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Lu C, Merrill C, Medellin A, Novak K, Wilson SR. Bowel Ultrasound State of the Art: Grayscale and Doppler Ultrasound, Contrast Enhancement, and Elastography in Crohn Disease. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:271-288. [PMID: 30604884 DOI: 10.1002/jum.14920] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/08/2018] [Accepted: 11/22/2018] [Indexed: 06/09/2023]
Abstract
Bowel ultrasound (US) is accurate for assessing bowel inflammation and complications in Crohn disease. Additionally, contrast-enhanced US provides a quantitative, objective measurement of inflammatory activity in inflammatory bowel disease, and shear wave elastography predicts the stiffness of bowel, an increase of which suggests less response to medical therapy, often necessitating surgery. Overall, bowel US is an excellent, safe, and repeatable choice for routine surveillance and for urgent imaging. We describe an approach to evaluating inflammatory bowel disease and review its features on standard grayscale US with Doppler imaging and show how contrast-enhanced US and shear wave elastography can distinguish between inflammatory and fibrostenotic bowel.
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Affiliation(s)
- Cathy Lu
- Department of Medicine, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Christina Merrill
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra Medellin
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Kerri Novak
- Department of Medicine, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Stephanie R Wilson
- Department of Medicine, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
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52
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Maaser C, Sturm A, Vavricka SR, Kucharzik T, Fiorino G, Annese V, Calabrese E, Baumgart DC, Bettenworth D, Borralho Nunes P, Burisch J, Castiglione F, Eliakim R, Ellul P, González-Lama Y, Gordon H, Halligan S, Katsanos K, Kopylov U, Kotze PG, Krustinš E, Laghi A, Limdi JK, Rieder F, Rimola J, Taylor SA, Tolan D, van Rheenen P, Verstockt B, Stoker J. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis 2019; 13:144-164. [PMID: 30137275 DOI: 10.1093/ecco-jcc/jjy113] [Citation(s) in RCA: 909] [Impact Index Per Article: 181.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Andreas Sturm
- Department of Gastroenterology, DRK Kliniken Berlin I Westend, Berlin, Germany
| | | | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Gionata Fiorino
- Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic & American Hospital, Dubai, UAE
| | - Emma Calabrese
- Department of Systems Medicine, University of Rome, Tor Vergata, Italy
| | - Daniel C Baumgart
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, Münster, Germany
| | - Paula Borralho Nunes
- Department of Anatomic Pathology, Hospital Cuf Descobertas; Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital; Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Fabiana Castiglione
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Pierre Ellul
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Yago González-Lama
- Department of Gastroenterology, University Hospital Puerta De Hierro, Majadahonda [Madrid], Spain
| | - Hannah Gordon
- Department of Gastroenterology, Royal London Hospital, London, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Paraná [PUCPR], Curitiba, Brazil
| | - Eduards Krustinš
- Department of of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Andrea Laghi
- Department of Clinical and Surgical Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester; Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Damian Tolan
- Clinical Radiology, St James's University Hospital, Leeds, UK
| | - Patrick van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, Groningen, The Netherlands
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven and CHROMETA - Translational Research in Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Center [AMC], University of Amsterdam, Amsterdam, The Netherlands
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53
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Serban ED. Treat-to-target in Crohn's disease: Will transmural healing become a therapeutic endpoint? World J Clin Cases 2018; 6:501-513. [PMID: 30397606 PMCID: PMC6212605 DOI: 10.12998/wjcc.v6.i12.501] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/17/2018] [Accepted: 10/08/2018] [Indexed: 02/05/2023] Open
Abstract
Crohn's disease (CD) represents a chronic transmural inflammatory condition of the gastrointestinal tract, which usually leads to structural damage and significant disability. Deep remission - defined by both clinical and endoscopic remission, signifying mucosal healing - represents the current endpoint in the treat-to-target strategy, significantly improving patients' long-term outcomes. Transmural healing (TH) could be a more effective target, but this possibility remains unclear. This narrative review aims to critically review and summarize the available literature relating TH to long-term outcomes, being the first of its kind and to the best of the author's knowledge. A systematic literature search (from inception to March 31 2018) was performed, using multiple databases, and identifying seven full-text manuscripts. In those studies, long-term favorable outcomes (≥ 52 wk) included sustained clinical remission, as well as fewer therapeutic changes, CD-related hospitalizations, and surgeries. Despite heterogeneous design and methodological limitations, six of the studies demonstrated that TH or intestinal healing (TH plus mucosal healing) were predictive for the aforementioned favorable outcomes. Therefore, TH may become a reasonable therapeutic target and be included in the concept of deep remission. Further prospective, well-designed, multicenter trials aiming to better define the role of TH in personalized therapy for CD and to determine the long-term influence of TH on bowel damage and disability are warranted.
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Affiliation(s)
- Elena Daniela Serban
- 2nd Department of Pediatrics, “Iuliu Hatieganu” University of Medicine and Pharmacy, Emergency Hospital for Children, Cluj-Napoca 400177, Romania
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54
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Kucharzik T, Maaser C. Intestinal ultrasound and management of small bowel Crohn's disease. Therap Adv Gastroenterol 2018; 11:1756284818771367. [PMID: 29881463 PMCID: PMC5987904 DOI: 10.1177/1756284818771367] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/11/2018] [Indexed: 02/04/2023] Open
Abstract
As Crohn's disease (CD) is predominantly located within the small bowel, imaging of the small bowel plays an intriguing role in the primary diagnosis as well as in the monitoring of patients with CD. Intestinal ultrasound (IUS) offers several advantages over endoscopy and other imaging modalities. Obvious advantages of IUS include noninvasiveness, rapid availability and cost effectiveness. IUS has been shown to have high accuracy in detecting small bowel CD and determining intra- and extramural complications such as stenoses, fistulae and abscesses. IUS has also been shown to be highly effective in determining postoperative disease recurrence and in follow up of patients under treatment. The following review summarizes current developments in the use of IUS for the detection of small bowel lesions and complications. The aim of this review is to suggest algorithms on how to use IUS in managing patients with small bowel CD in clinical practice. Suggested applications on the use of high frequency IUS in CD are extended by discussing new developments such as contrast-enhanced ultrasonography and elastography.
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55
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Bryant RV, Friedman AB, Wright EK, Taylor KM, Begun J, Maconi G, Maaser C, Novak KL, Kucharzik T, Atkinson NSS, Asthana A, Gibson PR. Gastrointestinal ultrasound in inflammatory bowel disease: an underused resource with potential paradigm-changing application. Gut 2018; 67:973-985. [PMID: 29437914 DOI: 10.1136/gutjnl-2017-315655] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 12/13/2017] [Accepted: 12/14/2017] [Indexed: 12/20/2022]
Abstract
Evolution of treatment targets in IBD has increased the need for objective monitoring of disease activity to guide therapeutic strategy. Although mucosal healing is the current target of therapy in IBD, endoscopy is invasive, expensive and unappealing to patients. GI ultrasound (GIUS) represents a non-invasive modality to assess disease activity in IBD. It is accurate, cost-effective and reproducible. GIUS can be performed at the point of care without specific patient preparation so as to facilitate clinical decision-making. As compared with ileocolonoscopy and other imaging modalities (CT and MRI), GIUS is accurate in diagnosing IBD, detecting complications of disease including fistulae, strictures and abscesses, monitoring disease activity and detecting postoperative disease recurrence. International groups increasingly recognise GIUS as a valuable tool with paradigm-changing application in the management of IBD; however, uptake outside parts of continental Europe has been slow and GIUS is underused in many countries. The aim of this review is to present a pragmatic guide to the positioning of GIUS in IBD clinical practice, providing evidence for use, algorithms for integration into practice, training pathways and a strategic implementation framework.
