The relationship between Central Nervous System morphometry changes and key symptoms in Crohn’s disease

Alterations in grey matter volume (GMV) and cortical thickness (CT) in Crohn’s disease (CD) patients has been previously documented. However, the findings are inconsistent, and not a true representation of CD burden, as only CD patients in remission have been studied thus far. We investigate alterations in brain morphometry in patients with active CD and those in remission, and study relationships between brain structure and key symptoms of fatigue, abdominal pain, and extraintestinal manifestations (EIM). Magnetic Resonance Imaging brain scans were collected in 89 participants; 34 CD participants with active disease, 13 CD participants in remission and 42 healthy controls (HCs); Voxel based morphometry (VBM) assessed GMV and white matter volume (WMV), and surface-based analysis assessed cortical thickness (CT). We show a significant reduction in global cerebrospinal fluid (CSF) volume in CD participants compared with HCs, as well as, a reduction in regional GMV, WMV and CT in the left precentral gyrus (motor cortex), and an increase in GMV in the frontal brain regions in CD compared with HCs. Atrophy of the supplementary motor area (SMA) was associated with greater fatigue in CD. We also show alterations in brain structure in multiple regions in CD associated with abdominal pain and extraintestinal inflammations (EIMs). These brain structural alterations likely reflect neuroplasticity to a chronic systemic inflammatory response, abdominal pain, EIMs and fatigue. These findings will aid our understanding of the cross-linking between chronic inflammation, brain structural changes and key unexplained CD symptomatology like fatigue.

Automatically detecting Crohn's disease and Ulcerative Colitis from endoscopic imaging

BACKGROUND

The SI-CURA project (Soluzioni Innovative per la gestione del paziente e il follow up terapeutico della Colite UlceRosA) is an Italian initiative aimed at the development of artificial intelligence solutions to discriminate pathologies of different nature, including inflammatory bowel disease (IBD), namely Ulcerative Colitis (UC) and Crohn's disease (CD), based on endoscopic imaging of patients (P) and healthy controls (N).

METHODS

In this study we develop a deep learning (DL) prototype to identify disease patterns through three binary classification tasks, namely (1) discriminating positive (pathological) samples from negative (healthy) samples (P vs N); (2) discrimination between Ulcerative Colitis and Crohn's Disease samples (UC vs CD) and, (3) discrimination between Ulcerative Colitis and negative (healthy) samples (UC vs N).

RESULTS

The model derived from our approach achieves a high performance of Matthews correlation coefficient (MCC) > 0.9 on the test set for P versus N and UC versus N, and MCC > 0.6 on the test set for UC versus CD.

CONCLUSION

Our DL model effectively discriminates between pathological and negative samples, as well as between IBD subgroups, providing further evidence of its potential as a decision support tool for endoscopy-based diagnosis.

Test Characteristics of Cross-sectional Imaging and Concordance With Endoscopy in Postoperative Crohn's Disease

BACKGROUND & AIMS

Postoperative Crohn's disease (CD) surveillance relies on endoscopic monitoring. The role of cross-sectional imaging is less clear. We evaluated the concordance of cross-sectional enterography with endoscopic recurrence and the predictive ability of radiography for future CD postoperative recurrence.

METHODS

We performed a multi-institution retrospective cohort study of postoperative adult patients with CD who underwent ileocolonoscopy and cross-sectional enterography within 90 days of each other following ileocecal resection. Imaging studies were interpreted by blinded, expert CD radiologists. Patients were categorized by presence of endoscopic postoperative recurrence (E+) (modified Rutgeerts' score ≥i2b) or radiographic disease activity (R+) and grouped by concordance status.

RESULTS

A total of 216 patients with CD with paired ileocolonoscopy and imaging were included. A majority (54.2%) exhibited concordance (34.7% E+/R+; 19.4% E-/R-) between studies. The plurality (41.7%; n = 90) were E-/R+ discordant. Imaging was highly sensitive (89.3%), with low specificity (31.8%), in detecting endoscopic postoperative recurrence. Intestinal wall thickening, luminal narrowing, mural hyper-enhancement, and length of disease on imaging were associated with endoscopic recurrence (all P < .01). Radiographic disease severity was associated with increasing Rutgeerts' score (P < .001). E-/R+ patients experienced more rapid subsequent endoscopic recurrence (hazard ratio, 4.16; P = .033) and increased rates of subsequent endoscopic (43.8% vs 22.7%) and surgical recurrence (20% vs 9.5%) than E-/R- patients (median follow-up, 4.5 years).

