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Perianal disease in pediatric Crohn disease: a review of MRI findings. Pediatr Radiol 2014; 44:1198-208; quiz 1195-7. [PMID: 25246189 DOI: 10.1007/s00247-014-3085-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 05/07/2014] [Accepted: 06/12/2014] [Indexed: 12/18/2022]
Abstract
Perianal complications of Crohn disease are a common occurrence in children and can result in significant morbidity when not accurately characterized prior to surgical intervention. MRI is an excellent imaging modality for the evaluation of perianal inflammatory bowel disease - allowing characterization and detailed description of perianal fistulas. MRI has many advantages over other imaging modalities for the pediatric patient. Radiologists will benefit from a sophisticated understanding of perianal anatomy, the classification of perianal fistulas, the advantages MRI offers in characterization of perianal fistulas as well as the common and incidental findings that are important in the MRI evaluation of perianal inflammatory bowel disease in children. Perianal fistulas are found at a high rate in pediatric referrals and are more commonly found in male patients.
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Abstract
PURPOSE OF REVIEW To review the various imaging modalities in the evaluation of pediatric inflammatory bowel disease (IBD) to determine disease location, clinical phenotype and the severity of disease in order to optimize treatment. RECENT FINDINGS Assessment of the extent, location and severity of IBD routinely involves imaging of the gastrointestinal tract. Cross-sectional modalities such as magnetic resonance enterography (MRE) and computed tomography enterography visualize the lumen, transmural involvement, extraintestinal manifestations and may facilitate decision-making in disease management. MRE has evolved as the imaging modality of choice for many pediatric IBD indications because it does not involve exposure to ionizing radiation. SUMMARY Advances in imaging modalities have revolutionized the assessment of children with IBD in recent years. Small-bowel follow-through is no longer considered the imaging modality of choice in this setting. Cross-sectional enterography is now preferred because, among other advantages, it can potentially distinguish active inflammation from fibrosis, characterize stricturing and penetrating complications, and diagnose extraintestinal manifestations. Although MRE avoids ionizing radiation exposure, it remains costly. Cross-sectional imaging and endoscopy complement each other in the development of objective measures for the assessment of disease activity and monitoring of response to treatment.
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53
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Vanbeckevoort D, Bielen D, Vanslembrouck R, Van Assche G. Magnetic resonance imaging of perianal fistulas. Magn Reson Imaging Clin N Am 2014; 22:113-23. [PMID: 24238135 DOI: 10.1016/j.mric.2013.07.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Perianal fistulization is the result of a chronic inflammation of the perianal tissues. A wide spectrum of clinical manifestations, ranging from simple to complex fistulas, can be seen, the latter especially in patients with Crohn disease. Failure to detect secondary tracks and hidden abscesses may lead to therapeutic failure, such as insufficient response to medical treatment and relapse after surgery. Currently, magnetic resonance (MR) imaging is the preferred technique for evaluating perianal fistulas and associated complications. Initially used most often in the preoperative setting, MR imaging now also plays an important role in evaluating the response to medical therapy.
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Affiliation(s)
- Dirk Vanbeckevoort
- Department of Radiology, University Hospitals Leuven, Herestraat 49, Leuven B-3000, Belgium.
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Schaeffer DF, Walsh JC, Kirsch R, Waterman M, Silverberg MS, Riddell RH. Distinctive histopathologic phenotype in resection specimens from patients with Crohn's disease receiving anti-TNF-α therapy. Hum Pathol 2014; 45:1928-35. [PMID: 25022570 DOI: 10.1016/j.humpath.2014.05.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 05/28/2014] [Accepted: 05/30/2014] [Indexed: 12/19/2022]
Abstract
Anti-tumor necrosis factor α (anti-TNF-α) therapy can result in endoscopic healing, reduction of symptoms, and reduced need for surgery and hospitalization in many patients with Crohn's disease (CD). Earlier data suggested that anti-TNF-α therapy may be associated with fibrosis and stricturing. We sought to determine whether anti-TNF-α therapy affects histologic inflammation, fibrosis, and granuloma formation. Hematoxylin and eosin sections from 62 patients with CD treated with either infliximab or adalimumab and 80 controls undergoing the same surgery but without prior exposure to anti-TNF-α therapy were compared. All patients with CD had undergone surgery within 6 months of therapy; CD controls were matched for steroid exposure, procedure, and indication for surgery and were subcategorized and case matched. Blinded histologic assessment of all slides was performed using a semiquantitative scoring system to assess inflammatory changes and fibrosis in all bowel layers. Compared with controls, the group treated with anti-TNF-α showed a reduction in mucosal and submucosal inflammation (P < .05), a decrease in granuloma formation (P < .05), and an increase in duplication of the muscularis mucosae (P < .05). A notable feature was a distinct pattern of hyalinizing submucosal fibrosis that was often devoid of inflammatory cells and that started directly below the muscularis mucosae; this pattern was not observed in the control group (P < .05). Resection specimens from patients with CD treated with anti-TNF-α therapy showed (a) reduced mucosal and submucosal inflammation; (b) a decrease in granuloma formation; and (c) a distinct pattern of submucosal hyaline fibrosis, with increased fibrosis in the muscularis mucosae and muscularis propria.