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Affiliation(s)
- Robert Venning Bryant
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, Australia.,Faculty of Health Sciences, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Antony B Friedman
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Emily Kate Wright
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
| | - Kirstin M Taylor
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Jakob Begun
- Department of Gastroenterology, Mater Hospital, Brisbane, Australia.,Mater Research Institute, University of Queensland, Brisbane, Australia
| | - Giovanni Maconi
- Department of Gastroenterology, Luigi Sacco University Hospital, Milan, Italy
| | - Christian Maaser
- Department of General Internal Medicine and Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | - Kerri L Novak
- Division of Gastroenterology, University of Calgary, Calgary, Canada
| | - Torsten Kucharzik
- Department of General Internal Medicine and Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg, Germany
| | | | - Anil Asthana
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
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Abstract
Contrast-enhanced ultrasound (CEUS) of the gastrointestinal tract provides vascular information helpful for characterizing masses and other pathologies in and around the bowel, similar to contrast applications in other solid organs. However, the use of microbubble contrast agents for the bowel provides additional unique contributions as it gives both subjective and objective information about mural and mesenteric blood flow, invaluable for the determination of disease activity in those many patients affected by inflammatory bowel disease (IBD). IBD is a lifelong chronic disease and has its peak age of onset in adolescence or young adult life. Today, we have moved away from treating patient’s symptoms and strive instead to alter the course of disease by obtaining mucosal healing. Expensive and aggressive biologic therapies and lack of agreement of patient’s symptoms with their disease activity and complications necessitate frequent imaging surveillance, which must be safe, readily available, inexpensive, and effective. Ultrasound with the benefit of contrast enhancement meets these requirements and is shown in meta-analysis to be equivalent to CT and MRI scans for these indications.
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57
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The role of intestinal ultrasound in diagnostics of bowel diseases. GASTROENTEROLOGY REVIEW 2018; 13:1-5. [PMID: 29657604 PMCID: PMC5894446 DOI: 10.5114/pg.2018.74554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 11/07/2017] [Indexed: 12/16/2022]
Abstract
Intestinal ultrasound is a safe and inexpensive method that allows visualisation of the gastrointestinal tract and detection of abnormalities. This examination involves the use of two different ultrasound transducers: a low-frequency convex probe and high-frequency linear probe. When needed, the performance of these methods can be enhanced by the use of contrast media or Doppler techniques. Intestinal ultrasound is mostly utilised for the diagnosis and follow-up of patients with inflammatory bowel diseases, helping to avoid frequent use of invasive and expensive diagnostic procedures and leading to early implementation of suitable treatment. This technique can also serve to detect other pathologic conditions that are present in the gastrointestinal tract. It is a promising method with high sensitivity and specificity, which has gained popularity in recent years and has the potential to become the method of choice in the diagnostics of many intestinal disorders.
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58
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Wilkens R, Hagemann-Madsen RH, Peters DA, Nielsen AH, Nørager CB, Glerup H, Krogh K. Validity of Contrast-enhanced Ultrasonography and Dynamic Contrast-enhanced MR Enterography in the Assessment of Transmural Activity and Fibrosis in Crohn's Disease. J Crohns Colitis 2018; 12:48-56. [PMID: 28981627 DOI: 10.1093/ecco-jcc/jjx111] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 08/01/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Increased small intestinal wall thickness correlates with both inflammatory activity and fibrosis in Crohn's disease [CD]. Assessment of perfusion holds promise as an objective marker distinguishing between the two conditions. Our primary aim was to determine if relative bowel wall perfusion measurements correlate with histopathological scores for inflammation or fibrosis in CD. METHODS A total of 25 patients were investigated before elective surgery for small intestinal CD. Unenhanced ultrasonography [US] and magnetic resonance enterography [MRE] were applied to describe bowel wall thickness. Perfusion was assessed with contrast-enhanced US [CEUS] and dynamic contrast-enhanced MRE [DCE-MRE]. Histopathology was used as gold standard. RESULTS Compared with histopathology, the mean wall thickness was 0.4 mm greater on US [range -0.3 to 1.0, p = 0.24] and 1.4 mm greater on MR [0.4 to 2.3, p = 0.006]. No correlation was found between the severity of inflammation or fibrosis on histopathology, and either DCE-MRE [r = -0.13, p = 0.54 for inflammation and r = 0.41, p = 0.05 for fibrosis] or CEUS [r = 0.16, p = 0.45 for inflammation and r = -0.28, p = 0.19 for fibrosis]. Wall thickness assessed with US was correlated with both histological inflammation [r = 0.611, p = 0.0012] and fibrosis [r = 0.399, p = 0.048]. The same was not true for MR [r = 0.41, p = 0.047 for inflammation and r = 0.29, p = 0.16 for fibrosis]. CONCLUSIONS Bowel wall thickness assessed with US is a valid marker of inflammation in small intestinal CD. However, relative contrast enhancement of US or of MRE cannot distinguish between inflammatory activity and fibrosis.
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Affiliation(s)
- Rune Wilkens
- University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Rikke H Hagemann-Madsen
- Department of Clinical Pathology, Lillebaelt Hospital, Vejle, Denmark.,Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - David A Peters
- Department of Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark
| | - Agnete H Nielsen
- University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Charlotte B Nørager
- Department of Colorectal Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - Henning Glerup
- University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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59
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Kopylov U, Koulaouzidis A, Klang E, Carter D, Ben-Horin S, Eliakim R. Monitoring of small bowel Crohn's disease. Expert Rev Gastroenterol Hepatol 2017; 11:1047-1058. [PMID: 28737951 DOI: 10.1080/17474124.2017.1359541] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In recent years, the therapeutic paradigm in Crohn's disease has shifted from a mere symptom-oriented approach, to aiming to healing of the underlying inflammation and prevention of long-term structural complications. Such 'treat-to-target' approach may allow for a more stable disease course with less hospitalizations, lower requirement for surgery and improved quality of life. In Crohn's disease, the small bowel is affected in the majority of patients; frequently, Crohn's involves only the small bowel, which remains inaccessible to conventional ileocolonoscopic techniques. Thus, non-invasive monitoring techniques are crucial for accurate disease assessment. Areas covered: This review addresses the indications and clinical implications of non-invasive small bowel monitoring modalities (magnetic resonance enterography, intestinal ultrasound, capsule endoscopy) in the assessment and management of Crohn's disease. Expert commentary: This review addresses the limitations of the current knowledge and future areas of research, including the possible utilization of transmural healing as an imaging target and the need to establish clear quantitative target values to guide treatment by imaging findings in Crohn's disease.