CONCLUSIONS

Cross-sectional imaging is highly sensitive, but poorly specific, in detecting endoscopic disease activity and postoperative recurrence. Advanced radiographic disease correlates with endoscopic severity. Patients with radiographic activity in the absence of endoscopic recurrence may be at increased risk for future recurrence, and closer monitoring should be considered.

The Role of Ultrasound in Chronic Intestinal Diseases in Pediatric Patients

Chronic inflammatory bowel diseases (IBD) are chronic disorders of the gastrointestinal tract, with an increasing incidence in pediatric populations. Ultrasound of the intestinal wall represents the first-line imaging technique in children since it is a noninvasive method, is free of ionizing radiation, and is inexpensive. Furthermore, the absence of intestinal wall thickening has a good negative predictive value for IBD, which is greater for Crohn's disease than for ulcerative colitis. Ultrasound is used for the diagnosis of disease, for the differential diagnosis in IBD, in the follow-up of known IBD, in the definition of the site and extent of the disease, for the diagnosis of intestinal complications, for the evaluation of disease activity, in the definition of prognostic parameters, and in the post-operative follow-up.

Correlation Between Ultrasonographic Response and Anti-Tumor Necrosis Factor Drug Levels in Crohn's disease

BACKGROUND

Ultrasound is valuable in tight control algorithms for Crohn's disease (CD). However, the correlation between ultrasonographic response and anti-tumor necrosis factor (TNF) drug levels remains unknown. Elucidating this correlation would be helpful in optimizing the use of anti-TNF drugs. Thus, the authors aimed to investigate this correlation.

METHODS

Between June 2020 and June 2021, all patients with CD who completed anti-TNF induction therapy were retrospectively included. Ultrasound was performed at week 0 and week 14, and proactive therapeutic drug monitoring of anti-TNF drugs was performed at week 14. The receiver operating characteristic (ROC) curve was used in the correlation analysis.

RESULTS

Ninety-two patients (60 treated with infliximab and 32 with adalimumab) were included. At week 14, an ultrasonographic response was detected in 43 patients. Patients with ultrasonographic response had significantly higher median drug levels (5.9 mcg/mL for infliximab; 18.2 mcg/mL for adalimumab) than those without (0.9 mcg/mL for infliximab, P < 0.001; 4.8 mcg/mL for adalimumab, P < 0.001). The ROC curve showed a significant correlation between ultrasonographic response and anti-TNF drug levels (area under the curve = 0.79 for infliximab, P < 0.001; area under the curve = 0.86 for adalimumab, P < 0.001). The optimal cut-off values for infliximab and adalimumab correlated with ultrasonographic response were 5.0 and 10.5 mcg/mL, respectively. An incremental increase was observed in ultrasonographic response with higher anti-TNF drug levels.

CONCLUSIONS

Higher anti-TNF drug levels are associated with an increased likelihood of ultrasonographic response in patients with CD.

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.

Computed tomography enterography predicts surgical-free survival in symptomatic stricturing Crohn's disease

OBJECTIVES

The study aimed to predict surgical risks for patients with symptomatic stricturing Crohn's disease (CD) using computed tomography enterography (CTE) and to assess the association between CTE findings and pathological changes.

METHODS

Crohn's disease patients with symptomatic stricture(s) were included. Exclusion criteria were concomitant penetrating disease, intra-abdominal abscess, previous bowel resection, or asymptomatic. Patients from January 2016 to December 2019 were identified as the primary cohort and those from January 2020 to June 2020 were identified as the validation cohort. Two independent experienced radiologists evaluated CTE variables including mucosal enhancement, mural stratification, wall enhancement, comb sign, lymphadenopathy, thick non-enhancing wall, bowel wall thickness, luminal diameter, and upstream lumen. Receiver operating characteristic, logistic regression, and nomogram were performed to identify the independent predictors of surgical-free survival. Histopathological scores of surgical specimens were also evaluated.

RESULTS

198 patients (primary cohort, 123 with surgery and 75 under non-surgical intervention, and 41 patients (validation cohort) were analyzed. Bowel wall thickness < 5.9 mm, luminal stenosis > 3.35 mm, and upstream lumen < 27.5 mm were predictors of surgical-free survival for symptomatic stricturing CD patients. Logistic analysis showed the three CTE variables were the independent predictors of surgical-free survival (p < 0.001). A nomogram was developed with the concordance indexes of 0.905 and 0.892 in the primary and validation cohorts. Histopathological analysis showed bowel wall muscular hyperplasia/hypertrophy significantly correlated with luminal stenosis (r = - 0.655, p = 0.008) and combined CTE variable (r = - 0.683, p = 0.005).

CONCLUSIONS

CTE is highly predictive of disease course and surgical-free survival for patients with symptomatic stricturing CD, suggesting the important role of CTE in decision-making of treatment.

