1
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McCurdy JD, Munir J, Parlow S, Reid J, Yanofsky R, Alenezi T, Meserve J, Becker B, Lahijanian Z, Eddin AH, Mallick R, Ramsay T, Rosenfeld G, Bessissow A, Bessissow T, Jairath V, Singh S, Bruining DH, Macdonald B. Development of an MRI-Based Prediction Model for Anti-TNF Treatment Failure in Perianal Crohn's Disease: A Multicenter Study. Clin Gastroenterol Hepatol 2024; 22:1058-1066.e2. [PMID: 38122958 DOI: 10.1016/j.cgh.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/10/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND & AIMS Clinical and radiologic variables associated with perianal fistula (PAF) outcomes are poorly understood. We developed prediction models for anti-tumor necrosis factor (TNF) treatment failure in patients with Crohn's disease-related PAF. METHODS In a multicenter retrospective study between 2005 and 2022 we included biologic-naive adults (>17 years) who initiated their first anti-TNF therapy for PAF after pelvic magnetic resonance imaging (MRI). Pretreatment MRI studies were prospectively reread centrally by blinded radiologists. We developed and internally validated a prediction model based on clinical and radiologic parameters to predict the likelihood of anti-TNF treatment failure, clinically, at 6 months. We compared our model and a simplified version of MRI parameters alone with existing imaging-based PAF activity indices (MAGNIFI-CD and modified Van Assche MRI scores) by De Long statistical test. RESULTS We included 221 patients: 32 ± 14 years, 60% males, 76% complex fistulas; 68% treated with infliximab and 32% treated with adalimumab. Treatment failure occurred in 102 (46%) patients. Our prediction model included age at PAF diagnosis, time to initiate anti-TNF treatment, and smoking and 8 MRI characteristics (supra/extrasphincteric anatomy, fistula length >4.3 cm, primary tracts >1, secondary tracts >1, external openings >1, tract hyperintensity on T1-weighted imaging, horseshoe anatomy, and collections >1.3 cm). Our full and simplified MRI models had fair discriminatory capacity for anti-TNF treatment failure (concordance statistic, 0.67 and 0.65, respectively) and outperformed MAGNIFI-CD (P = .002 and < .0005) and modified Van Assche MRI scores (P < .0001 and < .0001), respectively. CONCLUSIONS Our risk prediction models consisting of clinical and/or radiologic variables accurately predict treatment failure in patients with PAF.
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Affiliation(s)
- Jeffrey D McCurdy
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Javeria Munir
- Division of Diagnostic Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Simon Parlow
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jacqueline Reid
- Department of Medicine, UBC, Vancouver, British Columbia, Canada
| | - Russell Yanofsky
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Talal Alenezi
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Joseph Meserve
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Brenda Becker
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Zubin Lahijanian
- Division of Diagnostic Imaging, McGill University, Montreal, Quebec, Canada
| | - Anas Hussam Eddin
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Greg Rosenfeld
- Department of Medicine, UBC, Vancouver, British Columbia, Canada
| | - Ali Bessissow
- Division of Diagnostic Imaging, McGill University, Montreal, Quebec, Canada
| | - Talat Bessissow
- Division of Gastroenterology and Hepatology, Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Blair Macdonald
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; Division of Diagnostic Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
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2
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Crowley E, Ma C, Guizzetti L, Zou G, Lewindon PJ, Gee MS, Hyams JS, Rosen MJ, von Allmen D, de Buck van Overstraeten A, Shackelton LM, Remillard J, Schleicher L, Dillman JR, Rimola J, Taylor SA, Fletcher JG, Church PC, Feagan BG, Griffiths AM, Jairath V, Greer MLC. Recommendations for Standardizing MRI-based Evaluation of Perianal Fistulizing Disease Activity in Pediatric Crohn's Disease Clinical Trials. Inflamm Bowel Dis 2024; 30:357-369. [PMID: 37524088 DOI: 10.1093/ibd/izad134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Perianal fistulas and abscesses occur commonly as complications of pediatric Crohn's disease (CD). A validated imaging assessment tool for quantification of perianal disease severity and activity is needed to evaluate treatment response. We aimed to identify magnetic resonance imaging (MRI)-based measures of perianal fistulizing disease activity and study design features appropriate for pediatric patients. METHODS Seventy-nine statements relevant to MRI-based assessment of pediatric perianal fistulizing CD activity and clinical trial design were generated from literature review and expert opinion. Statement appropriateness was rated by a panel (N = 15) of gastroenterologists, radiologists, and surgeons using modified RAND/University of California Los Angeles appropriateness methodology. RESULTS The modified Van Assche Index (mVAI) and the Magnetic Resonance Novel Index for Fistula Imaging in CD (MAGNIFI-CD) were considered appropriate instruments for use in pediatric perianal fistulizing disease clinical trials. Although there was concern regarding the use of intravascular contrast material in pediatric patients, its use in clinical trials was considered appropriate. A clinically evident fistula tract and radiologic disease defined as at least 1 fistula or abscess on pelvic MRI were considered appropriate trial inclusion criteria. A coprimary clinical and radiologic end point and inclusion of a patient-reported outcome were also considered appropriate. CONCLUSION Outcomes of treatment of perianal fistulizing disease in children must include MRI. Existing multi-item measures, specifically the mVAI and MAGNIFI-CD, can be adapted and used for children. Further research to assess the operating properties of the indices when used in a pediatric patient population is ongoing.
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Affiliation(s)
- Eileen Crowley
- Department of Pediatrics, Division of Pediatric Gastroenterology, Children's Hospital Western Ontario, Western University, London Health Sciences Centre, London, Ontario, Canada
- Alimentiv Inc, London, ON, Canada
| | - Christopher Ma
- Alimentiv Inc, London, ON, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Guangyong Zou
- Alimentiv Inc, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Peter J Lewindon
- Department of Gastroenterology, Queensland Children's Hospital, University of Queensland, Brisbane, Queensland, Australia
- Children's Medical Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Michael S Gee
- Department of Radiology, Massachusetts General Hospital Boston, MA, USA
- Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Michael J Rosen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford Medicine, Stanford, CA, USA
| | - Daniel von Allmen
- Department of Pediatric Surgery and Surgical Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | | | | | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jordi Rimola
- IBD Unit, Radiology Department, Hospital Clinic Barcelona, IDIBAPS, Spain
| | - Stuart A Taylor
- Centre for Medical Imaging, Charles Bell House, University College London, London, UK
| | | | - Peter C Church
- Division of Gastroenterology, Hepatology & Nutrition, Department of Paediatrics and IBD Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Brian G Feagan
- Alimentiv Inc, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, Hepatology & Nutrition, Department of Paediatrics and IBD Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Vipul Jairath
- Alimentiv Inc, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Mary-Louise C Greer
- Department of Diagnostic Imaging, The Hospital for Sick Children, Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
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3
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Choshen S, Turner D, Pratt LT, Precel R, Greer ML, Castro DA, Assa A, Martínez-León MI, Herman-Sucharska I, Coppenrath E, Konen O, Davila J, Bekhit E, Alsabban Z, Focht G, Gavish M, Griffiths A, Cytter-Kuint R. Development and Validation of a Pediatric MRI-Based Perianal Crohn Disease (PEMPAC) Index-A Report from the ImageKids Study. Inflamm Bowel Dis 2022; 28:700-709. [PMID: 34151950 DOI: 10.1093/ibd/izab147] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND As part of the prospective multicenter ImageKids study, we aimed to develop and validate the pediatric MRI-based perianal Crohn disease (PEMPAC) index. METHODS Children with Crohn disease with any clinical perianal findings underwent pelvic magnetic resonance imaging at 21 sites globally. The site radiologist and 2 central radiologists provided a radiologist global assessment (RGA) on a 100 mm visual analog scale and scored the items selected by a Delphi group of 35 international radiologists and a review of the literature. Two weighted multivariable statistical models were constructed against the RGA. RESULTS Eighty children underwent 95 pelvic magnetic resonance imaging scans; 64 were used for derivation and 31 for validation. The following items were included: fistula number, location, length and T2 hyperintensity; abscesses; rectal wall involvement; and fistula branching. The last 2 items had negative beta scores and thus were excluded in a contending basic model. In the validation cohort, the full and the basic models had the same strong correlation with the RGA (r = 0.75; P < 0.01) and with the adult Van Assche index (VAI; r = 0.93 and 0.92; P < 0.001). The correlation of the VAI with the RGA was similar (r = 0.77; P < 0.01). The 2 models and the VAI had a similar ability to differentiate remission from active disease (area under the receiver operating characteristic curve, 0.91-0.94). The PEMPAC index had good responsiveness to change (area under the receiver operating characteristic curve, 0.89; 95% confidence interval, 0.69-1.00). CONCLUSIONS Using a blended judgmental and mathematical approach, we developed and validated an index for quantifying the severity of perianal disease in children with CD. The adult VAI may also be used with confidence in children.