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Affiliation(s)
- Uri Kopylov
- a Department of Gastroenterology, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
| | - Anastasios Koulaouzidis
- b Centre for Liver & Digestive Disorders , The Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Eyal Klang
- c Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
| | - Dan Carter
- a Department of Gastroenterology, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
| | - Shomron Ben-Horin
- a Department of Gastroenterology, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
| | - Rami Eliakim
- a Department of Gastroenterology, Sheba Medical Center, Tel Hashomer and Sackler Medical School , Tel Aviv University , Tel-Aviv , Israel
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Dillman JR, Dehkordy SF, Smith EA, DiPietro MA, Sanchez R, DeMatos-Maillard V, Adler J, Zhang B, Trout AT. Defining the ultrasound longitudinal natural history of newly diagnosed pediatric small bowel Crohn disease treated with infliximab and infliximab-azathioprine combination therapy. Pediatr Radiol 2017; 47:924-934. [PMID: 28421251 PMCID: PMC5511547 DOI: 10.1007/s00247-017-3848-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/07/2017] [Accepted: 03/22/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Little is known about changes in the imaging appearances of the bowel and mesentery over time in either pediatric or adult patients with newly diagnosed small bowel Crohn disease treated with anti-tumor necrosis factor-alpha (anti-TNF-α) therapy. OBJECTIVE To define how bowel ultrasound findings change over time and correlate with laboratory inflammatory markers in children who have been newly diagnosed with pediatric small bowel Crohn disease and treated with infliximab. MATERIALS AND METHODS We included 28 pediatric patients treated with infliximab for newly diagnosed ileal Crohn disease who underwent bowel sonography prior to medical therapy and at approximately 2 weeks, 1 month, 3 months and 6 months after treatment initiation; these patients also had laboratory testing at baseline, 1 month and 6 months. We used linear mixed models to compare mean results between visits and evaluate whether ultrasound measurements changed over time. We used Spearman rank correlation to assess bivariate relationships. RESULTS Mean subject age was 15.3±2.2 years; 11 subjects were girls (39%). We observed decreases in mean length of disease involvement (12.0±5.4 vs. 9.1±5.3 cm, P=0.02), maximum bowel wall thickness (5.6±1.8 vs. 4.7±1.7 mm, P=0.02), bowel wall color Doppler signal (1.7±0.9 vs. 1.2±0.8, P=0.002) and mesenteric color Doppler signal (1.1±0.9 vs. 0.6±0.6, P=0.005) at approximately 2 weeks following the initiation of infliximab compared to baseline. All laboratory inflammatory markers decreased at 1 month (P-values<0.0001). There was strong correlation between bowel wall color Doppler signal and fecal calprotectin (ρ=0.710; P<0.0001). Linear mixed models confirmed that maximum bowel wall thickness (P=0.04), length of disease involvement (P=0.0002) and bowel wall color Doppler signal (P<0.0001) change over time in response to infliximab, when adjusted for age, sex, azathioprine therapy, scanning radiologist and baseline short pediatric Crohn's disease activity index score. CONCLUSION The ultrasound appearance of the bowel changes as early as 2 weeks after the initiation of infliximab therapy. There is strong correlation between bowel wall color Doppler signal and fecal calprotectin.
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Affiliation(s)
- Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., ML5031, Cincinnati, OH, 45229-3039, USA.
| | - Soudabeh Fazeli Dehkordy
- Department of Radiology, Section of Pediatric Radiology, C. S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ethan A Smith
- Department of Radiology, Section of Pediatric Radiology, C. S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael A DiPietro
- Department of Radiology, Section of Pediatric Radiology, C. S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ramon Sanchez
- Department of Radiology, Section of Pediatric Radiology, C. S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Vera DeMatos-Maillard
- Department of Pediatrics, Division of Gastroenterology, C. S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jeremy Adler
- Department of Pediatrics, Division of Gastroenterology, C. S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., ML5031, Cincinnati, OH, 45229-3039, USA
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61
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Wei SC, Chang TA, Chao TH, Chen JS, Chou JW, Chou YH, Chuang CH, Hsu WH, Huang TY, Hsu TC, Lin CC, Lin HH, Lin JK, Lin WC, Ni YH, Shieh MJ, Shih IL, Shun CT, Tsang YM, Wang CY, Wang HY, Weng MT, Wu DC, Wu WC, Yen HH, Wong JM. Management of Crohn's disease in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease. Intest Res 2017; 15:285-310. [PMID: 28670226 PMCID: PMC5478754 DOI: 10.5217/ir.2017.15.3.285] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/02/2017] [Accepted: 05/02/2017] [Indexed: 12/12/2022] Open
Abstract
Crohn's disease (CD) is a chronic relapsing and remitting inflammatory disease of the gastrointestinal tract. CD is rare in Taiwan and other Asian countries, but its prevalence and incidence have been steadily increasing. A steering committee was established by the Taiwan Society of Inflammatory Bowel Disease to formulate statements on the diagnosis and management of CD taking into account currently available evidence and the expert opinion of the committee. Thorough clinical, endoscopic, and histological assessments are required for accurate diagnosis of CD. Computed tomography and magnetic resonance imaging are complementary to endoscopic evaluation for disease staging and detecting complications. The goals of CD management are to induce and maintain remission, reduce the risk of complications, and improve quality of life. Corticosteroids are the mainstay for inducing re-mission. Immunomodulating and biologic therapies should be used to maintain remission. Patients should be evaluated for hepatitis B virus and tuberculosis infection prior to treatment and receive regular surveillance for cancer. These consensus statements are based on current local evidence with consideration of factors, and could be serve as concise and practical guidelines for supporting clinicians in the management of patients with CD in Taiwan.
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Affiliation(s)
- Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ting-An Chang
- Department of Pathology, Taipei City Hospital Renai Branch, Taipei, Taiwan
| | - Te-Hsin Chao
- Division of Colorectal Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jinn-Shiun Chen
- Division of Colorectal Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jen-Wei Chou
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Yenn-Hwei Chou
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chiao-Hsiung Chuang
- Department of Internal Medicine, National Cheng Kung University Hospital, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tzu-Chi Hsu
- Division of Colon and Rectal Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chun-Chi Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hung-Hsin Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, National Yang-Ming University, Taipei, Taiwan
| | - Jen-Kou Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Chen Lin
- Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Jium Shieh
- Department of Oncology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - I-Lun Shih
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chia-Tung Shun
- Department of Pathology and Forensic Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yuk-Ming Tsang
- Division of Medical Imaging, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Cheng-Yi Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan.,MacKay Medical College, New Taipei City, Taiwan
| | - Meng-Tzu Weng
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Deng-Chyang Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Wen-Chieh Wu
- Division of Gastroenterology, Department of Medicine, Taipei City Hospital Renai Branch, Taipei, Taiwan
| | - Hsu-Heng Yen
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Panes J, Jairath V, Levesque BG. Advances in Use of Endoscopy, Radiology, and Biomarkers to Monitor Inflammatory Bowel Diseases. Gastroenterology 2017; 152:362-373.e3. [PMID: 27751880 DOI: 10.1053/j.gastro.2016.10.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 10/07/2016] [Accepted: 10/11/2016] [Indexed: 02/07/2023]
Abstract
Crohn's disease and ulcerative colitis are heterogeneous inflammatory bowel diseases, and therapeutic requirements vary among patients. We have a limited capacity to predict disease progression for individual patients, therefore it is important that they are evaluated for the presence of active disease when symptoms are mild or even absent, when patients are more likely to respond to new treatment interventions. It then is important to monitor responses to treatment, to quickly identify those therapies that are ineffective, modify or change therapy, and avoid disease complications. Studies are underway to assess the effects of different monitoring strategies. Because of the heavy burden of severe inflammatory bowel disease on patients' health and quality of life, and the association between intestinal healing and disease progression in high-risk patients, a treat-to-target strategy (based on tissue healing) is likely to be optimal.