[The use of ultrasound in IBD: an essential tool?]

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory bowel diseases (IBD) characterized by an inflammation of the digestive tract wall. Current guidelines recommend a «treat to target» management and a "tight control" of the inflammation for an optimal follow-up. Intestinal ultrasound, due to its low cost, its feasibility at bed side, its absence of preparation and its non-invasive character, has proved its place in the diagnosis and the follow-up of IBD. It allows the evaluation of various parameters of the lumen, the intestinal wall, the mesentery, the vascularization as well as complications.

Less Emergency Department Abdominopelvic Computed Tomography for Patients With Crohn's Disease: A New Scoring System

BACKGROUND

In recent years, the use of abdominal pelvic computed tomography (APCT) in the emergency department (ED) for patients with Crohn's disease (CD) has risen steadily. Thus, exposing these patients to recurrent radiation, despite studies showing that only 30% to 40% had significant findings in ED APCT.

GOAL

Our aim was to find clinical and laboratory variables that can predict substantial findings on ED APCT, which may require invasive intervention.

METHODS

We analyzed ED visits of patients with known CD that underwent an emergent APCT for gastrointestinal complaints, over a 10-year period. Patients with positive and negative findings in the APCT were compared in order to evaluate independent effects of different variables, including patients' characteristics, CD history, ED complaints, and laboratory tests.

RESULTS

In 44% of 183 ED visits, there were significant findings on ED APCT, however, only 22% of them underwent invasive intervention. Laboratory tests: C-reactive protein >50 mg/L, neutrophil count >75%, platelet count >350×10 9 /L, and ileocolon location at diagnosis were all positive predicting factors. Whereas, smoking or ED complaints of diarrhea/fever reduced the risk for significant findings.

CONCLUSIONS

Using the 7 most significant predicting factors, we built an easy to use scoring system-Crohn Assessment Tool for CT upon Hospitalization (CATCH) for ED clinicians. This scoring system could have prevented unnecessary ED APCT from 42% of the patients in our study, without missing those who required invasive intervention.

Initial Abdominal CT and Laboratory Findings Prior to Diagnosis of Crohn's Disease in Children

PURPOSE

To identify initial abdominal computed tomography (CT) and laboratory findings prior to a diagnosis of Crohn's disease (CD) in children.

MATERIALS AND METHODS

In this retrospective study, patients (≤18 year-old) who were diagnosed with CD from 2004 to 2019 and had abdominal CT just prior to being diagnosed with CD were included in the CD group. Patients (≤18 years old) who were diagnosed with infectious enterocolitis from 2018 to 2019 and had undergone CT prior to being diagnosed with enterocolitis were included as a control group. We assessed the diagnostic performances of initial CT and laboratory findings for the diagnosis of CD using logistic regression and the area under the curve (AUC).

RESULTS

In total, 107 patients (50 CD patients, 57 control patients) were included, without an age difference between groups (median 13 years old vs. 11 years old, p=0.119). On univariate logistic regression analysis, multisegmental bowel involvement, mesenteric vessel engorgement, higher portal vein/aorta diameter ratio, longer liver longitudinal diameter, lower hemoglobin (≤12.5 g/dL), lower albumin (≤4 g/dL), and higher platelet (>320×10³/µL) levels were significant factors for CD. On multivariate analysis, multisegmental bowel involvement [odds ratio (OR) 111.6, 95% confidence interval (CI) 4.778-2605.925] and lower albumin levels (OR 0.9, 95% CI 0.891-0.993) were significant factors. When these two features were combined, the AUC value was 0.985 with a sensitivity of 96% and specificity of 100% for differentiating CD.

CONCLUSION

Multisegmental bowel involvement on CT and decreased albumin levels can help differentiate CD from infectious enterocolitis in children prior to a definite diagnosis of CD.

Magnetic Resonance Enterography and Histology in Patients With Fibrostenotic Crohn's Disease: A Multicenter Study

INTRODUCTION

Magnetic resonance enterography (MRE) is useful for detecting bowel strictures, whereas a number of imaging biomarkers may reflect severity of fibrosis burden in Crohn's disease (CD). This study aimed to verify the association of MRE metrics with histologic fibrosis independent of inflammation.

METHODS

This prospective European multicenter study performed MRE imaging on 60 patients with CD with bowel strictures before surgical resection. Locations of 61 histological samples were annotated on MRE examinations, followed by central readings using the Chiorean score and measurement of delayed gain of enhancement (DGE), magnetization transfer ratio, T2-weighted MRI sequences (T2R), apparent diffusion coefficient (ADC), and the magnetic resonance index of activity (MaRIA). Correlations of histology and MRE metrics were assessed. Least Absolute Shrinkage and Selection Operator and receiver operator characteristic (ROC) curve analyses were used to select composite MRE scores predictive of histology and to estimate their predictive value.