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Affiliation(s)
- David F Schaeffer
- Department of Laboratory Medicine and Pathology, Mount Sinai Hospital, Toronto, ON, Canada Joseph and Wolf Lebovic Health Complex 600 University Avenue Toronto, Ontario, Canada M5G 1X5; Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, BC, Canada 910 W. 10th Avenue, Vancouver, British Columbia, Canada V5Z 1M9.
| | - Joanna C Walsh
- Department of Laboratory Medicine and Pathology, Mount Sinai Hospital, Toronto, ON, Canada Joseph and Wolf Lebovic Health Complex 600 University Avenue Toronto, Ontario, Canada M5G 1X5
| | - Richard Kirsch
- Department of Laboratory Medicine and Pathology, Mount Sinai Hospital, Toronto, ON, Canada Joseph and Wolf Lebovic Health Complex 600 University Avenue Toronto, Ontario, Canada M5G 1X5
| | - Matti Waterman
- Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, Toronto, ON, Canada Joseph and Wolf Lebovic Health Complex 600 University Avenue Toronto, Ontario, Canada M5G 1X5; Zane Cohen Centre for Digestive Diseases, Toronto, ON, Canada 60 Murray Street Toronto, Ontario, Canada M5T 3L9
| | - Mark S Silverberg
- Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, Toronto, ON, Canada Joseph and Wolf Lebovic Health Complex 600 University Avenue Toronto, Ontario, Canada M5G 1X5; Zane Cohen Centre for Digestive Diseases, Toronto, ON, Canada 60 Murray Street Toronto, Ontario, Canada M5T 3L9
| | - Robert H Riddell
- Department of Laboratory Medicine and Pathology, Mount Sinai Hospital, Toronto, ON, Canada Joseph and Wolf Lebovic Health Complex 600 University Avenue Toronto, Ontario, Canada M5G 1X5; Zane Cohen Centre for Digestive Diseases, Toronto, ON, Canada 60 Murray Street Toronto, Ontario, Canada M5T 3L9
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D'Incà R, Caccaro R. Measuring disease activity in Crohn's disease: what is currently available to the clinician. Clin Exp Gastroenterol 2014; 7:151-61. [PMID: 24876789 PMCID: PMC4035027 DOI: 10.2147/ceg.s41413] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Crohn’s disease (CD) is a chronic inflammatory bowel disease characterized by a relapsing-remitting clinical behavior and dominated by intestinal inflammation. Being a chronic disorder that with time develops into a disabling disease, it is important to monitor the severity of inflammation to assess the efficacy of medication, rule out complications, and prevent progression. This is particularly true now that the goals of treatment are mucosal healing and deep remission. Endoscopy has always been the gold standard for assessing mucosal activity in CD, but its use is limited by its invasiveness and its inability to examine the small intestine, proximal to the terminal ileum. Enteroscopy and the less invasive small bowel capsule endoscopy enable the small bowel to be thoroughly explored and scores are emerging for classifying small bowel disease activity. Cross-sectional imaging techniques (ultrasound, magnetic resonance, computed tomography) are emerging as valid tools for monitoring CD patients, assessing inflammatory activity in the mucosa and the transmucosal extent of the disease, and for excluding extra-intestinal complications. Neither endoscopy nor imaging are suitable for assessing patients frequently, however. Noninvasive markers such as C-reactive protein, and fecal biomarkers such as calprotectin and lactoferrin, are therefore useful to confirm the inflammatory burden of the disease and to identify patients requiring further investigations.