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Affiliation(s)
- Julian Panes
- Department of Gastroenterology Hospital Clinic of Barcelona, Institud d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
| | - Vipul Jairath
- Department of Medicine, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
| | - Barrett G Levesque
- Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
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63
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Wilkens R, Peters DA, Nielsen AH, Hovgaard VP, Glerup H, Krogh K. Dynamic Contrast-Enhanced Magnetic Resonance Enterography and Dynamic Contrast-Enhanced Ultrasonography in Crohn's Disease: An Observational Comparison Study. Ultrasound Int Open 2017; 3:E13-E24. [PMID: 28286879 PMCID: PMC5340279 DOI: 10.1055/s-0042-123841] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/19/2016] [Accepted: 12/04/2016] [Indexed: 12/12/2022] Open
Abstract
Purpose e Cross-sectional imaging methods are important for objective evaluationof small intestinal inflammationinCrohn'sdisease(CD).The primary aim was to compare relative parameters of intestinal perfusion between contrast-enhanced ultrasonography (CEUS) and dynamic contrast-enhanced magnetic resonance enterography (DCE-MRE) in CD. Furthermore, we aimed at testing the repeatability of regions of interest (ROIs) for CEUS. Methods This prospective study included 25 patients: 12 females (age: 37, range: 19-66) with moderate to severe CD and a bowel wall thickness>3mm evaluated with DCE-MRE and CEUS. CEUS bolus injection was performed twice for repeatability and analyzed in VueBox®. Correlations between modalities were described with Spearman's rho, limits of agreement(LoA) and intraclass correlation coefficient(ICC). ROIrepeatability for CEUS was assessed. Results s The correlation between modalities was good and very good for bowel wall thickness (ICC=0.71, P<0.001) and length of the inflamed segment (ICC=0.89, P<0.001). Moderate-weak correlations were found for the time-intensity curve parameters: peak intensity (r=0.59, P=0.006), maximum wash-in-rate (r=0.62, P=0.004), and wash-in perfusion index (r=0.47, P=0.036). Best CEUS repeatability for peak enhancement was a mean difference of 0.73 dB (95% CI: 0.17 to 1.28, P=0.01) and 95% LoA from -3.8 to 5.3 dB. Good quality of curve fit improved LoA to -2.3 to 2.8 dB. Conclusion The relative perfusion of small intestinal CD assessed with DCE-MRE and CEUS shows only a moderate correlation. Applying strict criteria for ROIs is important and allows for good CEUS repeatability.
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Affiliation(s)
- Rune Wilkens
- Divisions of Medicine and Radiology, Diagnostic Centre, Silkeborg Regional
Hospital, University Research Clinic for Innovative Diagnostic Pathways, Silkeborg,
Denmark
- Department of Hepatology and Gastroenterology, Aarhus University Hospital,
Aarhus C, Denmark
| | - David A. Peters
- Department of Clinical Engineering, Aarhus University Hospital, Aarhus N,
Denmark
| | - Agnete H. Nielsen
- Divisions of Medicine and Radiology, Diagnostic Centre, Silkeborg Regional
Hospital, University Research Clinic for Innovative Diagnostic Pathways, Silkeborg,
Denmark
| | - Valeriya P. Hovgaard
- Divisions of Medicine and Radiology, Diagnostic Centre, Silkeborg Regional
Hospital, University Research Clinic for Innovative Diagnostic Pathways, Silkeborg,
Denmark
| | - Henning Glerup
- Divisions of Medicine and Radiology, Diagnostic Centre, Silkeborg Regional
Hospital, University Research Clinic for Innovative Diagnostic Pathways, Silkeborg,
Denmark
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital,
Aarhus C, Denmark
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Mocci G, Migaleddu V, Cabras F, Sirigu D, Scanu D, Virgilio G, Marzo M. SICUS and CEUS imaging in Crohn's disease: an update. J Ultrasound 2017; 20:1-9. [PMID: 28298939 DOI: 10.1007/s40477-016-0230-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 11/07/2016] [Indexed: 12/21/2022] Open
Abstract
Endoscopy remains the main technique in the diagnosis and treatment of Crohn's disease (CD); nevertheless, the recent development of innovative and non-invasive imaging techniques has led to a new tool in the exploration of small bowel in CD patients. This paper reviews the available data on ultrasound imaging used for the evaluation of CD, highlighting the role of small intestine contrast-enhanced ultrasonography with the use of oral and intravenous contrast agents.
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Affiliation(s)
| | - Vincenzo Migaleddu
- Sardinian Mediterranean Imaging Research Group, SMIRG No-profit Foundation, Via Gorizia 11, 07100 Sassari, Italy
| | | | - Danilo Sirigu
- Sardinian Mediterranean Imaging Research Group, SMIRG No-profit Foundation, Via Gorizia 11, 07100 Sassari, Italy
| | - Domenico Scanu
- Sardinian Mediterranean Imaging Research Group, SMIRG No-profit Foundation, Via Gorizia 11, 07100 Sassari, Italy
| | - Giuseppe Virgilio
- Sardinian Mediterranean Imaging Research Group, SMIRG No-profit Foundation, Via Gorizia 11, 07100 Sassari, Italy
| | - Manuela Marzo
- Sardinian Mediterranean Imaging Research Group, SMIRG No-profit Foundation, Via Gorizia 11, 07100 Sassari, Italy
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65
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Bhatnagar G, Von Stempel C, Halligan S, Taylor SA. Utility of MR enterography and ultrasound for the investigation of small bowel Crohn's disease. J Magn Reson Imaging 2016; 45:1573-1588. [PMID: 27943484 DOI: 10.1002/jmri.25569] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/11/2016] [Indexed: 12/18/2022] Open
Abstract
Cross sectional Imaging plays an increasingly important role the diagnosis and management of Crohn's disease. Particular emphasis is placed on MRI and Ultrasound as they do not impart ionising radiation. Both modalities have reported high sensitivity for disease detection, activity assessment and evaluation of extra-luminal complications, and have positive effects on clinical decision making. International Guidelines now recommend MRI and Ultrasound in the routine management of Crohn's disease patients. This article reviews the current evidence base supporting both modalities with an emphasis on the key clinical questions. We describe current protocols, basic imaging findings and highlight areas in need of further research. LEVEL OF EVIDENCE 5 Technical Efficacy: Stage 4 J. MAGN. RESON. IMAGING 2017;45:1573-1588.
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Affiliation(s)
- Gauraang Bhatnagar
- Frimley Park Hospital NHS Foundation Trust, London, UK.,Centre for Medical Imaging, University College London, London, UK
| | | | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
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66
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Bor R, Fábián A, Szepes Z. Role of ultrasound in colorectal diseases. World J Gastroenterol 2016; 22:9477-9487. [PMID: 27920469 PMCID: PMC5116592 DOI: 10.3748/wjg.v22.i43.9477] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/11/2016] [Accepted: 10/19/2016] [Indexed: 02/06/2023] Open
Abstract
Ultrasound is an undervalued non-invasive examination in the diagnosis of colonic diseases. It has been replaced by the considerably more expensive magnetic resonance imaging and computed tomography, despite the fact that, as first examination, it can usefully supplement the diagnostic process. Transabdominal ultrasound can provide quick information about bowel status and help in the choice of adequate further examinations and treatment. Ultrasonography, as a screening imaging modality in asymptomatic patients can identify several colonic diseases such as diverticulosis, inflammatory bowel disease or cancer. In addition, it is widely available, cheap, non-invasive technique without the use of ionizing radiation, therefore it is safe to use in childhood or during pregnancy, and can be repeated at any time. New ultrasound techniques such as elastography, contrast enhanced and Doppler ultrasound, mini-probes rectal and transperineal ultrasonography have broadened the indication. It gives an overview of the methodology of various ultrasound examinations, presents the morphology of normal bowel wall and the typical changes in different colonic diseases. We will pay particular attention to rectal and transperineal ultrasound because of their outstanding significance in the diagnosis of rectal and perineal disorders. This article seeks to overview the diagnostic impact and correct indications of bowel ultrasound.
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67
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Kucharzik T, Kannengiesser K, Petersen F. The use of ultrasound in inflammatory bowel disease. Ann Gastroenterol 2016; 30:135-144. [PMID: 28243033 PMCID: PMC5320025 DOI: 10.20524/aog.2016.0105] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 10/18/2016] [Indexed: 02/07/2023] Open
Abstract
Imaging in inflammatory bowel disease (IBD) plays a pivotal role in the primary diagnosis, as well as during the management of patients with known IBD. The evolution of ultrasound equipment and the growing expertise of examiners have both enhanced the role of intestinal ultrasound in the assessment of the gastrointestinal tract in IBD patients. Intestinal ultrasound has been shown to have high sensitivity and specificity, as well as high positive and negative predictive value, in the detection or exclusion of intestinal inflammatory activity in IBD. The obvious advantages of intestinal ultrasound over other imaging modalities include non-invasiveness, rapid availability and low costs. This review summarizes the current developments in the use of intestinal ultrasound for the detection of IBD and its complications, and discusses its use in the management of patients with IBD. Indications for the use of intestinal ultrasound in daily practice are presented, expanded by new developments such as contrast-enhanced ultrasonography and elastography.