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Affiliation(s)
- Sapir Choshen
- Pediatric Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Li-Tal Pratt
- Pediatric Imaging Unit, Imaging Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Precel
- Pediatric Imaging Unit, Imaging Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Mary-Louise Greer
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Denise A Castro
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.,Department of Diagnostic Radiology, Kingston Health Science Centre, Queen's University, Kingston, Canada
| | - Amit Assa
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Diagnostic Imaging, Schneider Children's Hospital, Petach-Tikva, Israel
| | | | | | | | - Osnat Konen
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Diagnostic Imaging, Schneider Children's Hospital, Petach-Tikva, Israel
| | - Jorge Davila
- Department of Medical Imaging, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Elhamy Bekhit
- Department of Medicine and Radiology, The Royal Children's Hospital, Melbourne, Australia
| | - Zehour Alsabban
- Department of Radiology, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Gili Focht
- The Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Matan Gavish
- School of Computer Science and Engineering, The Hebrew University, Jerusalem, Israel
| | - Anne Griffiths
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Canada
| | - Ruth Cytter-Kuint
- Radiology Department, Shaare Zedek Medical Center, Jerusalem, Israel
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4
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Greer MLC, Taylor SA. Perianal Imaging in Crohn Disease: Current Status With a Focus on MRI, From the AJR Special Series on Imaging of Inflammation. AJR Am J Roentgenol 2022; 218:781-792. [PMID: 34549607 DOI: 10.2214/ajr.21.26615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Fistulizing perianal disease, a frequent, chronic, and often debilitating manifestation of Crohn disease (CD) in adults and children, has been relatively refractory to treatment in the past. The advent of biologic agents such as anti-tumor necrosis factor-α and cellular therapies, used in conjunction with a range of surgical interventions, has greatly improved disease outcomes, although complete remission can still be elusive. This Special Series review considers current perianal imaging options, specifically pelvic MRI and endoanal and transperineal ultrasound, as well as their roles in the diagnosis, management, and assessment of treatment response. Pelvic MRI is the first-line modality for imaging perianal CD, given the complexity of fistulas encountered in CD. MRI technical acquisition parameters for adults and children and an approach to MRI interpretation and reporting are provided. Anatomic classification systems for fistulizing peri-anal disease are presented. We also explore the history, current landscape, and future developments of MRI features of perianal disease as imaging biomarkers, to quantify activity and severity and to consider CD MRI-based inflammatory activity scores. We discuss the reliability and validation of a number of indexes (including the pediatric MRI-based perianal CD [PEMPAC] index, the MR novel index for fistula imaging in CD [MAGNIFI-CD], the Van Assche index, and the modified Van Assche index), their potential to quantify treatment response, and possible prognostic capabilities.
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Affiliation(s)
- Mary-Louise C Greer
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Stuart A Taylor
- Center for Medical Imaging, University College London, London, United Kingdom
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5
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Tabari A, Kaplan JL, Huh SY, Moran CJ, Gee MS. Clinical characteristics and MRI-based phenotypes of perianal abscess formation in children with fistulizing Crohn's Disease. Front Pediatr 2022; 10:1045583. [PMID: 36507146 PMCID: PMC9731150 DOI: 10.3389/fped.2022.1045583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/18/2022] [Indexed: 11/19/2022] Open
Abstract
PURPOSE The aim of this study was to explore potential correlation of the MR imaging features and clinical characteristics with formation of perianal abscess in children with Crohn's perianal fistulas (CPF). METHODS From 2010 to 2020, pediatric patients with CPF diagnosis on their first pelvic MRI were identified retrospectively. All patients were divided into two groups based on the presence or absence of perianal abscess. Baseline clinical and MRI characteristics were recorded for each patient. All the statistical calculations were performed using R (version 3.6.3). RESULTS A total of 60 patients [F:M 17:43, median age 14 years (IQR 10-15), ranging 3-18 years] were included in this study. Forty-four abscesses were identified in 36/60 children (mean volume 3 ± 8.6 ml, median 0.3 ml). In 24/60 patients with perianal disease, no abscess was detected on the MRI. Ten patients (28%) showed perianal abscess on pelvic MRI at the initial diagnosis. The rate of active disease on colonoscopy (visible ulcerations/aphthous ulcers) was similar in both groups (95% vs. 94%). With regards to disease location, the majority of patients (40/60, 66.6%) in both groups had ileocolonic CD. All patients without abscess had a single perianal fistula (n = 24; 3 simple and 21 complex fistulae), however, patients with perianal abscess tended to have >1 fistulous tracts (n = 50 fistulas; all complex, 27 single, 10 double and 1 triple). Intersphincteric fistula was the most common fistula type in both groups (79% and 66%, p = 0.1). The total length of fistula (3.8 ± 1.7 vs. 2.8 ± 0.8 cm, p = 0.006) and presence of multiple external openings (n = 25 vs. 7, p = 0.019) were significantly higher in patients with abscesses, and fistula length >3.3 cm showed 80% specificity and 83% PPV for the presence of perianal abscess. Fistulas were symptomatic (pain, bleeding or drainage) at similar rates in both groups (68% and 70%, p = 0.1). CONCLUSION Pediatric patients with CPF who develop perianal abscess have a distinct imaging phenotype defined by longer fistula length (>3.3 cm), multiple skin openings and multiple fistulous tracts (≥2) on MRI. Patients who have these features but does not have an abscess on imaging may merit more aggressive treatment (and close monitoring) to prevent the development of an abscess.