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Affiliation(s)
- Renata D'Incà
- Department of Surgical, Oncological and Gastroenterological Sciences, Gastroenterology Section, University of Padua, Padua, Italy
| | - Roberta Caccaro
- Department of Surgical, Oncological and Gastroenterological Sciences, Gastroenterology Section, University of Padua, Padua, Italy
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MRI-based score helps in assessing the severity and in follow-up of pediatric patients with perianal Crohn disease. J Pediatr Gastroenterol Nutr 2014; 58:252-7. [PMID: 24121148 DOI: 10.1097/mpg.0000000000000199] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The radiologic healing of perianal fistulizing Crohn disease (PfCD) lags behind the clinical healing. Contrast-enhanced pelvic magnetic resonance imaging (MRI) is the radiologic study of choice used to diagnose PfCD in children. The aim was to study whether the various MRI-based radiologic parameters and score can help in staging and follow-up of patients with PfCD. METHODS We performed a retrospective chart review of children with PfCD who underwent contrast-enhanced MRI of the pelvis. The demographic profile, clinical status, and laboratory data of the patients at the time of each MRI examination were noted. Based on the clinical status of the patient at the time of MRI examinations, the MRIs were classified into 3 groups: severe disease, mild-to-moderate disease, and asymptomatic. Each MRI examination was reviewed by a radiologist, who was blinded to the clinical status of the patient. RESULTS Of the radiologic parameters, the number of fistulas, the complexity of fistulas, and the number of abscesses were significantly lower in the asymptomatic group compared with the mild-to-moderate and severe disease groups. The Van Assche MRI-based score was significantly lower in the asymptomatic group compared with the mild-to-moderate disease (P = 0.01) and the severe disease group (P = 0.002). The percentage increase in fistula activity after gadolinium administration was significantly lower in the asymptomatic group compared with the mild-to-moderate disease (P = 0.026) and severe disease (P = 0.019) groups. The MRI-based scores were significantly higher in the MRI examinations performed at diagnosis compared with those that were performed while the patients were receiving the treatment (P = 0.017). CONCLUSIONS The Van Assche MRI score and the percentage increase in fistula activity after gadolinium administration help in assessing the severity perianal Crohn disease. The Van Assche MRI score may be helpful in documenting healing during therapy of perianal Crohn disease.
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Dewint P, Hansen BE, Verhey E, Oldenburg B, Hommes DW, Pierik M, Ponsioen CIJ, van Dullemen HM, Russel M, van Bodegraven AA, van der Woude CJ. Adalimumab combined with ciprofloxacin is superior to adalimumab monotherapy in perianal fistula closure in Crohn's disease: a randomised, double-blind, placebo controlled trial (ADAFI). Gut 2014; 63:292-9. [PMID: 23525574 DOI: 10.1136/gutjnl-2013-304488] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess whether a combination of adalimumab and ciprofloxacin is superior to adalimumab alone in the treatment of perianal fistulising Crohn's disease (CD). DESIGN Randomised, double-blind, placebo controlled trial in eight Dutch hospitals. In total, 76 CD patients with active perianal fistulising disease were enrolled. After adalimumab induction therapy (160/80 mg week 0, 2), patients received 40 mg every other week together with ciprofloxacin 500 mg or placebo twice daily for 12 weeks. After 12 weeks, adalimumab was continued. Follow-up was 24 weeks. Primary endpoint (clinical response) was defined as 50% reduction of fistulas from baseline to week 12. Secondary endpoints included remission (closure of all fistulas), Perianal Crohn's Disease Activity Index, Crohn's Disease Activity Index (CDAI) and Inflammatory Bowel Disease Questionnaire (IBDQ). RESULTS Clinical response was observed in 71% of patients treated with adalimumab plus ciprofloxacin and in 47% treated with adalimumab plus placebo (p=0.047). Likewise, remission rate at week 12 was significantly higher (p=0.009) in the combination group (65%) compared with adalimumab plus placebo (33%). Combination treatment was associated with a higher mean CDAI change and mean IBDQ change at week 12 (p=0.005 and p=0.009, respectively). At week 24, no difference in clinical response between the two treatment groups was observed (p=0.22). No difference in safety issues was observed. CONCLUSIONS Combination therapy of adalimumab and ciprofloxacin is more effective than adalimumab monotherapy to achieve fistula closure in CD. However, after discontinuation of antibiotic therapy, the beneficial effect of initial coadministration is not maintained. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00736983.