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Affiliation(s)
- Torsten Kucharzik
- Department of Gastroenterology, Lüneburg Hospital, University of Hamburg, Germany
| | - Klaus Kannengiesser
- Department of Gastroenterology, Lüneburg Hospital, University of Hamburg, Germany
| | - Frauke Petersen
- Department of Gastroenterology, Lüneburg Hospital, University of Hamburg, Germany
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The first joint ESGAR/ ESPR consensus statement on the technical performance of cross-sectional small bowel and colonic imaging. Eur Radiol 2016; 27:2570-2582. [PMID: 27757521 PMCID: PMC5408044 DOI: 10.1007/s00330-016-4615-9] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/11/2016] [Accepted: 09/15/2016] [Indexed: 12/28/2022]
Abstract
Objectives To develop guidelines describing a standardised approach to patient preparation and acquisition protocols for magnetic resonance imaging (MRI), computed tomography (CT) and ultrasound (US) of the small bowel and colon, with an emphasis on imaging inflammatory bowel disease. Methods An expert consensus committee of 13 members from the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) and European Society of Paediatric Radiology (ESPR) undertook a six-stage modified Delphi process, including a detailed literature review, to create a series of consensus statements concerning patient preparation, imaging hardware and image acquisition protocols. Results One hundred and fifty-seven statements were scored for agreement by the panel of which 129 statements (82 %) achieved immediate consensus with a further 19 (12 %) achieving consensus after appropriate modification. Nine (6 %) statements were rejected as consensus could not be reached. Conclusions These expert consensus recommendations can be used to help guide cross-sectional radiological practice for imaging the small bowel and colon. Key points • Cross-sectional imaging is increasingly used to evaluate the bowel • Image quality is paramount to achieving high diagnostic accuracy • Guidelines concerning patient preparation and image acquisition protocols are provided
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Ultrasonographic Changes at 12 Weeks of Anti-TNF Drugs Predict 1-year Sonographic Response and Clinical Outcome in Crohn's Disease: A Multicenter Study. Inflamm Bowel Dis 2016; 22:2465-73. [PMID: 27580385 DOI: 10.1097/mib.0000000000000882] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The objective was to assess the long-term effect of biological treatment on transmural lesions of Crohn's disease evaluated with ultrasound, including contrast-enhanced ultrasound. METHODS Fifty-one patients with active Crohn's disease were included in a prospective multicenter longitudinal study. All patients underwent a clinical assessment and sonographic examination at baseline, 12 weeks after treatment initiation, and after 1-year of treatment. Patients were clinically followed at least 2 years from inclusion until the end of the study. Ultrasonographic evaluation included bowel wall thickness, color Doppler grade, parietal enhancement, and presence of transmural complications or stenosis. Sonographic changes after treatment were classified as normalization, improvement, or lack of response. RESULTS Improvement at 52 weeks was more frequent in patients with improvement at final of induction (12 weeks) compared with patients who did not improve (85% versus 28%; P < 0.0001). One-year sonographic evolution correlated with clinical response; 28 of the 29 (96.5%) patients with sonographic improvement at 52 weeks showed clinical remission or response. Patients without sonographic improvement at 52 weeks of treatment were more likely to have a change or intensification in medication or surgery (13/20, 65%) during the next year of follow-up than patients with improvement on the sonography (3/28, 11%). Stricturing behavior was the only sonographic feature associated to a negative predictive value of response (P = 0.0001). CONCLUSIONS Sonographic response after 12 weeks of therapy is more pronounced and predicts 1-year sonographic response. Sonographic response at 1-year examination correlates with 1-year clinical response and is a predictor of further treatment's efficacy, 1-year or longer period of follow-up.
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Abstract
Therapeutic advances in the management of IBD have led to a paradigm shift in the assessment of IBD disease activity. Beyond clinical remission, objective assessment of inflammation is now critical to guiding subsequent therapy as part of a 'treat to target' strategy. Multiple domains of disease activity assessment in IBD exist, each of which has its merits, although none are perfect. The aim of this Review is to comprehensively evaluate measures of disease activity in both ulcerative colitis and Crohn's disease, including clinical, endoscopic, histological and radiological assessment tools, as well as the use of biomarkers and quality of life evaluation. A subjective appraisal of the best indices for use in clinical practice is provided, based on index validation, responsiveness and experience in clinical trials, international specialist opinion, and practicality and suitability for use in clinical practice. This Review aims to enable the reader to gain confidence in IBD disease activity assessment and to give ready access to the necessary tools.
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71
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Looking Beyond Mucosal Healing: Effect of Biologic Therapy on Transmural Healing in Pediatric Crohn's Disease. Inflamm Bowel Dis 2016; 22:2418-24. [PMID: 27598739 DOI: 10.1097/mib.0000000000000897] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Crohn's disease is a chronic inflammatory disease characterized by a progressive transmural bowel damage leading to complications. Anti-TNFα therapy is effective in achieving mucosal healing (MH), but its efficacy on transmural inflammation has been poorly investigated. The aim of this study is to evaluate, in pediatric Crohn's disease, the efficacy of anti-tumor necrosis factor α agents in inducing transmural healing (TH) as assessed by ultrasonography (US). METHODS Children with Crohn's disease requiring anti-tumor necrosis factor α therapy were prospectively enrolled. Clinical activity, laboratory tests, endoscopic activity, and transmural disease assessed by small intestine contrast US (SICUS) were evaluated at baseline (T0) and then after 9 to 12 months of therapy (T1). We evaluated US quantitative and qualitative parameters: disease extension (centimeters), bowel wall (BW) thickness >3 mm, BW vascularity and stratification strictures, and prestenotic dilatation. TH was defined as a BW thickness <3 mm and normalization of all US parameters at T1. RESULTS Thirty-two patients were included. Patients with mucosal healing (MH) showed a significant decrease of BW thickness and disease extension at T1 (4.3 ± 1.4 mm and 8 ± 6.3 cm versus 6.1 ± 2.3 mm and 13 ± 5 cm at baseline, respectively) (P < 0.001). Increased vascularity of the BW was found in 80% of patients at T0 and in 18% at T1 (P < 0.001). These parameters did not change in patients without MH, despite clinical and laboratory remission. The presence of stenosis and prestenotic dilatation did not modify in any group. A complete TH was achieved in 14% of patients, all of them showing complete MH. CONCLUSIONS Biologics induce clinical and laboratory remission and MH in pediatric CD. Although caution is needed due to the small sample size, our data suggest that transmural inflammation also improves during therapy, but a complete TH is achieved only in a small percentage of patients.
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72
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Evolving roles of cross-sectional imaging in Crohn's disease. Dig Liver Dis 2016; 48:975-83. [PMID: 27338853 DOI: 10.1016/j.dld.2016.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/13/2016] [Accepted: 05/21/2016] [Indexed: 12/11/2022]
Abstract
The implementation of cross-sectional imaging techniques for the clinical management of Crohn's disease patients has steadily grown over the recent years, thanks to a series of technological advances, including the evolution of contrast media for magnetic resonance, computed tomography and bowel ultrasound. This has resulted in a continuous improvement of diagnostic accuracy and capability to detect Crohn's disease-related complications. Additionally, a progressive widening of indications for cross-sectional imaging in Crohn's disease has been put forward, thus leading to hypothesize that in the near future imaging techniques can increasingly complement endoscopy in most clinical settings, including the grading of disease activity and the assessment of mucosal healing or Crohn's disease post-surgical recurrence.