RESULTS

ADC and MaRIA correlated with fibrosis (R = -0.71, P < 0.0001, and 0.59, P < 0.001) and more moderately with inflammation (R = -0.35, P < 0.01, and R = 0.53, P < 0.001). Lower or no correlations of fibrosis or inflammation were found with DGE, magnetization transfer ratio, or T2R. Least Absolute Shrinkage and Selection Operator and ROC identified a composite score of MaRIA, ADC, and DGE as a very good predictor of histologic fibrosis (ROC area under the curve = 0.910). MaRIA alone was the best predictor of histologic inflammation with excellent performance in identifying active histologic inflammation (ROC area under the curve = 0.966).

DISCUSSION

MRE-based scores for histologic fibrosis and inflammation may assist in the characterization of CD stenosis and enable development of fibrosis-targeted therapies and clinical treatment of stenotic patients.

Early sonographic response to a new medical therapy is associated with future treatment response or failure in patients with inflammatory bowel disease

OBJECTIVE

Gastrointestinal ultrasound (GIUS) accurately assesses inflammation and is responsive to changes in inflammatory bowel disease. This study aimed to determine the prognostic utility of sonographic response in the first 14 weeks of a newly-instituted therapy with therapeutic response at 46 weeks and to compare its performance with standard clinical assessment tools.

METHODS

Patients with sonographic evidence of inflammation were assessed by GIUS, clinical activity, serum C-reactive protein and faecal calprotectin again 2, 6 and 14 weeks after commencing a new biologic or thiopurine. Treatment failure was defined as undergoing surgery, hospitalisation, escalation of dosage or introduction of new medication over 46-weeks' follow-up. Sonographic response was defined as a decrease in bowel wall thickness and improved vascularity.

RESULTS

In 31 patients (median age 49 years, 74% Crohn's disease), sonographic response at 14 weeks [OR 19.3, 95% confidence interval (CI), 3.23-101.10; P = 0.0054] and faecal calprotectin (P = 0.018), but no clinical disease activity or C-reactive protein, were predictive of subsequent treatment response. Sonographic response alone was predictive at week 6 (P = 0.016), but not week 2. 16% reduction in bowel wall thickness at 6 weeks (area-under-the-receiver-operator-curve=0.86; P = 0.002; sensitivity 72%, specificity 90%), with similar performance for 10% at 14 weeks, was associated with treatment response.

CONCLUSION

Sonographic response as early as 6 weeks after initiation of a new therapy may accurately predict treatment outcomes over 46 weeks and is superior to other markers used to monitor disease activity.

A Magnetic Resonance Imaging Index to Predict Crohn's Disease Postoperative Recurrence: The MONITOR Index

BACKGROUND & AIMS

We developed and validated a magnetic resonance imaging-based index to predict Crohn's disease (CD) postoperative recurrence (POR).

METHODS

Patients with CD who underwent a postoperative evaluation for recurrence (with colonoscopy and MRI no longer than 105 days apart) were included between 2006 and 2016 in University Hospital of Nancy, France. MRI items with good levels of intra-rater and inter-rater agreement (Gwet's coefficient ≥0.5) were selected. The MRI in Crohn's Disease to Predict Postoperative Recurrence (MONITOR) index's performance was assessed in terms of the area under the receiver operating characteristic curve (AUROC) and accuracy, by considering the Rutgeerts score as the gold standard. The MONITOR index was validated with a bootstrap method and an independent cohort.

RESULTS

Seventy-three MRI datasets were interpreted by 2 radiologists. Seven items (bowel wall thickness, contrast enhancement, T2 signal increase, diffusion-weighted signal increase, edema, ulcers, and the length of the diseased segment) had a Gwet's coefficient ≥0.5 and were significantly associated with the Rutgeerts score, leading to their inclusion in the MONITOR index. All the items had a weighting of 1, except the "ulcers" item weighting 2.5, reflecting the higher adjusted odds ratio. The AUROC [95% confidence interval] for the prediction of endoscopic POR (Rutgeerts score >i1) was 0.80 [0.70-0.90]. The optimal threshold was a MONITOR index ≥1, giving a sensitivity of 79%, a specificity of 55%, a predictive positive value of 68%, and a predictive negative value of 68%. The bootstrap validation gave an AUROC of 0.85 [0.73-0.97]. In the validation cohort, a MONITOR index ≥1 gave a sensitivity of 87%, a specificity of 75%, a predictive positive value of 84.6%, and a predictive negative value of 75%.