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Affiliation(s)
- Pieter Dewint
- Department of Gastroenterology and Hepatology, Erasmus MC Rotterdam, , Rotterdam, The Netherlands
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Denmark VK, Mayer L. Current status of monoclonal antibody therapy for the treatment of inflammatory bowel disease: an update. Expert Rev Clin Immunol 2014; 9:77-92. [DOI: 10.1586/eci.12.91] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Imaging techniques and combined medical and surgical treatment of perianal Crohn's disease. J Ultrasound 2013; 18:19-35. [PMID: 25767636 DOI: 10.1007/s40477-013-0042-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 10/05/2013] [Indexed: 12/13/2022] Open
Abstract
Crohn's disease is a chronic inflammatory disease which may involve any segment of the gastrointestinal tract, most frequently the terminal ileum, the large intestine, and the perianal region. The symptoms of perianal Crohn's disease include skin disorders, hemorrhoids, anal ulcers, anorectal stenosis, perianal abscesses and fistulas, rectovaginal fistulas and carcinoma of the perianal region. The perianal manifestations of Crohn's disease cause great discomfort to the patient and are among the most difficult aspects to treat. Management of perianal disease requires a combination of different imaging modalities and a close cooperation between gastroenterologists and dedicated surgeons.
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60
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Abstract
Controlled trials and meta-analyses have shown that immunosuppressants are effective in steroid-dependent Crohn's disease (CD) and, although less well demonstrated, ulcerative colitis (UC). It has also been demonstrated that anti-TNF are effective in steroid-dependent and steroid-refractory CD and UC. Anti-TNF can also decrease hospitalization rate and the need for surgery. This seems also to be the case for immunosuppressants. The early use of anti-TNF seems more effective than later use, and early mucosal healing is associated with decreased rate of surgery. On the contrary, early use of purine analogues does not seem to improve outcome in CD. Anti-TNF therapies have been shown superior to immunosuppressants and combination therapy superior to anti-TNF monotherapy in inducing steroid-free remission and mucosal healing. The main strategic questions which remain at this stage include: When to start immunosuppressants or anti-TNF? Is there still a place for immunosuppressant monotherapy? How to optimize anti-TNF? Is it possible to stop anti-TNF? The main justification of immunosuppressant monotherapy is the low cost of this treatment and the possibility of achieving a very stable and long-standing remission in a subset of patients. According to this and provided there is no rapid need for more effective therapy, this treatment could be tried in any inflammatory bowel disease patient not correctly maintained after a course of steroids and 5-aminosalicylic acid. However, the failure to respond to this treatment should be recognized early and a step up to anti-TNF considered. An anti-TNF treatment should be considered early in patients at risk of rapid evolution towards tissue damage and complications. The benefit/risk of the immunosuppressant + anti-TNF combination therapy should be assessed on a case-by-case basis. Anti-TNF treatment should always be fully optimized by adapting dosage and potentially adding an immunosuppressant before considering treatment failure. Treatment de-escalation should only be considered when a long-standing stable remission has been achieved both clinically and biologically. The cost sparing and theoretical decrease in complication risk should be put in perspective with the risk of relapse and disease progression.
