensus (p = .05). The ensemble model had greater accuracy than the radiologists in consensus (p = .02). CONCLUSION. A radiomic machine learning model predicted CD diagnosis with better performance than two of three expert radiologists. Model performance improved when radiomic data were ensembled with clinical data. CLINICAL IMPACT. Deployment of a radiomic-based model including T2-weighted MRI data could decrease interradiologist variability and increase diagnostic accuracy for pediatric CD.

Reply to comment on "Ultrasonographic scores for ileal Crohn's disease assessment: better, worse or the same as contrast‑enhanced ultrasound?

We read the comments by Nylund K et al. regarding our paper "Ultrasonographic scores for ileal Crohn's disease assessment: Better, worse or the same as contrast‑enhanced ultrasound?". Intestinal ultrasound has become one of the most valuable developments in the past decade, a non-invasive, well-tolerated exam, with an easy repeatability, and absence of sedation, ionizing radiation, or preparation. Particularly for inflammatory bowel disease, where there is a lack of agreement of patient's symptoms with disease activity, in an era where the paradigm of mucosal healing is changing to transmural healing, and with the emergence of several therapies leading to repeated imaging surveillance, it is essential to highlight the role of intestinal ultrasound. Although intestinal ultrasound is an increasingly used tool to monitor inflammatory bowel disease activity, there is no widely accepted reproducible activity index, since the methodology for the development of the scores was shown to be insufficient in most studies and none have been adequately validated (Bots et al., J Crohns Colitis 12:920-9, 2018). In our study, we showed that the contrast-enhanced ultrasound (CEUS) peak enhancement derived from the time-intensity curve (TIC) is a promising non-invasive emerging method with a good accuracy to correlate clinical and endoscopic activity in the terminal ileum, superior to intestinal ultrasound scores relying on bowel wall thickness and colour Doppler.

Comment on "Ultrasonographic scores for ileal Crohn's disease assessment: better, worse or the same as contrast‑enhanced ultrasound?"

We read with interest the study by Freitas et al. comparing contrast-enhanced ultrasound (CEUS) and parameters from a time-intensity curve (TIC) with the SUS-CD score and IBUS-SAS score in patients with Crohn's disease (CD) undergoing gastrointestinal ultrasound (GIUS) and ileocolonoscopy. The aim was to compare the accuracy of CEUS and aforementioned scores in predicting terminal ileal inflammatory activity in patients with CD. In this retrospective study of 50 patients, inflammatory activity was defined as a segmental score of SES-CD ≥ 7 in the terminal ileum. The study found 30 patients with active endoscopic disease demonstrating no significant difference between the "inactive" and "active" SUS CD and IBUS-SAS scores. However, the CEUS peak enhancement derived from the TIC was shown to be significantly different. The authors conclude CEUS was superior for detecting inflammation in the terminal ileum, as opposed to ultrasound scores relying on bowel wall thickness and color Doppler.

MRI-Based Characterization of Intestinal Motility in Children and Young Adults With Newly Diagnosed Ileal Crohn Disease Treated by Biologic Therapy: A Controlled Prospective Study