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Abstract
Bowel imaging had experienced relevant technical advances during the last decade. The developments in the field of cross-sectional imaging had a particular impact on the assessment of Crohn's disease. The purpose of this manuscript is to provide a review of the main progress of cross-sectional imaging in the assessment of Crohn's disease and other small bowel diseases with relevance in clinical practice and in research. Also, we outline the technical advances, trends, and potential contributions of new technological cross-sectional imaging improvements that may have potential impact and contribution in the near future.
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Affiliation(s)
- Jordi Rimola
- Department of Radiology, IBD Unit, Hospital Clínic de Barcelona, Villarroel 170, 08036, Barcelona, Catalonia, Spain.
| | - Julián Panés
- Department of Gastroenterology, IBD Unit, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
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74
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Asthana AK. Intestinal ultrasound in inflammatory bowel disease. J Gastroenterol Hepatol 2016; 31 Suppl 1:21-2. [PMID: 27273031 DOI: 10.1111/jgh.13355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2016] [Indexed: 12/18/2022]
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Quantitative Contrast-Enhanced Ultrasound Parameters in Crohn Disease: Their Role in Disease Activity Determination With Ultrasound. AJR Am J Roentgenol 2016; 206:64-73. [PMID: 26700336 DOI: 10.2214/ajr.15.14506] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The primary objective of our study was to examine the association between contrast-enhanced ultrasound (CEUS) parameters and established gray-scale ultrasound with color Doppler imaging (CDI) for the determination of disease activity in patients with Crohn disease. Our secondary objective was to develop quantitative time-signal intensity curve thresholds for disease activity. MATERIALS AND METHODS One hundred twenty-seven patients with Crohn disease underwent ultrasound with CDI and CEUS. Reviewers graded wall thickness, inflammatory fat, and mural blood flow as showing remission or inflammation (mild, moderate, or severe). If both gray-scale ultrasound and CDI predicted equal levels of disease activity, the studies were considered concordant. If ultrasound images suggested active disease not supported by CDI findings, the ultrasound results for disease activity were indeterminate. Time-signal intensity curves from CEUS were acquired with calculation of peak enhancement (PE), and AUCs. Interobserver variation and associations between PE and ultrasound parameters were examined. Multiclass ROC analysis was used to develop CEUS thresholds for activity. RESULTS Ninety-six (76%) studies were concordant, 19 of which showed severe disease, and 31 (24%) studies were indeterminate. Kappa analyses revealed good interobserver agreement on grades for CDI (κ = 0.76) and ultrasound (κ = 0.80) assessments. PE values on CEUS and wall thickness showed good association with the Spearman rank correlation coefficient for the entire population (ρ = 0.62, p < 0.01) and for the concordant group (ρ = 0.70, p < 0.01). Multiclass ROC analyses of the concordant group using wall thickness alone as the reference standard showed cutoff points of 18.2 dB for differentiating mild versus moderate activity (sensitivity, 89.0% and specificity, 87.0%) and 23.0 dB for differentiating moderate versus severe (sensitivity, 90% and specificity, 86.8%). Almost identical cutoff points were observed when using ultrasound global assessment as the reference standard: using 18.2 dB to differentiate mild versus moderate activity yielded sensitivity of 89.2% and specificity of 90.9% and using 22.9 dB to differentiate moderate versus severe activity yielded sensitivity of 89.5% and specificity of 83.1%. CONCLUSION Quantitative CEUS parameters integrated into inflammatory assessments with ultrasound reduce indeterminate results and improve disease activity level determinations.
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Bowel Ultrasonography in the Management of Crohn's Disease. A Review with Recommendations of an International Panel of Experts. Inflamm Bowel Dis 2016; 22:1168-83. [PMID: 26958988 DOI: 10.1097/mib.0000000000000706] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Bowel ultrasonography (US) is considered a useful technique for assessing mural inflammation and complications in Crohn's disease (CD). The aim of this review is to appraise the evidence on the accuracy of bowel US for CD. In addition, we aim to provide recommendations for its optimal use. METHODS Publications were identified by literature search from 1992 to 2014 and selected based on predefined criteria: 15 or more patients; bowel US for diagnosing CD, complications, postoperative recurrence, activity; adequate reference standards; prospective study design; data reported to allow calculation of sensitivity, specificity, agreement, or correlation values; articles published in English. RESULTS The search yielded 655 articles, of which 63 were found to be eligible and retrieved as full-text articles for analysis. Bowel US showed 79.7% sensitivity and 96.7% specificity for the diagnosis of suspected CD, and 89% sensitivity and 94.3% specificity for initial assessment in established patients with CD. Bowel US identified ileal CD with 92.7% sensitivity, 88.2% specificity, and colon CD with 81.8% sensitivity, 95.3% specificity, with lower accuracy for detecting proximal lesions. The oral contrast agent improves the sensitivity and specificity in determining CD lesions and in assessing sites and extent. CONCLUSIONS Bowel US is a tool for evaluation of CD lesions in terms of complications, postoperative recurrence, and monitoring response to medical therapy; it reliably detects postoperative recurrence and complications, as well as offers the possibility of monitoring disease progression.
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Novak KL, Jacob D, Kaplan GG, Boyce E, Ghosh S, Ma I, Lu C, Wilson S, Panaccione R. Point of Care Ultrasound Accurately Distinguishes Inflammatory from Noninflammatory Disease in Patients Presenting with Abdominal Pain and Diarrhea. Can J Gastroenterol Hepatol 2016; 2016:4023065. [PMID: 27446838 PMCID: PMC4904691 DOI: 10.1155/2016/4023065] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 09/29/2015] [Indexed: 12/15/2022] Open
Abstract
Background. Approaches to distinguish inflammatory bowel disease (IBD) from noninflammatory disease that are noninvasive, accurate, and readily available are desirable. Such approaches may decrease time to diagnosis and better utilize limited endoscopic resources. The aim of this study was to evaluate the diagnostic accuracy for gastroenterologist performed point of care ultrasound (POCUS) in the detection of luminal inflammation relative to gold standard ileocolonoscopy. Methods. A prospective, single-center study was conducted on convenience sample of patients presenting with symptoms of diarrhea and/or abdominal pain. Patients were offered POCUS prior to having ileocolonoscopy. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) with 95% confidence intervals (CI), as well as likelihood ratios, were calculated. Results. Fifty-eight patients were included in this study. The overall sensitivity, specificity, PPV, and NPV were 80%, 97.8%, 88.9%, and 95.7%, respectively, with positive and negative likelihood ratios (LR) of 36.8 and 0.20. Conclusion. POCUS can accurately be performed at the bedside to detect transmural inflammation of the intestine. This noninvasive approach may serve to expedite diagnosis, improve allocation of endoscopic resources, and facilitate initiation of appropriate medical therapy.