CONCLUSIONS

The MONITOR index is an efficient, reliable, easy-to-apply tool that can be used in clinical practice to predict the POR of CD.

ACR Appropriateness Criteria® Crohn Disease-Child

Crohn disease is an inflammatory condition of the gastrointestinal tract with episodes of exacerbation and remission occurring in children, adolescents, and adults. Crohn disease diagnosis and treatment depend upon a combination of clinical, laboratory, endoscopic, histological, and imaging findings. Appropriate use of imaging provides critical information in the settings of diagnosis, assessment of acute symptoms, disease surveillance, and therapy monitoring. Four variants are discussed. The first variant discusses the initial imaging for suspected Crohn disease before established diagnosis. The second variant pertains to appropriateness of imaging modalities during suspected acute exacerbation. The third variant is a substantial discussion of recommendations related to disease surveillance and monitoring of Crohn disease. Finally, panel recommendations and discussion of perianal fistulizing disease imaging completes the document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Radiology plus ileocolonoscopy versus radiology alone in Crohn's disease: prognosis prediction and mutual agreement

BACKGROUND/AIMS

The optimal tools for monitoring Crohn's disease (CD) are controversial. We compared radiology plus ileocolonoscopy and radiology alone in terms of prognosis prediction and evaluated the agreement between radiologic and ileocolonoscopic findings in patients with CD.

METHODS

Patients with CD who were followed up with computed tomography enterography (CTE) or magnetic resonance enterography (MRE) alone or CTE or MRE plus ileocolonoscopy were retrospectively recruited. Time to relapse was investigated to evaluate the difference in prognosis using the log-rank and Cox regression tests, and the agreement between radiologic and ileocolonoscopic findings was determined using a kappa value.

RESULTS

A total of 501 patients with CD in clinical remission who underwent CTE or MRE and/or ileocolonoscopy were analyzed. Of these, 372 (74.3%) patients underwent CTE or MRE alone and 129 (25.7%) patients underwent CTE or MRE plus ileocolonoscopy. The cumulative maintenance rate of clinical remission between the two groups was not significantly different (p = 0.526, log-rank test). In multivariate analysis, age <40 years (hazard ratio [HR], 2.756; 95% confidence interval [CI], 1.263 to 6.013) and a history of steroid use (HR, 2.212; 95% CI, 1.258 to 3.577) were found to independently predict an increased risk for clinical relapse in patients with CD in clinical remission. Radiologic and ileocolonoscopic findings had a moderate degree of agreement (κ = 0.401, -0.094 to 0.142). The comparison of agreement between radiologic and ileocolonoscopic findings was the highest in the anastomotic site (κ = 0.749, -0.168 to 0.377).

CONCLUSION

Radiology plus ileocolonoscopy was not superior to radiology alone in predicting the prognosis of CD.

Artificial Intelligence Algorithm-Based Differential Diagnosis of Crohn's Disease and Ulcerative Colitis by CT Image

The aim of this study was to investigate the effect of low-dose CT enterography (CTE) based on modified guided image filtering (GIF) algorithm in the differential diagnosis of ulcerative colitis (UC) and Crohn's disease (CD). Methods. One hundred and twenty patients with suspected diagnosis of IBD were studied. They were randomly divided into control group (routine CT examination) and observation group (low-dose CTE examination based on improved GIF algorithm), with 60 cases in each group. Comprehensive diagnosis was used as the standard to assess the diagnostic effect. Results. (1) The peak signal-to-noise ratio (PSNR) (26.02 dB) and structural similarity (SSIM) (0.8921) of the algorithm were higher than those of GIF (17.22 dB/0.8491), weighted guided image filtering (WGIF) (23.78 dB/0.8489), and gradient domain guided image filtering (GGIF) (23.77 dB/0.7567) (P < 0.05); (2) the diagnostic sensitivity (91.49%), specificity (92.31%), accuracy (91.67%), positive predictive value (97.73%), and negative predictive value (75%) of the observation group were higher than those of the control group (P < 0.05); the sensitivity and specificity of CTE in the diagnosis of UD and CD were 96.77% and 81.25% and 98.33% and 93.33%, respectively (P < 0.05); there were significant differences in symmetrical intestinal wall thickening and smooth serosal surface between UD and CD (P < 0.05). Conclusion. (1) The improved GIF algorithm has a more effective application value in the denoising processing of low-dose CT images and can better improve the image quality; (2) the accuracy of CTE in the diagnosis of IBD is high, and CTE is of great value in the differential diagnosis of UD and CD.