BACKGROUND. Changes in intestinal motility in patients with newly diagnosed Crohn disease have historically been evaluated primarily in a subjective manner. OBJECTIVE. The purpose of this study was to assess longitudinal changes in objective intestinal motility scores in children and young adults with newly diagnosed ileal Crohn disease treated with biologic (anti-tumor necrosis factor-α) medical therapy compared with those in control participants. METHODS. This prospective study included 20 children and young adults (eight female and 12 male patients; mean age, 14.6 ± 2.1 [SD] years) with newly diagnosed ileal Crohn disease who were recruited between December 2018 and October 2021 as well as 15 control participants without any known gastrointestinal conditions (eight female and seven male patients; mean age, 18.1 ± 4.4 years). All participants underwent research MRI examinations of the small bowel, including dynamic cine 2D SSFP sequences. Patients with Crohn disease underwent additional research MRI examinations performed at both 6 weeks and 6 months after initiation of biologic therapy. Two operators independently derived terminal ileal intestinal motility scores from the dynamic cine sequences by use of FDA-approved software (with higher scores indicating greater intestinal motility). Intestinal motility scores were compared between patient and control groups by use of t tests, whereas changes in intestinal motility scores after treatment were assessed using linear mixed models. Interoperator absolute agreement was assessed using the intra-class correlation coefficient (ICC). RESULTS. Mean terminal ileal intestinal motility scores were not significantly different between patients with newly diagnosed ileal Crohn disease and control participants (for operator 1, 180.9 ± 63.3 vs 229.7 ± 115.2, respectively [p = .12]; for operator 2, 175.0 ± 62.2 vs 236.4 ± 117.4, respectively [p = .05]). Mean intestinal motility scores changed over time compared with baseline in response to biologic therapy, for operator 1 (180.9 ± 63.3 at baseline, 248.1 ± 104.9 at 6 weeks after treatment initiation, and 249.1 ± 73.2 at 6 months after treatment initiation [p = .04]) and operator 2 (175.0 ± 62.2 at baseline, 247.8 ± 112.7 at 6 weeks after treatment initiation, and 239.6 ± 72.7 at 6 months after treatment initiation [p = .03]). Absolute agreement in intestinal motility scores was excellent between operators (ICC = 0.89). CONCLUSION. MRI measurements of intestinal motility are dynamic in children and adults with newly diagnosed small-bowel Crohn disease, showing early increases in response to biologic therapy. CLINICAL IMPACT. MRI-based intestinal motility scores may aid individualized assessment of disease activity and treatment response in patients with small-bowel Crohn disease.

Quality of Life Is Related to Fecal Calprotectin Concentrations in Colonic Crohn Disease and Ulcerative Colitis, but not in Ileal Crohn Disease

To formulate therapy goals, we aimed to define the relationship between fecal calprotectin and health-related quality of life in inflammatory bowel diseases (IBDs). This retrospective single-center cross-sectional study included ambulatory IBD patients who had completed standardized questionnaires comprising items of health-related quality of life (Short Inflammatory Bowel Disease Questionnaire) and clinical disease activity scores, and who had provided stool samples for calprotectin determination within 30 days of questionnaire completion. Correlation analyses were performed between the indicated parameters. Post hoc analysis was conducted, taking into account only data from patients with fecal calprotectin concentrations measured within 3 days of questionnaire completion. One hundred ninety-seven patients with Crohn disease and 111 patients with ulcerative colitis were enrolled in the study. Lower fecal calprotectin concentrations were associated with better health-related quality of life. The correlations were weak, but stronger if only fecal calprotectin concentrations measured within 3 days of questionnaire completion were included (results for 3 days; Crohn disease: n = 86, rS = -0.419, P < 0.001; ulcerative colitis: n = 43, rS = -0.432, P = 0.004). In Crohn disease, a significant correlation between fecal calprotectin concentration and health-related quality of life was found in patients with colonic involvement (n = 59, rS = -0.470, P < 0.001), but not in patients with purely ileal disease (n = 27, rS = -0.268, P = 0.18). Correlations between fecal calprotectin concentrations and clinical disease activity were also only weak to moderate. Owing to its moderate correlation with fecal calprotectin concentrations in IBD patients with colonic involvement, health-related quality of life should be used in combination with other markers for IBD management. This is even more important in isolated ileal Crohn disease, where no significant correlation between fecal calprotectin concentration and health-related quality of life was found. Especially for use in research studies, care should be taken to keep the time between clinical evaluation of IBD patients and the determination of fecal calprotectin concentrations as short as possible.

Is non-operative intussusception reduction effective in older children? Ten-year experience in a university affiliated medical center

Ileo-colic intussusception in older children is frequently caused by a pathological lead point. Therefore, in many cases, no attempts at hydrostatic or air reduction are performed in non-pediatric hospitals. This study summarizes our experience in management of intussusception in children aged 3 years or older, in order to determine its efficacy and safety in this age group. We retrospectively reviewed medical records and radiological images of 26 cases of intussusception in 24 children older than 3 years admitted to our hospital over a 10-year period. In one child no attempt of reduction was made. Three children underwent unsuccessful imaging-guided reduction and an underlying tumor was identified at surgery and resected. In 18 cases air reduction was successful and no pathological lead point was discovered. In four children hydrostatic or air reductions failed. Manual reduction was performed, with no predisposing cause found. No complications were observed in any of our patients. Older age is not a contraindication for imaging-guided intussusception reduction attempt. Most of these patients can benefit from such an attempt, thereby avoiding surgery.