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Affiliation(s)
- Edouard Louis
- Department of Gastroenterology, University Hospital CHU of Liège, Liège, Belgium
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61
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Optimising monitoring in the management of Crohn's disease: a physician's perspective. J Crohns Colitis 2013; 7:653-69. [PMID: 23562672 DOI: 10.1016/j.crohns.2013.02.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 02/05/2013] [Indexed: 02/08/2023]
Abstract
Management of Crohn's disease has traditionally placed high value on subjective symptom assessment; however, it is increasingly appreciated that patient symptoms and objective parameters of inflammation can be disconnected. Therefore, strategies that objectively monitor inflammatory activity should be utilised throughout the disease course to optimise patient management. Initially, a thorough assessment of the severity, location and extent of disease is needed to ensure a correct diagnosis, identify any complications, help assess prognosis and select appropriate therapy. During follow-up, clinical decision-making should be driven by disease activity monitoring, with the aim of optimising treatment for tight disease control. However, few data exist to guide the choice of monitoring tools and the frequency of their use. Furthermore, adaption of monitoring strategies for symptomatic, asymptomatic and post-operative patients has not been well defined. The Annual excHangE on the ADvances in Inflammatory Bowel Disease (IBD Ahead) 2011 educational programme, which included approximately 600 gastroenterologists from 36 countries, has developed practice recommendations for the optimal monitoring of Crohn's disease based on evidence and/or expert opinion. These recommendations address the need to incorporate different modalities of disease assessment (symptom and endoscopic assessment, measurement of biomarkers of inflammatory activity and cross-sectional imaging) into robust monitoring. Furthermore, the importance of measuring and recording parameters in a standardised fashion to enable longitudinal evaluation of disease activity is highlighted.
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Amitai MM, Ben-Horin S, Eliakim R, Kopylov U. Magnetic resonance enterography in Crohn's disease: a guide to common imaging manifestations for the IBD physician. J Crohns Colitis 2013; 7:603-15. [PMID: 23122965 DOI: 10.1016/j.crohns.2012.10.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 10/05/2012] [Accepted: 10/07/2012] [Indexed: 02/08/2023]
Abstract
Patients with Crohn's disease (CD) frequently require cross-sectional imaging. Magnetic resonance enterography (MRE) is an accurate tool for assessment of bowel disease and of various complications of CD. The lack of non-ionizing radiation exposure is an important advantage of this imaging modality. Familiarity with common and pathognomonic imaging features of CD is essential for every clinician that is involved in inflammatory bowel disease (IBD) patients' care. This review is aimed to describe the indications for performing MRE in CD, essentials of MRE techniques and typical radiological findings in patients with CD to aid the IBD doctor in daily practice.
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Affiliation(s)
- Marianne M Amitai
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel Hashomer, Israel
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63
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Bouguen G, Siproudhis L, Gizard E, Wallenhorst T, Billioud V, Bretagne JF, Bigard MA, Peyrin-Biroulet L. Long-term outcome of perianal fistulizing Crohn's disease treated with infliximab. Clin Gastroenterol Hepatol 2013; 11:975-81.e1-4. [PMID: 23376316 DOI: 10.1016/j.cgh.2012.12.042] [Citation(s) in RCA: 130] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 12/11/2012] [Accepted: 12/28/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Little is known about the long-term efficacy of infliximab for patients with fistulizing perianal Crohn's disease. We evaluated outcomes and predictors of outcomes in these patients. METHODS The medical records of 156 patients treated with infliximab for fistulizing perianal Crohn's disease at 2 referral centers from 1999 through 2010 were reviewed through September 2011. Cumulative probabilities of fistula closure and recurrence were estimated by using the Kaplan-Meier method. Predictors of outcomes were identified by using a Cox proportional hazards model. RESULTS When infliximab treatment began, only 17.9% of patients had a simple fistula; seton drainage was performed for 97 patients (62%). Concomitant immunosuppressants were given to 90 patients (56%). After a median follow-up period of 250 weeks, 108 patients (69%) had at least 1 fistula closure. Cumulative probabilities of first fistula closure were 40% and 65% at 1 and 5 years, respectively. Factors that predicted fistula closure were ileocolonic disease (hazard ratio [HR] = 1.88), concomitant immunosuppressants (HR = 2.58), duration of seton drainage <34 weeks (HR = 2.31), and long duration of infliximab treatment (HR = 1.76). Of the 108 patients with fistula closure, cumulative probabilities of first fistula recurrence were 16.6% and 40.1% at 1 and 5 years, respectively. Forty-four patients (28.9%) developed an abscess during follow-up. A number of infliximab infusions greater than 19 was associated with less abscess recurrence (HR = 0.33). At the maximal follow-up time, 55% of patients had fistula closure. CONCLUSIONS About two-thirds of patients with fistulizing perianal Crohn's disease had fistula closure, and one-third had fistula recurrence after infliximab initiation. Combination therapy, duration of seton drainage less than 34 weeks, and long-term treatment with infliximab were associated with better outcomes.