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Affiliation(s)
- Kerri L. Novak
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada T2N 2T9
| | - Deepti Jacob
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada T2N 2T9
| | - Gilaad G. Kaplan
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada T2N 2T9
- Department of Community Health Sciences, Calgary, AB, Canada T2N 2T9
| | - Emma Boyce
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada T2N 2T9
| | - Subrata Ghosh
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada T2N 2T9
| | - Irene Ma
- Division of General Internal Medicine, Calgary, AB, Canada T2N 2T9
| | - Cathy Lu
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada T2N 2T9
| | - Stephanie Wilson
- Diagnostic Imaging, University of Calgary, Calgary, AB, Canada T2N 2T9
| | - Remo Panaccione
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada T2N 2T9
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Strik AS, Bots SJA, D’Haens G, Löwenberg M. Optimization of anti-TNF therapy in patients with Inflammatory Bowel Disease. Expert Rev Clin Pharmacol 2016; 9:429-39. [DOI: 10.1586/17512433.2016.1133288] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Ben-Horin S, Mao R, Chen M. Optimizing biologic treatment in IBD: objective measures, but when, how and how often? BMC Gastroenterol 2015; 15:178. [PMID: 26678147 PMCID: PMC4683713 DOI: 10.1186/s12876-015-0408-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 12/03/2015] [Indexed: 12/16/2022] Open
Abstract
Background The advent of biologic agents for the treatment of inflammatory bowel disease (IBD) was accompanied in parallel with emerging understanding of persisting underlying inflammation and ensuing bowel damage that can occur even in patients with seeming clinical remission. This lead to the concepts of mucosal healing and deep remission gaining acceptance as the more desired goals for therapy within an ambitious disease-control therapeutic approach, namely, treat-to-target strategy. However, how to practically monitor IBD patients, which objective measures to follow, at what time-points and whether to act upon results in asymptomatic patients are all questions that remain disputed. Methods and result In this concise review we aim to provide an overview of objective measures for monitoring of IBD patients, focusing on the challenging group of patients treated by infliximab, adalimumab, vedolizumab and other biologics. These objective measures are discussed in the context of the different common clinical scenarios wherein the clinician may contemplate their use. Specifically, we will delineate the role of objective parameters to be monitored during induction phase of treatment, during maintenance therapy, at loss of response and after elective cessation of therapy in patients in remission. Conclusion Coupled with the non-negligible costs of therapy, and the over-all worse prognosis of moderate-severe patients who are the usual recipients of biologic therapies, this challenging patients seem to be the first candidates for this more proactive strategy combining inflammatory and pharmacokinetic monitoring of objective inflammatory and pharmacokinetic measures. More data is still desirable to better define the exact parameters to be followed and their optimal thresholds, and to delineate the optimal cost-effective interventions for these patients.
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Affiliation(s)
- Shomron Ben-Horin
- IBD service, Department of Gastroenterology, Sheba Medical Center & Sackler School of Medicine, Tel-Aviv University, Tel Hashomer, 52621, Israel. .,Department of Gastroenterology, First Affilated Hospital, Sun-Yatsen University, 58 Zhongshan II Road, Guangzhou, 510080, P.R. China.
| | - Ren Mao
- Department of Gastroenterology, First Affilated Hospital, Sun-Yatsen University, 58 Zhongshan II Road, Guangzhou, 510080, P.R. China.
| | - Minhu Chen
- Department of Gastroenterology, First Affilated Hospital, Sun-Yatsen University, 58 Zhongshan II Road, Guangzhou, 510080, P.R. China.
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80
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Novak K, Tanyingoh D, Petersen F, Kucharzik T, Panaccione R, Ghosh S, Kaplan GG, Wilson A, Kannengiesser K, Maaser C. Clinic-based Point of Care Transabdominal Ultrasound for Monitoring Crohn's Disease: Impact on Clinical Decision Making. J Crohns Colitis 2015; 9:795-801. [PMID: 26079723 DOI: 10.1093/ecco-jcc/jjv105] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 05/27/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS The use of cross-sectional imaging is important to characterise inflammatory bowel disease [IBD] activity, extent, and location and to exclude complications, regardless of symptoms. The aim of this study was to evaluate the impact of routine use of sonography in the management of inflammatory bowel disease. METHODS A total of 49 patients with Crohn's disease were prospectively evaluated. Clinical symptoms (Harvey-Bradshaw Index [HBI]), disease character, serological markers of inflammation [C-reactive protein], and endoscopic evaluation were collected and reviewed by two independent IBD-specialty physicians. Clinical decisions regarding management were recorded. A separate, blinded physician then performed bowel ultrasound [US] and graded disease activity:] as inactive, mild, or active. A second blinded physician read and graded a sub-set of the US images. Clinical decisions of both IBD-physicians after US were independently recorded. Changes in clinical management following US information and inter-rater agreement on US disease activity parameters were evaluated. The concordance between US, CRP and clinical symptoms [HBI] were analysed. Follow-up data after US evaluation were collected. RESULTS Clinical decisions were changed after ultrasound assessment in 30/49 [60%] and 28/48 [58%] of cases, for each physician respectively [p < 0.0001 for each]. Many [59%] of the patients seen in clinic were asymptomatic with an HBI of 3 or less [n = 29]; however, 52% [n = 15] of these had active disease found on US, resulting in alterations in clinical management. The agreement in overall score between the US reviewers was good, ĸ = 0.749 [0.5814, 0.9180], p < 0.001. CONCLUSIONS Clinic-based point of care US can play a significant role in guiding therapeutic management and is an important adjunct to routine clinical and laboratory assessment.
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Affiliation(s)
- Kerri Novak
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - Divine Tanyingoh
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada
| | | | - Torsten Kucharzik
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - Remo Panaccione
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - Subrata Ghosh
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - Gilaad G Kaplan
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada
| | - Alex Wilson
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada
| | | | - Christian Maaser
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada
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81
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Horjus Talabur Horje CS, Bruijnen R, Roovers L, Groenen MJM, Joosten FBM, Wahab PJ. Contrast Enhanced Abdominal Ultrasound in the Assessment of Ileal Inflammation in Crohn's Disease: A Comparison with MR Enterography. PLoS One 2015; 10:e0136105. [PMID: 26322970 PMCID: PMC4556376 DOI: 10.1371/journal.pone.0136105] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 07/29/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND AIMS To prospectively examine the feasibility and accuracy of Contrast Enhanced Ultrasound (CEUS) in the assessment of Crohn's disease (CD) activity in the terminal ileum in comparison to Magnetic Resonance Enterography (MRE), using endoscopy as a reference standard. METHODS 105 consecutive patients with alleged clinically active CD were assessed by MRE and CEUS. CEUS of the terminal ileum was performed using an intravenous microbubble contrast enhancer. Accuracy values of CEUS and MRE for the presence of active terminal ileitis were evaluated using the Receiver Operating Characteristic method, using endoscopic findings as a reference standard. Sensitivity and specificity values of MRE and CEUS were compared by the McNemar test. RESULTS CEUS was feasible in 98% of patients, MRE in all. Optimal diagnostic accuracy in CEUS was obtained at a peak intensity value of 10%, showing 100% sensitivity, 92% specificity and an accuracy of 99% in demonstrating ileal mucosal inflammation. For MRE, overall sensitivity, specificity and accuracy were, 87%, 100%, and 88%, respectively. CEUS and MRE were highly correlated in assessing length and wall thickness of the terminal ileum. CEUS identified 11 of 16 MRE-detected strictures, but no fistulae. CONCLUSION The accuracy of CEUS is comparable to that of MRE in the assessment of active, uncomplicated terminal ileal CD and therefore a valuable bedside alternative to MRE in the follow-up of these patients.
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Affiliation(s)
| | - R. Bruijnen
- Department of Radiology, Rijnstate Hospital, Arnhem, the Netherlands
| | - L. Roovers
- Department of Epidemiology and Statistics, Rijnstate Hospital, Arnhem, the Netherlands
| | - M. J. M. Groenen
- Department of Gastroenterology, Rijnstate Hospital, Arnhem, the Netherlands
| | - F. B. M. Joosten
- Department of Radiology, Rijnstate Hospital, Arnhem, the Netherlands
| | - P. J. Wahab
- Department of Gastroenterology, Rijnstate Hospital, Arnhem, the Netherlands
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82
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Zorzi F, Pallone F, Calabrese E. Reply: To PMID 24813174. Clin Gastroenterol Hepatol 2015; 13:1551. [PMID: 25967749 DOI: 10.1016/j.cgh.2015.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Francesca Zorzi
- Gastroenterology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Francesco Pallone
- Gastroenterology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Emma Calabrese
- Gastroenterology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
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83
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Ultrasonography and Transmural Healing in Crohn's Disease. Clin Gastroenterol Hepatol 2015; 13:1549-51. [PMID: 25724705 DOI: 10.1016/j.cgh.2015.02.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 02/14/2015] [Accepted: 02/17/2015] [Indexed: 02/07/2023]
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Civitelli F, Casciani E, Maccioni F, Oliva S, Al Ansari N, Bonocore V, Cucchiara S. Use of Imaging Techniques in Inflammatory Bowel Diseases That Minimize Radiation Exposure. Curr Gastroenterol Rep 2015; 17:28. [PMID: 26122246 DOI: 10.1007/s11894-015-0448-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The use of imaging in the management of inflammatory bowel disease (IBD) has grown exponentially in the last few years. This has raised concerns about the risk of high cumulative level of radiation exposure from medical imaging in IBD patients during their lifetime, especially when the disease begins in pediatric age. Physicians caring for IBD children should be aware of the malignant potential of ionizing radiation and of the availability of alternative radiation-free techniques such as magnetic resonance imaging (MRI) and ultrasonography (US), in order to use them whenever possible. This review will focus on the value of US and MRI in pediatric IBD.