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Affiliation(s)
- Azadeh Tabari
- Division of Pediatric Imaging, Department of Radiology, MassGeneral Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jess L Kaplan
- Harvard Medical School, Boston, MA, USA.,Division of Pediatric Gastroenterology, MassGeneral Hospital for Children, Boston, MA, USA
| | - Susanna Y Huh
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA.,Takeda Pharmaceuticals International Co, Cambridge, MA, USA
| | - Christopher J Moran
- Harvard Medical School, Boston, MA, USA.,Division of Pediatric Gastroenterology, MassGeneral Hospital for Children, Boston, MA, USA
| | - Michael S Gee
- Division of Pediatric Imaging, Department of Radiology, MassGeneral Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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6
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Khan MR, Ulrich JA, Hull NC, Inoue A, Harmsen WS, Faubion WA, Fletcher JG, Absah I. Perianal magnetic resonance imaging findings and their potential impact on outcome in children with perianal fistulizing Crohn disease. Pediatr Radiol 2021; 51:2481-2491. [PMID: 34490496 DOI: 10.1007/s00247-021-05158-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 05/25/2021] [Accepted: 07/20/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Children with perianal fistulizing Crohn disease require intensive medical management but also have a higher risk for subsequent surgical interventions. OBJECTIVE We performed a retrospective study to identify patient factors and perianal anatomical features by pelvic MR that are associated with surgical interventions in these children. MATERIALS AND METHODS We included children with Crohn disease and perianal fistula who underwent pelvic MR with available, archived images and collected demographic, clinical and laboratory data. Radiologists reviewed pelvic MR exams and identified Park classification and additional anatomical features of perianal fistulas, including fistula branching, horseshoe ramifications, abscess, inflammatory mass, supralevator extension, anal sphincter damage, proctitis and posterior anal space involvement. We performed univariate and subsequent multivariate analysis to determine features associated with subsequent surgical intervention. RESULTS Ninety-nine children with Crohn disease underwent pelvic MR. In this cohort, 69 children had no surgical interventions prior to baseline MRI, with subsequent median clinical follow-up of 5.5 years. Univariate analysis demonstrated that branching (P=0.009), supralevator extension (P=0.015) and anal sphincter damage (P=0.031) were significantly associated with subsequent surgical intervention. Age at baseline MRI was also associated with intervention (hazard ratio [HR] every 5 years: 2.13; 95% confidence interval [CI]: 1.18-3.83; P=0.012). A multivariable model identified only fistula branching (HR: 2.31; 95% CI: 1.28-4.15; P=0.005) and age (HR: 5.18; CI: 1.57-17.14; P=0.007) as independent predictors of subsequent surgery. No demographic, clinical or laboratory parameter predicted subsequent surgical intervention. CONCLUSION Age and anatomical MR features indicating fistula complexity (branching, supralevator extension) and sphincter damage confer a higher risk of subsequent surgical intervention in children with perianal Crohn disease.
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Affiliation(s)
- Muhammad Rehan Khan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine at Peoria, Children's Hospital of Illinois, 530 NE Glen Oak Ave., Peoria, IL, 61637, USA. .,Department of Pediatrics & Child Health, Aga Khan University, Karachi, Pakistan.
| | | | - Nathan C Hull
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Akitoshi Inoue
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - William S Harmsen
- Department of Biomedical Statistics and informatics, Mayo Clinic, Rochester, MN, USA
| | - William A Faubion
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Imad Absah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.,Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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7
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Abstract
The incidence of Crohn's disease is increasing worldwide. The clinical course of childhood onset Crohn's disease is particularly aggressive with characteristic disease localization in the ileocecal region and colon, often associated with perianal disease. Severe complications of perianal disease include recurrent perianal sepsis, chronic fistulae, fecal incontinence, and rectal strictures that impair quality of life and may require fecal diversion. Care of patients with perianal Crohn's disease requires a multidisciplinary approach with systematic clinical evaluation, endoscopic assessment, and imaging studies followed by combined medical and surgical management. In this review, we provide an update of the epidemiology, pathophysiology, diagnostics, and management of perianal Crohn's disease in children and adolescents.
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Affiliation(s)
- Annika Mutanen
- Department of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, Helsinki, Finland
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8
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Greer MLC, Cytter-Kuint R, Pratt LT, Soboleski D, Focht G, Castro DA. Clinical-stage Approaches for Imaging Chronic Inflammation and Fibrosis in Crohn's Disease. Inflamm Bowel Dis 2020; 26:1509-1523. [PMID: 32946578 DOI: 10.1093/ibd/izaa218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Indexed: 02/06/2023]
Abstract
The number of imaging-based indices developed for inflammatory bowel disease as research tools, objectively measuring ileocolonic and perianal activity and treatment response, has expanded in the past 2 decades. Created primarily to assess Crohn's disease (CD), there is increasing adoption of these indices into the clinical realm to guide patient care. This translation has been facilitated by validation in adult and pediatric populations, prompted by simplification of score calculations needed for practical application outside the research environment. The majority of these indices utilize magnetic resonance imaging (MRI), specifically MR enterography (MRE) and pelvic MRI, and more recently ultrasound. This review explores validated indices by modality, anatomic site and indication, including for documentation of the presence and extent of CD, disease progression, complications, and treatment response, highlighting those in clinical use or with the potential to be. As well, it details index imaging features used to quantify chronic inflammatory activity, severity, and to lesser extent fibrosis, in addition to their reference standards and any modifications. Validation in the pediatric population of indices primarily developed in adult cohorts such as the Magnetic Resonance Index of Activity (MaRIA), the Simplified Magnetic Resonance Index of Activity (MARIAs), and the MRE global score (MEGS), together with newly developed pediatric-specific indices, are discussed. Indices that may be predictive of disease course and investigational techniques with the potential to provide future imaging biomarkers, such as multiparametric MRI, are also briefly considered.
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Affiliation(s)
- Mary-Louise C Greer
- Department of Diagnostic Imaging, The Hospital for Sick Children; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | | | - Li-Tal Pratt
- Pediatric Imaging Unit, Imaging Division, Sourasky Medical Center, Tel Aviv, Israel
| | - Don Soboleski
- Department of Diagnostic Imaging, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Gili Focht
- The Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Denise A Castro
- Department of Diagnostic Imaging, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
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9
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McCurdy JD, Parlow S, Dawkins Y, Samji K, Rhee GG, Oliveira L, Macdonald B, Sabri E, Murthy S. Tumor Necrosis Factor Inhibitors May Have Limited Efficacy for Complex Perianal Fistulas Without Luminal Crohn's Disease. Dig Dis Sci 2020; 65:1784-1789. [PMID: 31642006 DOI: 10.1007/s10620-019-05905-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/12/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND Complex perianal fistulas occurring in the absence of luminal inflammation (isolated perianal disease, IPD) may represent a specific phenotype of Crohn's disease (CD). AIM We assessed the effectiveness of tumor necrosis factor (TNF)-antagonists in patients with IPD compared to those with perianal CD (PCD) with luminal inflammation. METHODS Patients were identified through our institutional radiology database and were classified as PCD or IPD based on the presence or absence of luminal inflammation by ileocolonoscopy and abdominal enterography. Consecutive adults (> 17 years) with recurrent IPD who were treated with TNF antagonists were matched by age and gender to patients with complex PCD (1:2 ratio). Fistula remission was defined as an absence of fistula drainage. Surgery-free survival was assessed by Cox proportional hazard models. RESULTS Twenty-two patients with IPD treated with a TNF antagonist were compared with 44 matched patients with PCD. A similar proportion of patients with IPD and PCD were treated with concomitant immunomodulators (55% vs. 66%) and underwent examinations under anesthesia prior to therapy (36% vs. 46%). Fistula remission at 3, 6, and 12 months was lower for the IPD cohort: 9.5% versus 34%; 19% versus 39%; and 19% versus 43%. Surgical intervention after initiating anti-TNF therapy was more common for patients with IPD (HR 3.99: 95% CI, 1.62-9.83; p = 0.0026). CONCLUSIONS Fewer patients with IPD achieved fistula remission, and more required surgical intervention after anti-TNF therapy, suggesting that TNF antagonists may not be as effective in these patients.