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Affiliation(s)
- Guillaume Bouguen
- Department of Hepato-Gastroenterology, University Hospital of Rennes, Pontchaillou, Inserm U991 University of Rennes 1, Rennes, France
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Panes J, Bouhnik Y, Reinisch W, Stoker J, Taylor SA, Baumgart DC, Danese S, Halligan S, Marincek B, Matos C, Peyrin-Biroulet L, Rimola J, Rogler G, van Assche G, Ardizzone S, Ba-Ssalamah A, Bali MA, Bellini D, Biancone L, Castiglione F, Ehehalt R, Grassi R, Kucharzik T, Maccioni F, Maconi G, Magro F, Martín-Comín J, Morana G, Pendsé D, Sebastian S, Signore A, Tolan D, Tielbeek JA, Weishaupt D, Wiarda B, Laghi A. Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines. J Crohns Colitis 2013; 7:556-85. [PMID: 23583097 DOI: 10.1016/j.crohns.2013.02.020] [Citation(s) in RCA: 446] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 02/20/2013] [Indexed: 12/12/2022]
Abstract
The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence of complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic techniques for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.
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Affiliation(s)
- J Panes
- Gastroenterology Department, Hospital Clinic Barcelona, CIBERehd, IDIBAPS, Barcelona, Spain.
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Abstract
BACKGROUND It was the aim of this prospective study to analyze both the feasibility and preliminary results of video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair for complex fistulas in Crohn's disease. METHODS All patients with perianal Crohn's disease suffering from complex fistulas who underwent definitive surgery using VAAFT combined with advancement flap repair were prospectively enrolled in the study. Only complex fistulas with concurrent stable disease and without any evidence of severe inflammatory activity or perianal sepsis were treated using the VAAFT technique. Patients with Crohn's proctitis or prior proctectomy were not candidates for the procedure. VAAFT was performed by using the VAAFT equipment (Karl Storz, Tuttlingen, Germany). Key steps included visualization of the fistula tract and/or side tracts using the fistuloscope and correct localization of the internal fistula opening under direct vision with irrigation. Diagnostic fistuloscopy was followed by advancement flap repair. In addition to feasibility, primary end points included detection of side tracts, success and continence status (assessed by the Cleveland Clinic Incontinence Score). Success was defined as closure of both internal and external openings, absence of drainage without further intervention and absence of abscess formation. Follow-up information was derived from clinical examination 3, 6 and 9 months postoperatively. RESULTS Within a 3-month observation period (September to November 2011), VAAFT was attempted in 13 patients with Crohn's associated complex fistulas. The completion rate was 85% (11/13). In these 11 patients (median age 34 years, 64% females), complex fistulas were transsphincteric (8), suprasphincteric (2) and recto-vaginal (1). Forty-six percent (5/11) had concomitant therapy with biologic drugs. In 36% (4/11), VAAFT was performed with fecal diversion. Median duration of surgery was 22 (range 18-42) minutes. Using VAAFT, additional side tracts not detected preoperatively could be identified in 64% (7/11). No morbidity occurred. After a mean follow-up of 9 months, the success rate was 82% (9/11). No deterioration of continence was documented (Cleveland Clinic Incontinence Score 2.4 vs. 1.6, p > 0.05). CONCLUSION Preliminary results of the addition of the VAAFT technique to advancement flap repair in Crohn's fistulas demonstrate that this leads to a high identification rate of occult side tracts with encouraging short-term healing rates. Moreover, a completion rate of 85% seems promising.
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66
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Di Nardo G, Aloi M, Oliva S, Civitelli F, Casciani E, Cucchiara S. Investigation of small bowel in pediatric Crohn's disease. Inflamm Bowel Dis 2012; 18:1760-76. [PMID: 22275336 DOI: 10.1002/ibd.22885] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Accepted: 12/28/2011] [Indexed: 12/16/2022]
Abstract
Investigation of the small bowel has been traditionally a challenge for pediatric gastroenterologists due to its location, anatomical tortuosity, and invasiveness of the available techniques. Recently, there has been a remarkable improvement in imaging and endoscopic tools aimed at exploring successfully the small intestine in inflammatory bowel disease. The former are represented by ultrasonography (either alone or with administration of oral contrast agents) and by magnetic resonance: both have provided accurate methods to detect structural bowel changes, diminishing patient discomfort and precluding radiation hazard. The use of traditional radiologic techniques such as fluoroscopy have been markedly reduced due to radiation exposure and inability to depict transmural inflammation or extraluminal complications. Among the novel endoscopic tools, capsule endoscopy and balloon-assisted enteroscopy have tremendously opened new diagnostic and therapeutic perspectives, by allowing the direct visualization of small intestinal mucosa and, through enteroscopy, histological diagnosis as well as therapeutic interventions such as stricture dilation and bleeding treatment. These endoscopic techniques should always be preceded by imaging of the intestine in order to identify strictures. This review describes the most recent progress with the employment of novel imaging and endoscopic methodologies for investigating the small bowel in children with suspected or established Crohn's disease.