Ileocecal intussusception in an adult: the laparoscopic approach

Adult intussusception is uncommon and requires a surgical approach. Malignancy is associated with 31% (43/137) of small bowel intussusception and 70% (74/106) of large bowel intussusception. Computerized tomography (CT) findings are pathognomonic for this condition. Often, the patient presents with long-standing, nonspecific complaints. A 63-year-old man presented with sudden onset of abdominal pain. CT demonstrated colonic inflammation. A laparoscopic right hemicolectomy for ileocecal intussusception was performed. The pathology report revealed a lipoma of the cecum. The postoperative course was uneventful, and he was discharged the fifth postoperative day. Despite a high incidence of malignancy, colonic or ileocecal intussusception can be successfully treated by laparoscopic resection. Review of the literature and treatment options are discussed.

An unusual complication of ureteroneocystostomy discovered at laparoscopy

BACKGROUND

Laparoscopy is an important surgical technique, and an understanding of normal and altered anatomy is crucial for successful surgery. We describe herein a patient in whom the left ureter follows an anomalous course due to previous surgery.

METHODS

This is the case report of a 28-year-old female with a history of ureteral reimplantation evaluated with laparoscopy for dysmenorrhea and infertility.

RESULTS

The left ureter followed an anomalous, transperitoneal course, lateral to the fallopian tube, starting at the infundibulopelivc ligament down to its insertion in the bladder. During its transperitoneal course, the ureter perforated the ileum.

CONCLUSION

This case describes an anomalous course of the ureter presumed to be due to previous childhood surgery. As more individuals with a history of ureteral reimplantation reach adulthood, an increasing number will require abdominal, surgical procedures. An understanding of potential anatomic abnormalities will reduce the risk of inadvertent visceral damage at surgery.

Waugh's syndrome: report of two cases

The association of intussusception and intestinal malrotation has been reported rarely in the literature. This association is called Waugh's syndrome. The authors report 2 cases of Waugh's syndrome and discuss diagnostic features and treatment methods.

Ileoileal intussusception caused by a Ewing sarcoma tumour. An unusual case report

Intussusception typically occurs in childhood, presenting with a well-known medical history and clinical symptoms. Pathologically, a "leading point" may be attributed to lymphadenomatosis, polyps, or a tumour. In older patients and adolescents, the diagnosis can be complicated due to the lower incidence and variable subacute symptoms. We report on an 18-year-old patient with increasing abdominal discomfort over several weeks. External diagnostics showed no pathological signs or were misinterpreted as a malfunction of intestinal motility. The patient experienced increasing colics, recurrent vomiting, dehydration and weight loss. Finally he was transferred to our paediatric surgical department and laparotomy had to be performed for the clinical and radiological signs of an ileus. An ileoilealic intussusception was found, caused by a small bowel tumour, which almost completely obstructed the intestinal lumen. It was resected and bowel continuity was re-established. Histopathology revealed a very rare, highly malignant mesenchymal Ewing sarcoma, infiltrating the complete bowel wall. After the postoperative course, the patient was transferred to our oncological department for chemotherapy. In older children or young adults, intestinal malignancies are extremely rare. Nevertheless, if these patients suffer from unspecific complaints of chronic intestinal obstruction, a tumour must be ruled out. A Ewing sarcoma may be responsible for an intussusception.

[Retrogastric colon mimicking foramen of Winslow hernia or left paraduodenal hernia: case report]

We report the case of a 54-year-old woman who developed epigastralgia and vomit. Because of the abnormal gas in the epigastrium on abdominal X-ray, ileus due to foramen of Winslow hernia or left paraduodenal hernia was suspected. However, abdominal CT and barium study revealed the gas in the epigastrium to be the air in the transverse colon interposed between the stomach and pancreatic body. This anomalous interposition of the transverse colon is called retrogastric colon. The ileus was due to non-specific inflammatory duodenal stenosis. It is important to prevent misdiagnosis of retrogastric colon as lesser sac pathologic condition such as abscess, bowel perforation and internal hernia.