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Affiliation(s)
- Jeffrey D McCurdy
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, 737 Parkdale Ave, Suite 468, Ottawa, ON, K1Y 1J8, Canada. .,The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.
| | - Simon Parlow
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, 737 Parkdale Ave, Suite 468, Ottawa, ON, K1Y 1J8, Canada
| | - Yvonne Dawkins
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, 737 Parkdale Ave, Suite 468, Ottawa, ON, K1Y 1J8, Canada
| | - K Samji
- Department of Medical Imaging, The Ottawa Hospital, Ottawa, ON, Canada
| | - Glara Gaeun Rhee
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, 737 Parkdale Ave, Suite 468, Ottawa, ON, K1Y 1J8, Canada
| | - Lilianna Oliveira
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, 737 Parkdale Ave, Suite 468, Ottawa, ON, K1Y 1J8, Canada
| | - Blair Macdonald
- Department of Medical Imaging, The Ottawa Hospital, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Elham Sabri
- The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sanjay Murthy
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, 737 Parkdale Ave, Suite 468, Ottawa, ON, K1Y 1J8, Canada.,The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
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10
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Kedia S, Sharma R, Makharia G, Ahuja V, Desai D, Kandasamy D, Eapen A, Ganesan K, Ghoshal UC, Kalra N, Karthikeyan R, Madhusudhan KS, Philip M, Puri A, Puri S, Sinha SK, Banerjee R, Bhatia S, Bhat N, Dadhich S, Dhali GK, Goswami BD, Issar SK, Jayanthi V, Misra SP, Nijhawan S, Puri P, Sarkar A, Singh SP, Srivastava A, Abraham P, Ramakrishna BS. Indian guidelines on imaging of the small intestine in Crohn's disease: A joint Indian Society of Gastroenterology and Indian Radiology and Imaging Association consensus statement. Indian J Radiol Imaging 2019; 29:111-132. [PMID: 31367083 PMCID: PMC6639863 DOI: 10.4103/ijri.ijri_153_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients suspected to have or having Crohn's disease. The 29 consensus statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.
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Affiliation(s)
- Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Radiadiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Devendra Desai
- Division of Gastroenterology, P D Hinduja Hospital, Mumbai, Maharashtra, India
| | | | - Anu Eapen
- Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
| | - Karthik Ganesan
- Department of Radiodiagnosis, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
| | - Naveen Kalra
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - R Karthikeyan
- Department of Radiodiagnosis, SRM Institute of Medical Sciences and Research, Chennai, India
| | | | - Mathew Philip
- Department of Gastroenterology, PVS Memorial Hospital, Kochi, Kerala, India
| | - Amarender Puri
- Department of Gastroenterology, GB Pant Institute of Medical Education and Research, New Delhi, India
| | - Sunil Puri
- Department of Radiodiagnosis, GB Pant Institute of Medical Education and Research, New Delhi, India
| | - Saroj K Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rupa Banerjee
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Shobna Bhatia
- Department of Gastroenterology, KEM Hospital, Mumbai, India
| | - Naresh Bhat
- Department of Gastroenterology, Aster CMI Hospital, Bengaluru, Karnataka, India
| | - Sunil Dadhich
- Department of Gastroenterology, SN Medical College, Jodhpur, Rajasthan, India
| | - G K Dhali
- Department of Gastroenterology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, West Bengal, India
| | - B D Goswami
- Department of Gastroenterology, Guwahati Medical College, Guwahati, Assam, India
| | - S K Issar
- Department of Gastroenterology, Jawaharlal Nehru Hospital and Research Centre, Bhilai, Chhattishgarh, India
| | - V Jayanthi
- Department of Gastroenterology, Gleneagles Global Hospitals, Chennai, India
| | - S P Misra
- Department of Gastroenterology, MLN Medical College, Allahabad, UP, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, Gleneagles Global Hospitals, Chennai, India
| | - Pankaj Puri
- Department of Gastroenterology, Military Hospital, Jodhpur, Rajasthan, India
| | - Avik Sarkar
- Department of Radiodiagnosis, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, West Bengal, India
| | - S P Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Odisha, India
| | - Anshu Srivastava
- Department of Paediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
| | - Philip Abraham
- Division of Gastroenterology, P D Hinduja Hospital, Mumbai, Maharashtra, India
| | - B S Ramakrishna
- Department of Gastroenterology, SRM Institute of Medical Sciences and Research, Chennai, India
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11
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Cahalane AM, Kilcoyne A, Tabari A, McDermott S, Gee MS. Computed tomography texture features can discriminate benign from malignant lymphadenopathy in pediatric patients: a preliminary study. Pediatr Radiol 2019; 49:737-745. [PMID: 30741316 DOI: 10.1007/s00247-019-04350-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 11/26/2018] [Accepted: 01/24/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Differentiation of benign from malignant lymphadenopathy remains challenging in pediatric radiology. Textural analysis (TA) quantitates heterogeneity of tissue signal intensities and has been applied to analysis of CT images. OBJECTIVE The purpose of this study was to establish whether CT textural analysis of enlarged lymph nodes visualized on pediatric CT can distinguish benign from malignant lymphadenopathy. MATERIALS AND METHODS We retrospectively identified enlarged lymph nodes measuring 10-20 mm on contrast-enhanced CTs of patients age 18 years and younger that had been categorized as benign or malignant based on the known diagnoses. We placed regions of interest (ROIs) over lymph nodes of interest and performed textural analysis with and without feature size filtration. We then calculated test performance characteristics for TA features, along with multivariate logistic regression modeling using Akaike Information Criterion (AIC) minimization, to determine the optimal thresholds for distinguishing benign from malignant lymphadenopathy. RESULTS We identified 34 enlarged malignant nodes and 29 benign nodes from 63 patients within the 10- to 20-mm size range. Filtered image TA exhibited 82.4% sensitivity, 86.2% specificity and 84.1% accuracy for detecting malignant lymph nodes using mean and entropy parameters, whereas unfiltered TA exhibited 88.2% sensitivity, 72.4% specificity and 81.0% accuracy using mean and mean value of positive pixels parameters. CONCLUSION This preliminary study demonstrates that the use of TA features improves the utility of pediatric CT to distinguish benign from malignant lymphadenopathy. The addition of TA to pediatric CT protocols has great potential to aid the characterization of indeterminate lymph nodes. If definitive differentiation between benign and malignant lymphadenopathy is possible by TA, it has the potential to reduce the need for follow-up imaging and tissue sampling, with reduced associated radiation exposure. However future studies are needed to confirm the clinical applicability of TA in distinguishing benign from malignant lymphadenopathy.