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Affiliation(s)
- Giovanni Di Nardo
- Department od Pediatrics and Infantile Neuropsychiatry, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, University Hospital Umberto I, Rome, Italy
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Wise PE, Schwartz DA. The evaluation and treatment of Crohn perianal fistulae: EUA, EUS, MRI, and other imaging modalities. Gastroenterol Clin North Am 2012; 41:379-91. [PMID: 22500524 DOI: 10.1016/j.gtc.2012.01.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Perianal fistulizing disease is a common complication of CD that requires a multidisciplinary collaboration between gastroenterology, surgery, and radiology professionals for successful assessment and treatment. Optimal success comes from a combined medical and surgical approach to treat the fistulizing disease (see Fig. 1). Unfortunately, even with a variety of surgical options, a subset of patients require permanent fecal diversion and/or proctectomy to successfully treat their disease. Further studies (likely requiring large, multicenter trials) of novel medical and surgical treatments are still warranted to formulate optimal management of this complex condition.
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Affiliation(s)
- Paul E Wise
- Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Nashville, TN 37232-0252, USA
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de Miguel Criado J, del Salto LG, Rivas PF, del Hoyo LFA, Velasco LG, de las Vacas MIDP, Marco Sanz AG, Paradela MM, Moreno EF. MR imaging evaluation of perianal fistulas: spectrum of imaging features. Radiographics 2012; 32:175-94. [PMID: 22236900 DOI: 10.1148/rg.321115040] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Perianal fistulization is an inflammatory condition that affects the region around the anal canal, causing significant morbidity and often requiring repeated surgical treatments due to its high tendency to recur. To adopt the best surgical strategy and avoid recurrences, it is necessary to obtain precise radiologic information about the location of the fistulous track and the affected pelvic structures. Until recently, imaging techniques played a limited role in evaluation of perianal fistulas. However, magnetic resonance (MR) imaging now provides more precise information on the anatomy of the anal canal, the anal sphincter complex, and the relationships of the fistula to the pelvic floor structures and the plane of the levator ani muscle. MR imaging allows precise definition of the fistulous track and identification of secondary fistulas or abscesses. It provides accurate information for appropriate surgical treatment, decreasing the incidence of recurrence and allowing side effects such as fecal incontinence to be avoided. Radiologists should be familiar with the anatomic and pathologic findings of perianal fistulas and classify them using the St James's University Hospital MR imaging-based grading system.
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Affiliation(s)
- Jaime de Miguel Criado
- Department of Radiology, Central Radiodiagnostic Unit, Hospital del Henares, 28822 Coslada, Spain.
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Affiliation(s)
- Charles P Heise
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Fiorino G, Bonifacio C, Malesci A, Balzarini L, Danese S. MRI in Crohn's disease--current and future clinical applications. Nat Rev Gastroenterol Hepatol 2011. [PMID: 22105109 DOI: 10.1038/nrgastro.2011.2142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Crohn's disease is a chronic, disabling disease that, over time, can lead to irreversible bowel damage. MRI can be used to diagnose and assess the activity, severity and complications of Crohn's disease; however, the role of MRI in therapeutic monitoring of changes in disease-related intestinal damage is still to be defined. Objective, validated MRI-based scores have been developed to assess the activity of Crohn's disease; these indices are based on the extent and severity of intestinal inflammation, postoperative recurrence and perianal disease. MRI is accurate, safe, reproducible and can allow repeated evaluations of patients without radiation exposure. Evidence that MRI might be valuable in the therapeutic monitoring of patients with Crohn's disease is increasing and, in combination with endoscopy and surgical history, this imaging technique could enable clinicians to assess Crohn's-disease-related intestinal damage. MRI could, therefore, have a crucial role in a future 'damage-driven' treatment paradigm--in which imaging is used to monitor intestinal damage and medication use is targeted to prevent the accumulation of further damage. This damage-driven therapeutic approach could potentially change the course of Crohn's disease.