Effectiveness and Power of Abdominal Ultrasonography in the Assessment of Crohn's Disease Activity: Comparison with Clinical, Endoscopic, and CT Enterography Findings

BACKGROUND

Non-invasive methods play an important role in clinical assessment of Crohn's disease. Recent studies have highlighted the effectiveness and reliability of intestinal ultrasonography. We aimed to examine the relationship between intestinal ultrasonography and the clinical, endoscopic, and computed tomography enterography findings, and to assess the activity of Crohn's disease.

METHODS

This was a 1-year prospective study involving patients diagnosed with Crohn's Disease. Clinical and endoscopic activity indi- ces, and intestinal ultrasonography and computed tomography enterography findings were evaluated. Intestinal wall thickness, mes- enteric inflammation, lymphadenopathy, and complications were evaluated by intestinal ultrasonograpy and computed tomography enterography, while the superior mesenteric artery flow velocity, resistive index, and Limberg score were assessed by Doppler intestinal ultrasonography.

RESULTS

Seventy-nine patients with Crohn's disease were included. A significant correlation was found between intestinal wall thick- ness, mesenteric inflammation, and complications in intestinal ultrasonography and computed tomography enterography (P = .0001). According to the receiver operating curve analysis, the intestinal wall thickness, and mesenteric inflammation were correlated with the Crohn's Disease Activity Index, Harvey-Bradshaw Index, and SES-CD scores (P < .05), and they were very effective in distinguishing active from inactive disease. According to the Crohn's Disease Activity Index and SES-CD scores, Doppler flow velocity of the superior mesenteric artery was significantly higher in the active group than in the inactive group (P < .05). The Limberg score was very consistent with the Crohn's Disease Activity Index, Harvey-Bradshaw Index , and the results of the Simple Endoscopic Score for Crohn's Disease (P < .0001).

CONCLUSION

Our study showed that intestinal ultrasonography is an effective and reliable method for assessment of Crohn's disease activity compared to clinical, endoscopic, and CTE findings.

Gastrointestinal Ultrasound Can Predict Endoscopic Activity in Crohn's Disease

PURPOSE

 To explore the ability of gastrointestinal ultrasound (GIUS) to separate patients in endoscopic remission from patients with active disease in a heterogeneous hospital cohort with Crohn's disease (CD).

MATERIALS AND METHODS

 145 CD patients scheduled for ileocolonoscopy were prospectively included. The endoscopic disease activity was quantified using the Simple Endoscopic Score for Crohn's disease (SES-CD), and mucosal healing was strictly defined as SES-CD = 0. Ultrasound remission was defined as wall thickness < 3 mm (< 4 mm in the rectum). Additionally, SES-CD was compared to color Doppler, Harvey Bradshaw's index (HBI), C-reactive protein (CRP) and calprotectin. 23 patients were examined by two investigators for interobserver assessment.

RESULTS

 102 had active disease and 43 patients were in remission. GIUS yielded a sensitivity of 92.2 % and a specificity of 86 % for wall thickness and a sensitivity of 66.7 % and a specificity of 97.7 % for color Doppler. The sensitivity and specificity were 34.3 % and 88.4 %, respectively, for HBI, 35.7 % and 82.9 %, respectively, for CRP and 55.9 % and 82.1 %, respectively, for calprotectin. The interobserver analysis revealed excellent agreement for wall thickness (k = 0.90) and color Doppler (k = 0.91) measurements.

CONCLUSION

 GIUS has a high sensitivity for detecting endoscopic activity. Accordingly, bowel ultrasound has the potential to reduce the number of routine ileocolonoscopies in patients with CD.

Combined Endoscopic and Radiologic Healing Is Associated With a Better Prognosis Than Endoscopic Healing Only in Patients With Crohn's Disease Receiving Anti-TNF Therapy

INTRODUCTION

Although endoscopic healing (EH) is recommended as the therapeutic goal in patients with Crohn's disease (CD), combined EH and radiologic healing (RH) could be a more ideal therapeutic goal considering the transmural nature of CD. We compared the prognosis of patients with CD who achieved EH, RH, both EH and RH (deep healing; DH), or no healing under treatment with anti-tumor necrosis factor (TNF) agents.

METHODS

We analyzed 392 patients with CD who received anti-TNF treatment for more than 1 year and evaluated with CT enterography or magnetic resonance enterography together with colonoscopy within 3 months between July 2017 and December 2018. Major outcomes (anti-TNF dose intensification, switch to other biologics, CD-related bowel resection, and hospitalization) were compared according to the EH and RH status.