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Affiliation(s)
- Alexis M Cahalane
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA.
| | - Aoife Kilcoyne
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - Azadeh Tabari
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - Shaunagh McDermott
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - Michael S Gee
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA
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12
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Yan X, Zhu M, Feng Q, Yan Y, Peng J, Xu X, Xu A, Ran Z. Evaluating the effectiveness of infliximab on perianal fistulizing Crohn's disease by magnetic resonance imaging. Gastroenterol Rep (Oxf) 2018; 7:50-56. [PMID: 30792866 PMCID: PMC6375345 DOI: 10.1093/gastro/goy036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/11/2018] [Accepted: 07/05/2018] [Indexed: 12/23/2022] Open
Abstract
Background and aim Data on the radiologic evaluation of perianal fistulizing Crohn’s disease (PFCD) naïve to anti-tumor necrosis factor therapy are scarce, especially in Asian populations. We assessed the effectiveness of infliximab (IFX) on PFCD and explored predictors of ‘deep remission’ based on clinical and radiologic assessments. Methods Patients with Crohn’s disease and active anal fistulas attending our care center for IFX therapy were prospectively enrolled. Each patient underwent clinical examination according to the Fistula Drainage Assessment Index, endoscopy for assessment of Crohn’s Disease Activity Index (CDAI) and Perianal Crohn’s Disease Activity Index (PCDAI), magnetic resonance imaging (MRI) to determine Van Assche score and Ng score, and laboratory tests up to 2 weeks prior to the start of and up to 2 weeks after the sixth IFX therapy (Week 32). Results Among 38 patients treated with IFX, 52.6% achieved clinical remission based on the Fistula Drainage Assessment Index and 42.1% achieved deep remission based on Ng score. Van Assche score (from 14.5 ± 4.26 to 7.36 ± 7.53), CDAI (from 170 ± 92 to 71 ± 69) and PCDAI (from 7.45 ± 2.65 to 2.44 ± 3.20) decreased significantly after six IFX treatments. The only predictor of deep remission was simple fistula (P = 0.004, odds ratio = 3.802, 95% confidence interval: 1.541–9.383). Conclusions IFX has been shown to have appreciable effectiveness in Chinese patients with PFCD. MRI is the gold standard for evaluating PFCD, but Van Assche score has some limitations.
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Affiliation(s)
- Xiaohan Yan
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health; Shanghai Inflammatory Bowel Disease Research Center; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mingming Zhu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health; Shanghai Inflammatory Bowel Disease Research Center; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qi Feng
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yunqi Yan
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jiangchen Peng
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health; Shanghai Inflammatory Bowel Disease Research Center; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xitao Xu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health; Shanghai Inflammatory Bowel Disease Research Center; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Antao Xu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health; Shanghai Inflammatory Bowel Disease Research Center; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhihua Ran
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health; Shanghai Inflammatory Bowel Disease Research Center; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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13
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Lung PFC, Sahnan K, Burling D, Burn J, Tozer P, Yassin N, Adegbola SO, Baldwin-Cleland R, Warusavitarne J, Gupta A, Faiz O, Phillips RKS, Hart AL. Volume assessment magnetic resonance imaging technique for monitoring perianal Crohn's fistulas. Therap Adv Gastroenterol 2018; 11:1756284818793609. [PMID: 35154383 PMCID: PMC8832291 DOI: 10.1177/1756284818793609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/25/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Perianal Crohn's fistula and their response to anti-tumour necrosis factor (TNF) therapies are best assessed with magnetic resonance imaging (MRI), but radiologist reporting is subjective and variable. This study investigates whether segmentation software could provide precise and reproducible objective measurements of fistula volume. METHODS Retrospective analysis of patients with perianal Crohn's fistula at our institution between 2007 and 2013. Pre- and post-biologic MRI scans were used with varying time intervals. A total of two radiologists recorded fistula volumes, mean signal intensity and time taken to measure fistula volumes using validated Open Source segmentation software. A total of three radiologists assessed fistula response to treatment (improved, worse or unchanged) by comparing MRI scans. RESULTS A total of 18 cases were reviewed for this pilot study. Inter-observer variability was very good for volume and mean signal intensity; intra-class correlation (ICC) 0.95 [95% confidence interval (CI) 0.91-0.98] and 0.95 (95% CI 0.90-0.97) respectively. Intra-observer variability was very good for volume and mean signal intensity; ICC 0.99 (95% CI 0.97-0.99) and 0.98 (95% CI 0.95-0.99) respectively. Average time taken to measure fistula volume was 202 s and 250 s for readers 1 and 2. Agreement between three specialist radiologists was good [kappa 0.69 (95% CI 0.49-0.90)] for the subjective assessment of fistula response. Significant association was found between objective percentage volume change and subjective consensus agreement of response (p = 0.001). Median volume change for improved, stable or worsening fistula response was -67% [interquartile range (IQR): -78, -47], 0% (IQR: -16, +17), and +487% (IQR: +217, +559) respectively. CONCLUSION Quantification of fistula volumes and signal intensities is feasible and reliable, providing an objective measure of perianal Crohn's fistula and response to treatment.
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Affiliation(s)
| | - Kapil Sahnan
- Fistula Research Unit, St Mark’s Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, UK Department of Surgery and Cancer, Imperial College, St Mary’s Hospital, Praed Street, London, UK
| | - David Burling
- Gastrointestinal Imaging, St Mark’s Hospital & Academic Institute, Harrow, Middlesex, UK
| | - James Burn
- Gastrointestinal Imaging, St Mark’s Hospital & Academic Institute, Harrow, Middlesex, UK
| | - Phillip Tozer
- Fistula Research Unit, St Mark’s Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, UK Department of Surgery and Cancer, Imperial College, St Mary’s Hospital, Praed Street, London, UK
| | - Nuha Yassin
- Fistula Research Unit, St Mark’s Hospital & Academic Institute, Harrow, Middlesex, UK
| | - Samuel O. Adegbola
- Fistula Research Unit, St Mark’s Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, UK Department of Surgery and Cancer, Imperial College, St Mary’s Hospital, Praed Street, London, UK
| | - Rachel Baldwin-Cleland
- Gastrointestinal Imaging, St Mark’s Hospital & Academic Institute, Harrow, Middlesex, UK
| | - Janindra Warusavitarne
- Fistula Research Unit, St Mark’s Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, UK Department of Surgery and Cancer, Imperial College, St Mary’s Hospital, Praed Street, London, UK
| | - Arun Gupta
- Gastrointestinal Imaging, St Mark’s Hospital & Academic Institute, Harrow, Middlesex, UK
| | - Omar Faiz