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Affiliation(s)
- Gionata Fiorino
- Division of Gastroenterology and Digestive Endoscopy, Istituto Clinico Humanitas, Via Manzoni 56, Rozzano, Milan 20089, Italy
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Abstract
Crohn's disease is a chronic, disabling disease that, over time, can lead to irreversible bowel damage. MRI can be used to diagnose and assess the activity, severity and complications of Crohn's disease; however, the role of MRI in therapeutic monitoring of changes in disease-related intestinal damage is still to be defined. Objective, validated MRI-based scores have been developed to assess the activity of Crohn's disease; these indices are based on the extent and severity of intestinal inflammation, postoperative recurrence and perianal disease. MRI is accurate, safe, reproducible and can allow repeated evaluations of patients without radiation exposure. Evidence that MRI might be valuable in the therapeutic monitoring of patients with Crohn's disease is increasing and, in combination with endoscopy and surgical history, this imaging technique could enable clinicians to assess Crohn's-disease-related intestinal damage. MRI could, therefore, have a crucial role in a future 'damage-driven' treatment paradigm--in which imaging is used to monitor intestinal damage and medication use is targeted to prevent the accumulation of further damage. This damage-driven therapeutic approach could potentially change the course of Crohn's disease.
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Daperno M, Castiglione F, de Ridder L, Dotan I, Färkkilä M, Florholmen J, Fraser G, Fries W, Hebuterne X, Lakatos PL, Panés J, Rimola J, Louis E. Results of the 2nd part Scientific Workshop of the ECCO. II: Measures and markers of prediction to achieve, detect, and monitor intestinal healing in inflammatory bowel disease. J Crohns Colitis 2011; 5:484-98. [PMID: 21939926 DOI: 10.1016/j.crohns.2011.07.003] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 07/08/2011] [Indexed: 12/13/2022]
Abstract
The healing of the intestine is becoming an important objective in the management of inflammatory bowel diseases. It is associated with improved disease outcome. Therefore the assessment of this healing both in clinical studies and routine practice is a key issue. Endoscopy for the colon and terminal ileum and computerized tomography or magnetic resonance imaging for the small bowel are the most direct ways to evaluate intestinal healing. However, there are many unsolved questions about the definition and the precise assessment of intestinal healing using these endoscopic and imaging techniques. Furthermore, these are relatively invasive and expensive procedures that may be inadequate for regular patients' monitoring. Therefore, biomarkers such as C-reactive protein and fecal calprotectin have been proposed as surrogate markers for intestinal healing. Nevertheless, the sensitivity and specificity of these markers for the prediction of healing may be insufficient for routine practice. New stool, blood or intestinal biomarkers are currently studied and may improve our ability to monitor intestinal healing in the future.
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Affiliation(s)
- Marco Daperno
- Gastroenterology Division, AO Ordine Mauriziano, Torino, Italy
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Gastroenterology review and perspective: the role of cross-sectional imaging in evaluating bowel damage in Crohn disease. AJR Am J Roentgenol 2011; 197:42-9. [PMID: 21701009 DOI: 10.2214/ajr.11.6632] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This article will review the performance and limitations of cross-sectional imaging methods to detect and display critical features of Crohn disease (CD)-related bowel damage, including stenosis and penetrating complications (i.e., fistula, abscess). International efforts to incorporate cross-sectional imaging findings along with endoscopic and surgical findings to create a global bowel damage score over the length of the gastrointestinal tract are summarized along with the rationale for these efforts. CONCLUSION The first digestive damage score, the Lémann score, will incorporate surgical history, endoscopic findings, and imaging findings of stenosis and penetrating complications to provide a global assessment of CD-related destruction of the gastrointestinal tract. It is anticipated that the score will permit better understanding of the impact of modern therapeutics on the natural history of CD. Because CT is a technique that involves ionizing radiation and accuracy of ultrasound is highly related to CD location, MRI is proposed as first choice for nonemergent follow-up of CD patients.
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