RESULTS

During the follow-up (median 18 months; interquartile range, 15-21), the DH group showed a better rate of major outcome-free survival compared with other groups (P < 0.001). In multivariable analysis, elevated C-reactive protein (adjusted hazard ratio [aHR], 2.166; 95% confidence interval [CI], 1.508-3.110; P < 0.001), EH-only (aHR, 3.903; 95% CI, 1.635-9.315; P = 0.002), RH-only (aHR, 3.843; 95% CI, 1.545-9.558; P = 0.004), and no healing (aHR, 8.844; 95% CI, 4.268-18.323; P < 0.001) were associated with increased risks of major outcomes.

DISCUSSION

Patients with CD who achieved DH under anti-TNF therapy showed a better prognosis compared with those who only achieved EH. The possibility of DH being used as a new therapeutic target for patients with CD should be investigated in further studies.

Evaluation of the relationship between the spleen volume and the disease activity in ulcerative colitis and Crohn disease

Inflammatory bowel disease (IBD) is caused by the activation of an abnormal immune response in the intestinal mucosa; the spleen is involved in the main immune response. Ulcerative colitis (UC) and Crohn disease (CD) have different inflammatory mechanisms; this study aimed to quantitatively measure and compare the spleen volumes between patients with UC and CD and examine the relationship between spleen volume and disease activity in both.We retrospectively analyzed 44 patients with IBD aged 30-60 years (UC group, n = 24; CD group, n = 20). The control group comprised 19 patients with pancreatic cysts that did not affect the spleen volume. All patients underwent computed tomography (CT) between April 2014 and March 2019. Using the Image J software, spleen volumes in the UC, CD, and control groups were measured accurately from the CT images and adjusted for the body weight.No significant differences in the sex, age, or body weight were noted between the UC and CD groups and the control group. The spleen volumes, adjusted for the body weight, were 2.2 ± 1.0 cm3/kg, 2.0 ± 1.0 cm3/kg, and 3.6 ± 1.7 cm3/kg in the control, UC, and CD groups, respectively. The volumes differed significantly between the CD and control groups (P = .01), but not between the UC and control groups (P = .43). Furthermore, a significant strong correlation was found between the disease activity and the body weight-adjusted spleen volume in patients with CD (P < .01).The spleen volume, adjusted for the body weight, was significantly larger in patients with CD than in the controls and was also strongly correlated with the CD activity. These results suggest that the immune response in CD may affect the spleen volume.

Is the Mixed Use of Magnetic Resonance Enterography and Computed Tomography Enterography Adequate for Routine Periodic Follow-Up of Bowel Inflammation in Patients with Crohn's Disease?

OBJECTIVE

Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) are considered substitutes for each other for evaluating Crohn's disease (CD). However, the adequacy of mixing them for routine periodic follow-up for CD has not been established. This study aimed to compare MRE alone with the mixed use of CTE and MRE for the periodic follow-up of small bowel inflammation in patients with CD.

MATERIALS AND METHODS

We retrospectively compared two non-randomized groups, each comprising 96 patients with CD. One group underwent CTE and MRE (MRE followed by CTE or vice versa) for the follow-up of CD (interval, 13-27 months [median, 22 months]), and the other group underwent MRE alone (interval, 15-26 months [median, 21 months]). However, these two groups were similar in clinical characteristics. Three independent readers from three different institutions determined whether inflammation had decreased, remained unchanged, or increased within the entire small bowel and the terminal ileum based on sequential enterography of the patients after appropriate blinding. We compared the two groups for inter-reader agreement and accuracy (terminal ileum only) using endoscopy as the reference standard for enterographic interpretation.

RESULTS

The inter-reader agreement was greater in the MRE alone group for the entire small bowel (intraclass correlation coefficient [ICC]: 0.683 vs. 0.473; p = 0.005) and the terminal ileum (ICC: 0.656 vs. 0.490; p = 0.030). The interpretation accuracy was higher in the MRE alone group without statistical significance (70.9%-74.5% vs. 57.9%-64.9% in individual readers; adjusted odds ratio = 3.21; p = 0.077).

CONCLUSION

The mixed use of CTE and MRE was inferior to MRE alone in terms of inter-reader reliability and could probably be less accurate than MRE alone for routine monitoring of small bowel inflammation in patients with CD. Therefore, the consistent use of MRE is favored for this purpose.

Prediction of the activity of Crohn's disease based on CT radiomics combined with machine learning models

PURPOSE

To investigate the value of a CT-based radiomics model in identification of Crohn's disease (CD) active phase and remission phase.