- Fistula Research Unit, St Mark’s Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, UK Department of Surgery and Cancer, Imperial College, St Mary’s Hospital, Praed Street, London, UK
| | - Robin K. S. Phillips
- Fistula Research Unit, St Mark’s Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, UK Department of Surgery and Cancer, Imperial College, St Mary’s Hospital, Praed Street, London, UK
| | - Ailsa L. Hart
- Fistula Research Unit, St Mark’s Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, UK Department of Surgery and Cancer, Imperial College, St Mary’s Hospital, Praed Street, London, UK
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14
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AlSabban Z, Carman N, Moineddin R, Lo RT, King SK, Langer JC, Walters TD, Griffiths AM, Church PC, Greer MLC. Can MR enterography screen for perianal disease in pediatric inflammatory bowel disease? J Magn Reson Imaging 2017; 47:1638-1645. [DOI: 10.1002/jmri.25888] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 10/22/2017] [Indexed: 12/18/2022] Open
Affiliation(s)
- Zehour AlSabban
- Department of Diagnostic Imaging; The Hospital for Sick Children; Toronto Canada
- Department of Medical Imaging; University of Toronto; Toronto Canada
| | - Nicholas Carman
- Division of Gastroenterology, Hepatology and Nutrition; The Hospital for Sick Children; Toronto Canada
- Department of Pediatrics; University of Toronto; Toronto Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine; University of Toronto; Toronto Canada
| | - Ryan T. Lo
- Department of Medical Imaging; University of Toronto; Toronto Canada
| | - Sebastian K. King
- Division of General and Thoracic Surgery; Toronto Canada
- The Hospital for Sick Children, Department of Surgery; University of Toronto; Toronto Canada
| | - Jacob C. Langer
- Division of General and Thoracic Surgery; Toronto Canada
- The Hospital for Sick Children, Department of Surgery; University of Toronto; Toronto Canada
| | - Thomas D. Walters
- Division of Gastroenterology, Hepatology and Nutrition; The Hospital for Sick Children; Toronto Canada
- Department of Pediatrics; University of Toronto; Toronto Canada
| | - Anne M. Griffiths
- Division of Gastroenterology, Hepatology and Nutrition; The Hospital for Sick Children; Toronto Canada
- Department of Pediatrics; University of Toronto; Toronto Canada
| | - Peter C. Church
- Division of Gastroenterology, Hepatology and Nutrition; The Hospital for Sick Children; Toronto Canada
- Department of Pediatrics; University of Toronto; Toronto Canada
| | - Mary-Louise C. Greer
- Department of Diagnostic Imaging; The Hospital for Sick Children; Toronto Canada
- Department of Medical Imaging; University of Toronto; Toronto Canada
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15
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Kedia S, Sharma R, Makharia GK, Ahuja V, Desai D, Kandasamy D, Eapen A, Ganesan K, Ghoshal UC, Kalra N, Karthikeyan D, Madhusudhan KS, Philip M, Puri AS, Puri S, Sinha SK, Banerjee R, Bhatia S, Bhat N, Dadhich S, Dhali GK, Goswami BD, Issar SK, Jayanthi V, Misra SP, Nijhawan S, Puri P, Sarkar A, Singh SP, Srivastava A, Abraham P, Ramakrishna BS. Imaging of the small intestine in Crohn's disease: Joint position statement of the Indian Society of Gastroenterology and Indian Radiological and Imaging Association. Indian J Gastroenterol 2017; 36:487-508. [PMID: 29307029 DOI: 10.1007/s12664-017-0804-y] [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] [Received: 11/22/2017] [Accepted: 11/26/2017] [Indexed: 02/07/2023]
Abstract
The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients with suspected or known Crohn's disease. These 29 position statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.
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Affiliation(s)
- Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India.
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Devendra Desai
- Division of Gastroenterology, P D Hinduja Hospital and Medical Research Centre, Veer Sawarkar Marg, Mumbai, 400 016, India
| | - Devasenathipathy Kandasamy
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Anu Eapen
- Department of Radiodiagnosis, Christian Medical College, Vellore, 632 004, India
| | - Karthik Ganesan
- Department of Radiodiagnosis, Sir H N Reliance Foundation Hospital and Research Centre, Prarthana Samaj, Raja Rammohan Roy Road, Mumbai, 400 004, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Naveen Kalra
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - D Karthikeyan
- Department of Radiodiagnosis, SRM Institutes for Medical Science, 1, Jawaharlal Nehru Salai, Vadapalani, Chennai, 600 026, India
| | | | - Mathew Philip
- Department of Gastroenterology, PVS Memorial Hospital, Kochi, 682 017, India
| | - Amarender Singh Puri
- Department of Gastroenterology, GB Pant Institute of Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi, 110 002, India
| | - Sunil Puri
- Department of Radiodiagnosis, GB Pant Institute of Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi, 110 002, India
| | - Saroj K Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Rupa Banerjee
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad, 500 082, India
| | - Shobna Bhatia
- Department of Gastroenterology, KEM Hospital, Acharya Donde Marg, Parel, Mumbai, 400 012, India
| | - Naresh Bhat
- Department of Gastroenterology, Aster CMI Hospital, 43/2, New Airport Road, NH.7, Sahakara Nagar, Bengaluru, 560 092, India
| | - Sunil Dadhich
- Department of Gastroenterology, SN Medical College, Residency Road, Shastri Nagar, Jodhpur, 342 003, India
| | - G K Dhali
- Department of Gastroenterology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, 700 020, India
| | - B D Goswami
- Department of Gastroenterology, Guwahati Medical College, GMC Hospital Road, Bhangagarh, Guwahati, 781 032, India
| | - S K Issar
- Department of Gastroenterology, Jawaharlal Nehru Hospital and Research Centre, Hospital Sector, Bhilai, 490 009, India
| | - V Jayanthi
- Department of Gastroenterology, Gleneagles Global Hospitals, 439, Cheran Nagar, Perumbakkam, Chennai, 600 100, India
| | - S P Misra
- Department of Gastroenterology, MLN Medical College, Allahabad, 211 002, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, SMS Medical College, J L N. Marg, Jaipur, 302 004, India
| | - Pankaj Puri
- Department of Gastroenterology, Military Hospital, Cantt Area, Jodhpur, 342 006, India
| | - Avik Sarkar
- Department of Radiodiagnosis, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, 700 020, India
| | - S P Singh
- Department of Gastroenterology, SCB Medical College, Dock Road, Manglabag, Cuttack, 753 007, India
| | - Anshu Srivastava
- Department of Paediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Philip Abraham
- Division of Gastroenterology, P D Hinduja Hospital and Medical Research Centre, Veer Sawarkar Marg, Mumbai, 400 016, India
| | - B S Ramakrishna
- Institute of Gastroenterology, SRM Institutes for Medical Science, 1, Jawaharlal Nehru Salai, Vadapalani, Chennai, 600 026, India
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16
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Abstract
Perianal disease is a common manifestation of Crohn disease (CD) that results in significant morbidity and decreased quality of life. Despite several medical and surgical options, complex perianal CD remains difficult to treat. Before the advent of biologic therapy, antibiotics were the mainstay of medical treatment. Infliximab remains the most well-studied medical therapy for perianal disease. Surgical interventions are limited by the risk of nonhealing wounds and potential incontinence. When treatment options fail, fecal diversion or proctectomy may be necessary. Stem cell therapies may offer improved results and seem to be safe, but are not yet widely used.