[Free bowel perforation as the onset and as a complication in the evolution of crohn's disease]

Free bowel perforation is a relatively infrequent complication of Crohn's disease. It may present during the evolution of the disease or, occasionally, in the onset of the same and may involve the small intestine or colon. We herein present 4 cases, three of ileal localization and one of colonic localization. In one of the 3 former cases and the latter case perforation took place prior to diagnosis of the disease. Review of the literature was performed with respect to the frequency, pathogenesis and characteristics of this complication and the importance of determined diagnostic techniques such as echography and CAT in addition to the most adequate treatment are commented upon.

Ileocecal intussusception of small-bowel lymphoma: diagnosis by colonoscopy

Intussusception is rare in adults. There is little information on the role of colonoscopy in colonic intussusception. We report, to our knowledge, the first adult case of small-bowel lymphoma causing ileocecal intussusception in which the diagnosis was made by colonoscopy. Colonoscopy has a useful role in the diagnosis and management of ileocecal intussusception.

[Intestinal obstruction and sepsis caused by Torulopsis glabrata]

A 27-year-old woman previously diagnosed of aplastic anemia secondary to treatment with gold salts for rheumatoid arthritis, presented with an episode of intestinal occlusion with acute renal failure. A CT scan revealed dilated intestinal loops, thickening of the ileum wall without cecal involvement, and multiple punctuate lesions (micro-abcesses) of liver, spleen and kidneys. At laparotomy, one meter of proximal jejunum was resected. The cultures of jejunal biopsy specimens yielded Torulopsis glabrata. The patient underwent multiorgan failure and died on the 8th postoperative day.

Intestinal endometriosis: presentation, investigation, and surgical management

The study was undertaken to identify the presenting features of intestinal endometriosis and to evaluate its investigation and surgical management. Twenty-six cases of intestinal endometriosis were identified during a fourteen year period. The commonest site of occurrence was the rectosigmoid region (11 cases) followed by the appendix (9 cases), and ileocaecal region (6 cases). Abdominal pain was the main presenting feature in 20 cases, with associated nausea and vomiting in 12 cases and altered bowel habit in ten. Other presenting features included rectal bleeding, abdominal bloating and tenesmus. Endometriosis was not suspected preoperatively in any of the patients without a past history of this condition. Accurate preoperative diagnosis proved very difficult, with only laparoscopy providing definite evidence of intestinal endometriosis prior to formal surgery. Colonic resections were performed in 12 cases, small bowel resection in six cases and appendicectomy in nine cases, together with resection of adjacent adherent structures. This series illustrates the difficulty of establishing an accurate preoperative diagnosis, and the propensity of intestinal endometriosis to mimic other gastrointestinal diseases, particularly carcinoma and inflammatory bowel disease.

Ultrastructural alterations in ileal M cells of rats after chronic ethanol ingestion: reversal after cessation of ethanol

Membranous (M) cells within the dome epithelium of ileal Peyer's patches have been shown to provide selective antigen entry for mucosa-associated lymphoid tissue. This study produced morphologic evidence of ethanol-induced disruption of the architecture in follicle-associated epithelium. The adherens type junctions of the lateral plasma membranes between M cells and columnar absorptive cells were disrupted. A 45-day exposure by ingestion of ethanol also produced marked changes in the ultrastructure of M cells. All experimental animals showed mitochondrial swelling with loss of matrix density, dilation of the endoplasmic reticulum and cytoplasmic vacuolization. The ethanol content of serum and chyme samples were 180 mg/dl and 160 mg/dl, respectively. This was well below the 4,280 mg/dl of the diet therefore a systemic mechanism was implicated for the changes observed. Membranous cells from the recovery group were normal 15 days after withdrawal from ethanol. We concluded that the ethanol-induced cytopathology in ileal M cells is reversible when ethanol exposure is discontinued.

Anorectal physiology after anterior resection and pull-through operation

Sensory and motor investigations have been performed in normal subjects, in patients who had undergone low anterior resection of the rectum and in patients following Bacon-type pull-through operation. The electromechanical relationship has been clearly defined in the anal sphincter activity. The motor findings, the threshold for sensation and its quality in the patients following low anterior resection were similar to those of the controls. Following pull-through operation the anorectal inhibitory reflex is frequently replaced by a contraction of the sphincteric zone. But, sometimes, this reflex is preserved as well as a fine discriminatory sensation. These data suggest that at least some of the mechanisms of anal sphincter continence have been preserved even after complete excision of the rectum.

Rovsing's sign

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