METHODS

CT images of 101 patients diagnosed with CD were retrospectively collected, which included 60 patients in active phase and 41 patients in remission phase. These patients were randomly divided into training group and test group at a ratio of 7 : 3. First, the lesion areas were manually delineated by the physician. Meanwhile, radiomics features were extracted from each lesion. Next, the features were selected by t-test and the least absolute shrinkage and selection operator regression algorithm. Then, several machine learning models including random forest (RF), extreme gradient boosting (XGBoost), support vector machine (SVM), logistic regression (LR) and K-nearest neighbor (KNN) algorithms were used to construct CD activity classification models respectively. Finally, the soft-voting mechanism was used to integrate algorithms with better effects to perform two classifications of data, and the receiver operating characteristic curves were applied to evaluate the diagnostic value of the models.

RESULTS

Both on the training set and the test set, AUC of the five machine learning classification models reached 0.85 or more. The ensemble soft-voting classifier obtained by using the combination of SVM, LR and KNN could better distinguish active CD from CD remission. For the test set, AUC was 0.938, and accuracy, sensitivity, and specificity were 0.903, 0.911, and 0.892, respectively.

CONCLUSION

This study demonstrated that the established radiomics model could objectively and effectively diagnose CD activity. The integrated approach has better diagnostic performance.

Evaluation of bone mineral density and body compositions interrelation in young and middle-aged male patients with Crohn's disease by quantitative computed tomography

BACKGROUND

The aim of this study was to investigate the characteristics of bone mineral density (BMD) and body compositions, and the impact of body compositions on BMD in young and middle-aged male patients with Crohn's disease (CD).

METHODS

Patients with CD (n = 198) and normal controls (n = 123) underwent quantitative computed tomography (QCT) examination of lumbar vertebrae 1-3 (L1-3). The BMD and bone geometric parameters were measured and outputted by QCT post-process software. Meanwhile, body composition parameters, including subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), lean mass (LM), and muscles mass around lumbar vertebrae were also acquired by QCT. Blood indicators [interleukin (IL)-6, IL-8, tumor necrosis factor alpha (TNF-α), C-reactive protein (CRP), Ca, and P] were collected from clinical medical records. Independent t-test was used to compare these variables between the CD group and the normal control group.

RESULTS

There was no significant difference in age, height, and weight between the CD group and the control group (p > 0.05), indicating that the sample size was relatively balanced. Mean BMD in the CD group were lower than those in the control group, but the difference was not statistically significant (p > 0.05). The bone geometric parameters of the CD group, including cortical area/density (Ct. Ar, Ct. BMD) and trabecular area/density (Tb. Ar and Tb. BMD), were significantly lower than those of the control group (p < 0.05), so were the body composition parameters including total adipose tissue (TAT), visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), lean mass (LM), and muscles mass (p < 0.05). In addition, the level of plasma IL-6, IL-8, CRP, and TNF-α of the CD group were higher than those of the control group (p < 0.05). On the contrary, the body mass index (BMI) and serum Ca and P levels of the CD group were lower than those of the control group (p < 0.05). Through multiple linear regression analysis, Tb. BMD, VAT, Ct. Ar, LM, Ca, and IL-8 entered the regression model and revealed a significant contribution to BMD.

CONCLUSIONS

Patients with CD could suffer from reduction in BMD. However, the parameters of bone geometric parameters are more sensitive and accurate than BMD changes. Among them, Tb. BMD, VAT, Ct. Ar, and LM have significant effects on BMD reduction.

Crohn's Disease Activity Evaluation by Transabdominal Ultrasonography: Correlation with Double-Balloon Endoscopy

OBJECTIVES

Transabdominal ultrasonography (US) has been reported as a useful tool for evaluating Crohn's disease (CD) activity. Endoscopic findings and Crohn's disease activity index (CDAI) are currently considered the gold standard for assessing CD activity. We assessed the correlation between US and double-balloon endoscopy (DBE), and CDAI for evaluating CD activity.

METHODS

We analyzed patients with CD undergoing US and DBE within 10 days between the procedures. The intestine was divided into four segments and analyzed by the US scoring system (US-CD) and the simple endoscopic score for Crohn's disease (SES-CD). CDAI was compared with US-CD and SES-CD. Spearman's rank correlation coefficient was used for statistical analysis.

RESULTS

Twenty-five patients with CD (11 women, 14 men; mean age 35.4 ± 14.9 years, range 16-65 years) were enrolled. Twenty-four patients received antitumor necrosis factor inhibitor therapy. CDAI was 128.1 (range 36-227). A significant moderate correlation was found between the US-CD and SES-CD in all segments (ρ = .64, P < .01). The US-CD showed a strong correlation with CDAI (ρ = .78, P < .01), whereas the SES-CD showed a moderate correlation (ρ = .55, P < .05).

CONCLUSIONS

US-CD and SES-CD showed a moderate correlation for assessing CD activity. US-CD showed a stronger correlation with CDAI than SES-CD, suggesting that US could more accurately evaluate the disease activity.