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17
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Zhu J, Zhang F, Zhou J, Li H. Assessment of therapeutic response in Crohn's disease using quantitative dynamic contrast enhanced MRI (DCE-MRI) parameters: A preliminary study. Medicine (Baltimore) 2017; 96:e7759. [PMID: 28796069 PMCID: PMC5556235 DOI: 10.1097/md.0000000000007759] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The aim of the study was to investigate dynamic contrast enhanced MRI (DCE-MRI) as a potential marker to assess the therapeutic responses of fecal microbiota transplantation (FMT) in patients with Crohn's disease (CD) and to determine the parameter or combination of parameters most strongly associated with changes in clinical indicators after treatment.In 22 CD patients, DCE-MRI was performed with a 3.0T scanner. Parameters of DCE-MRI (vascular transfer constant [K] and blood volume [BV]) in the terminal ileum were compared between before and day 90 after FMT treatment. The differences of clinical indicators (C-reactive protein [CRP], Harvey-Bradshaw index [HBI]) and DCE-MRI parameters (K, BV) between pre- and post-treatment was calculated by Student's 2-tailed, paired t-test. The correlations between percent change of clinical indicators (ΔCRP, ΔHBI) with DCE-MRI parameters (ΔK, ΔBV) were analyzed by Pearson's correlation coefficients. A logistic regression model was used to identify the changes of DCE-MRI parameters related to the treatment outcomes. Receiver operating characteristic curves (ROCs) were generated to assess which DCE-MRI parameter showed the best accuracy for evaluation of therapeutic response.After treatment, mean values of clinical indicators decreased significantly (CRP: 62.68 ± 31.86 vs 43.55 ± 29.63 mg/L, P = .008; HBI: 7.18 ± 2.10 vs 5.73 ± 2.33, P = 0.012). Both DCE-MRI parameters showed prominent differences before and after treatment: K (1.86 ± 0.87 vs 1.39 ± 0.83 min, P = .017), BV (61.02 ± 28.49 vs 41.96 ± 22.75 mL/100 g, P = .005). There were significant correlations between ΔCRP or ΔHBI and percent change of CDE-MRI parameters (ΔK to ΔCRP: 0.659; ΔK to ΔHBI: 0.496; ΔBV to ΔCRP: 0.442; ΔBV to ΔHBI: 0.476). Compared to ΔK and ΔBV individually, the combination of both parameters performed best in assessment of therapeutic response with an area under the ROCs (AUC) of 0.948.K and BV parameters derived from DCE-MRI have the potential to assess for therapeutic response after FMT treatment for CD. The combination of K and BV measurements improved the predictive capability compared to the individual parameters.
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Affiliation(s)
| | - Faming Zhang
- Center of Intestinal Diseases, the Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Amil-Dias J, Kolacek S, Turner D, Pærregaard A, Rintala R, Afzal NA, Karolewska-Bochenek K, Bronsky J, Chong S, Fell J, Hojsak I, Hugot JP, Koletzko S, Kumar D, Lazowska-Przeorek I, Lillehei C, Lionetti P, Martin-de-Carpi J, Pakarinen M, Ruemmele FM, Shaoul R, Spray C, Staiano A, Sugarman I, Wilson DC, Winter H, Kolho KL. Surgical Management of Crohn Disease in Children: Guidelines From the Paediatric IBD Porto Group of ESPGHAN. J Pediatr Gastroenterol Nutr 2017; 64:818-835. [PMID: 28267075 DOI: 10.1097/mpg.0000000000001562] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The incidence of Crohn disease (CD) has been increasing and surgery needs to be contemplated in a substantial number of cases. The relevant advent of biological treatment has changed but not eliminated the need for surgery in many patients. Despite previous publications on the indications for surgery in CD, there was a need for a comprehensive review of existing evidence on the role of elective surgery and options in pediatric patients affected with CD. We present an expert opinion and critical review of the literature to provide evidence-based guidance to manage these patients. Indications, surgical options, risk factors, and medications in pre- and perioperative period are reviewed in the light of available evidence. Risks and benefits of surgical options are addressed. An algorithm is proposed for the management of postsurgery monitoring, timing for follow-up endoscopy, and treatment options.
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Affiliation(s)
- Jorge Amil-Dias
- *Department of Pediatrics, Centro Hospitalar, S. João, Porto, Portugal †Children's Hospital Zagreb, Faculty of Medicine, Zagreb, Croatia ‡The Juliet Keidan Institute of Pediatric Gastroenterology & Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel §Department of Pediatrics, Hvidovre University Hospital, Hvidovre, Denmark ||Pediatric Surgery, Children's Hospital, University of Helsinki, Helsinki, Finland ¶Department of Pediatric Gastroenterology, University Hospital Southampton, Southampton, UK #Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Warsaw, Poland **Department of Pediatrics, University Hospital Motol, Prague, Czech Republic ††Queen Mary's Hospital for Children, Epsom and St Helier NHS Trust, Surrey ‡‡Chelsea and Westminster Hospital, London, UK §§Paris-Diderot Sorbonne-Paris-Cité University and Robert Debré Hospital, Paris, France ||||Pediatric Gastroenterology and Hepatology, Dr. von Hauner Children's Hospital, Ludwig Maximilians-University, Munich, Germany ¶¶St George's, University of London, London, UK ##Boston Children's Hospital and Harvard Medical School, Boston, MA ***Department NEUROFARBA, University of Florence - Meyer Hospital, Florence, Italy †††Unit for the Comprehensive Care of Pediatric Inflammatory Bowel Disease, Hospital Sant Joan de Déu, Barcelona, Spain ‡‡‡Department of Pediatric Gastroenterology, Necker Enfants Malades University Hospital, Sorbonne Paris Cité University, Paris Descartes University, Institut IMAGINE - INSERM U1163, Paris, France §§§Pediatric Gastroenterology Institute, Ruth Children's Hospital, Rambam Medical Center, Haifa, Israel ||||||Department of Pediatric Gastroenterology, Bristol Royal Hospital for Children, Bristol, UK ¶¶¶Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II," Naples, Italy ###Department of Pediatric Surgery, Leeds Children's Hospital, Leeds General Infirmary, Leeds, UK ****Child Life and Health, University of Edinburgh, Scotland, UK ††††MassGeneral Hospital for Children, Harvard Medical School, Boston, MA ‡‡‡‡Children's Hospital, University of Helsinki, Helsinki, Finland
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Ferrari L, Krane MK, Fichera A. Inflammatory bowel disease surgery in the biologic era. World J Gastrointest Surg 2016; 8:363-370. [PMID: 27231514 PMCID: PMC4872064 DOI: 10.4240/wjgs.v8.i5.363] [Citation(s) in RCA: 39] [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] [Received: 09/29/2015] [Revised: 01/13/2016] [Accepted: 03/14/2016] [Indexed: 02/06/2023] Open
Abstract
Anti-tumour necrosis factor (TNF)-α therapy has revolutionized inflammatory bowel disease (IBD) treatment. Infliximab and adalimumab either as monotherapy or in combination with an immunomodulator are able to induce clinical and biological remission in patients with moderate and severe Crohn’s disease (CD) and ulcerative colitis (UC). These new therapies have led to a shift in the goals of IBD management from just controlling clinical symptoms to preventing disease progression. However, despite these advances in medical therapy, surgery is still required in 30%-40% of patients with CD and 20%-30% of patients with UC at some point during their lifetime. While biologics certainly play a major role in the medical treatment of IBD, there is concern about the effects of these anti-TNF-α agents on postoperative complications and morbidity. The purpose of this article is to review the role of surgery in the treatment of IBD in the age of biologics and the impact of these medications on per-operative outcomes. In this manuscript we review the relationship between biologic agents and surgery in the treatment of IBD. We also discuss in detail the periopetative risks and complications.