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Affiliation(s)
- Fortunata Civitelli
- Department of Pediatrics, Pediatric Gastroenterology & Liver Unit, Sapienza University of Rome, Viale Regina Elena, 324-00161, Rome, Italy,
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85
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Neurath MF. Advances in imaging to allow personalized medicine in Crohn's disease. Curr Opin Pharmacol 2015; 23:6-10. [PMID: 26002559 DOI: 10.1016/j.coph.2015.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/04/2015] [Indexed: 12/16/2022]
Abstract
Crohn's disease is a destructive inflammatory bowel disease of unknown origin that may lead to various complications such as strictures, stenosis, fistulas and colitis-associated neoplasias. However, the course of the disease varies substantially among patients and disease behaviour may also change with time. At diagnosis behaviour is inflammatory in the majority of patients, while penetrating or structuring behaviour become more prominent at later time points. Thus, medication in Crohn's disease needs frequent optimization over time. Therefore, new strategies for prediction of response to therapy are urgently needed. Here, recent advantages in imaging techniques for personalized medicine in Crohn's disease are reviewed. Such advantages include ultrasonography, computed tomography, magnetic resonance imaging and new endoscopic approaches such as molecular endoscopy. It is expected that these novel techniques will lead to marked improvements in the assessment of disease behaviour and the prediction of response to clinical therapy with biologicals.
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Affiliation(s)
- Markus F Neurath
- Department of Medicine 1, University of Erlangen-Nuremberg, Kussmaul Campus for Medical Research & Translational Research Center, Erlangen, Germany.
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86
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Asthana AK, Friedman AB, Maconi G, Maaser C, Kucharzik T, Watanabe M, Gibson PR. Failure of gastroenterologists to apply intestinal ultrasound in inflammatory bowel disease in the Asia-Pacific: a need for action. J Gastroenterol Hepatol 2015; 30:446-52. [PMID: 25529767 DOI: 10.1111/jgh.12871] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2014] [Indexed: 12/14/2022]
Abstract
Intestinal ultrasound (IUS) is a cheap, noninvasive, risk-free procedure that is significantly underutilized in the diagnosis and management of patients with inflammatory bowel disease (IBD) in the Asia-Pacific region. More cost-effective methods of monitoring disease activity are required in light of the increasing global burden of IBD (especially in Asia), the advent of personalized medicine, and the rising cost of healthcare. IUS is a prime example of a technique that meets these needs. Its common clinical applications include assessing the activity and complications of IBD. In continental Europe, countries such as Germany and Italy use this imaging tool as the standard of care and have integrated it into management protocols. There are formal training programs in these countries to train gastroenterologists in IUS, and it is used in an outpatient setting during patient consultations. Barriers to its use in the Asia-Pacific region include lack of experience and research data, and there are few established centers with active training programs. These concerns can be addressed by investing more in IUS service provision and by increasing allocation of resources toward local research and training. Increased uptake of IUS will ultimately benefit patients with IBD.
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Affiliation(s)
- Anil Kumar Asthana
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Victoria, Australia; Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Ercole E, Rigazio C. Role of bowel ultrasound in the management of postoperative Crohn's disease. World J Gastrointest Pathophysiol 2014; 5:457-461. [PMID: 25400989 PMCID: PMC4231510 DOI: 10.4291/wjgp.v5.i4.457] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 08/01/2014] [Accepted: 09/10/2014] [Indexed: 02/06/2023] Open
Abstract
The use of biological and immunosuppressive therapy in Crohn’s disease (CD) changed favorably the course of the disease and is currently suggested in the prevention of clinical recurrence. Symptomatic exacerbation is a feature of the natural course of the disease. Endoscopic recurrence may occur earlier than clinical manifestations and its rate is still high ever since the first year after surgery. The severity of mucosal lesions is highly predictive of a new flare of the disease so that the early detection of recurrence warrants strong therapeutic changes or a closer monitoring of the case. Endoscopy is at present the gold-standard technique for the diagnosis and grading of recurrence severity, but is poorly accepted by patients for its invasiveness. A simple and easy repeatable examination able to detect early signs of recurrence could be useful in the follow-up as an alternative or as a backing in the choice of the right timing for endoscopy in questionable cases. The use of bowel ultrasound (B-US) in the management of CD has grown in the past twenty years. Its accuracy in the real time detection of the disease and its complications, known since the 80’s, together with the non-invasiveness, low cost and wide availability of the technique have influenced the extension of its clinical use in many referral centers in Europe. The latest generation of ultrasound scanners allows a precise and reproducible morphological assessment of the intestinal tract and the surrounding tissues and enables a complete evaluation of the disease. This review analyzes the literature history about B-US in the diagnosis of postoperative recurrence of CD and outlines the clinical implications of its use. Published works confirm a very good accuracy of B-US in the diagnosis of CD recurrence compared to endoscopy, also in the early phase. B-US shows a good correlation with Rutgeert’s score grading, but does not prove significant association with C-reactive protein or CD Activity Index values. A wider use of B-US in the daily practice could allow to set a prompt diagnosis and an earlier and targeted treatment, probably sparing more invasive tests.
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88
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Bowel perfusion measured with dynamic contrast-enhanced ultrasound predicts treatment outcome in patients with Crohn's disease. Inflamm Bowel Dis 2014; 20:2029-37. [PMID: 25185684 PMCID: PMC4213134 DOI: 10.1097/mib.0000000000000159] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND To improve management of patients with Crohn's disease (CD), objective measurements of the degree of local inflammation in the gastrointestinal wall are needed. Increased microvessel density and perfusion are typical features of acute inflammation and can be estimated with contrast-enhanced ultrasound (CEUS). The aim of the study was to investigate whether CEUS can provide prognostic information about patients treated medically for an acute exacerbation of CD. METHODS Fourteen patients with CD who received medical treatment for acute exacerbation with systemic steroids or tumor necrosis factor-α inhibitors were prospectively recruited. The patients were examined with clinical scoring, blood tests, and CEUS at time 0, 1, 3, and 12 months after initiation of the treatment. Outcome was treatment efficacy or treatment failure defined as change in medical treatment after 1 month or later. The perfusion analysis was performed with a commercially available software program that analyzes the contrast intensity in a selected area, fits the data to a standardized time-intensity curve, and derives several relative perfusion parameters. RESULTS Six of the 14 patients had treatment failure during the study period. There was a significant difference between the groups for peak contrast enhancement (P = 0.013), rate of wash-in (P = 0.020) and wash-out (P = 0.008), and the area under the time-intensity curve in the wash-in phase (0.013) at the examination 1 month after the start of treatment. CONCLUSIONS Perfusion analysis of the intestinal wall with CEUS 1 month after starting treatment in patients with CD can provide prognostic information regarding treatment efficacy.
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