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Magnetic resonance imaging of perianal Crohn disease in children. Pediatr Radiol 2016; 46:838-46. [PMID: 27229501 DOI: 10.1007/s00247-016-3575-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 01/02/2016] [Accepted: 02/04/2016] [Indexed: 12/18/2022]
Abstract
Perianal penetrating complications of Crohn disease are among the most important causes of symptoms in the pediatric population. High-quality diagnostic imaging of the perianal region is crucial for treatment planning and therapeutic response assessment. MRI, with its absence of ionizing radiation and high soft-tissue resolution, provides an excellent noninvasive tool for evaluation of perianal fistulae and associated abscesses, as well as their anatomical relationship to the anal sphincter complex. In this review we discuss the role of MRI in initial diagnosis and follow-up of perianal fistulizing Crohn disease in the pediatric population.
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Abstract
To date, there have been many advances in inflammatory bowel disease (IBD) imaging in every cross-sectional imaging modality, particularly in children. The main emphasis in pediatric IBD imaging is on robust and reproducible measures of small bowel Crohn's disease inflammation, accurate diagnosis of IBD-related complications, and minimizing radiation burden to the patient, as repeat imaging is necessary over the course of their disease. In this article, we discuss the current state-of-the-art imaging techniques, in addition to routine fluoroscopy, including MR and CT enterography and bowel ultrasound. We also present the emerging use of new methods to characterize disease severity and distinguish active inflammation from fibrosis such as diffusion-weighted imaging, bowel elastography, and contrast-enhanced ultrasound. The diagnostic performance of particular examinations, their strengths and weaknesses, and role in IBD management will be discussed. Although these advanced imaging techniques applied to children are similar to those performed in adults, special considerations related to their application in pediatric patients will also be reviewed.
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Ognibene NMG, Basile M, Di Maurizio M, Petrillo G, De Filippi C. Features and perspectives of MR enterography for pediatric Crohn disease assessment. Radiol Med 2016; 121:362-77. [PMID: 26838591 DOI: 10.1007/s11547-015-0613-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/01/2015] [Indexed: 02/07/2023]
Abstract
The aim of this paper is to provide indications for performing magnetic resonance enterography (MRE) in Crohn's disease (CD), the essential technical elements of MRE techniques and typical findings in patients with CD. Patients suffering from CD frequently require cross-sectional imaging. By performing MRE, it is possible to obtain results comparable to those obtained with endoscopy in terms of identifying and assessing disease activity and better than other cross-sectional imaging techniques, such as CT, in the evaluation of the fibrosis and complications of disease. The MR imaging of diffusion MR is a technique which enables medical staff to add important additional information and which may replace the use of intravenous contrast agents in the near future. Magnetic resonance enterography is an accurate tool for assessing bowel disease and the various complications associated with CD. The lack of exposure to non-ionizing radiation is an important advantage of this imaging technique, especially in the case of pediatric patients. Familiarity with common and pathognomonic imaging features of CD is essential for every clinician involved in the treatment of inflammatory bowel disease and the care of patients.
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Affiliation(s)
- Noemi Maria Giovanna Ognibene
- Radiodiagnostic and Oncological Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Massimo Basile
- Pediatric Radiology, Meyer Children's University Hospital, Florence, Italy
| | - Marco Di Maurizio
- Pediatric Radiology, Meyer Children's University Hospital, Florence, Italy
| | - Giuseppe Petrillo
- Radiodiagnostic and Oncological Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Claudio De Filippi
- Pediatric Radiology, Meyer Children's University Hospital, Florence, Italy.
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Kilcoyne A, Kaplan JL, Gee MS. Inflammatory bowel disease imaging: Current practice and future directions. World J Gastroenterol 2016; 22:917-932. [PMID: 26811637 PMCID: PMC4716045 DOI: 10.3748/wjg.v22.i3.917] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 09/18/2015] [Accepted: 11/24/2015] [Indexed: 02/06/2023] Open
Abstract
The purpose of this paper is to evaluate the role of imaging in inflammatory bowel disease (IBD), including detection of extraluminal complications and extraintestinal manifestations of IBD, assessment of disease activity and treatment response, and discrimination of inflammatory from fibrotic strictures. IBD is a chronic idiopathic disease affecting the gastrointestinal tract that is comprised of two separate, but related intestinal disorders; Crohn’s disease and ulcerative colitis. The paper discusses, in detail the pros and cons of the different IBD imaging modalities that need to be considered in order to optimize the imaging and clinical evaluation of patients with IBD. Historically, IBD evaluation of the bowel has included imaging to assess the portions of the small bowel that are inaccessible to optical endoscopic visualization. This traditionally was performed using barium fluoroscopic techniques; however, cross-sectional imaging techniques (computed tomography and magnetic resonance imaging) are being increasingly utilized for IBD evaluation because they can simultaneously assess mural and extramural IBD manifestations. Recent advances in imaging technology, that continue to improve the ability of imaging to noninvasively follow disease activity and treatment response, are also discussed. This review article summarizes the current imaging approach in inflammatory bowel disease as well as the role of emerging imaging modalities.
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Abstract
Perianal fistula is a complication of Crohn's disease that carries a high morbidity. It is a channel that develops between the lower rectum, anal canal and perianal or perineal skin. The development of perianal fistulas typically connotes a more aggressive disease phenotype and may warrant escalation of treatment to prevent poor outcomes over time. Based on fistula anatomy, debris can form inside these tracts and cause occlusion, which subsequently leads to abscess formation, fever and malaise. The clinical presentation is often with complaints of pain, continuous rectal drainage of fecal matter as well as malodorous discharge. Considering that the presence of fistulas often indicates refractory and aggressive disease, early identification of its presence is important. Some patients may not have the classic symptoms of fistulizing disease at presentation and others may have significant scarring and/or pain from previous fistulizing episodes, which can make an accurate assessment on physical exam alone problematic. As a result, utilizing diagnostic imaging is the best means of identifying the early signs of perianal fistulas or abscess formation in these patients. Several imaging modalities exist which can be used for diagnosis and management. Endoscopic ultrasound and pelvic MRI are considered the most useful in establishing the diagnosis. However, a combination of multiple imaging modalities and/or examination under anesthesia is probably the most ideal. Incomplete characterization of the fistula tract(s) extent or the presence of abscess carries a high morbidity and far-reaching personal expense for the patient - promoting worsening of the disease.
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Affiliation(s)
- Vivian N Chidi
- Division of Gastroentorology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
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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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Gecse KB, Bemelman W, Kamm MA, Stoker J, Khanna R, Ng SC, Panés J, van Assche G, Liu Z, Hart A, Levesque BG, D'Haens G. A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease. Gut 2014; 63:1381-92. [PMID: 24951257 DOI: 10.1136/gutjnl-2013-306709] [Citation(s) in RCA: 248] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To develop a consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease (pCD), based on best available evidence. METHODS Based on a systematic literature review, statements were formed, discussed and approved in multiple rounds by the 20 working group participants. Consensus was defined as at least 80% agreement among voters. Evidence was assessed using the modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. RESULTS Highest diagnostic accuracy can only be established if a combination of modalities is used. Drainage of sepsis is always first line therapy before initiating immunosuppressive treatment. Mucosal healing is the goal in the presence of proctitis. Whereas antibiotics and thiopurines have a role as adjunctive treatments in pCD, anti-tumour necrosis factor (anti-TNF) is the current gold standard. The efficacy of infliximab is best documented although adalimumab and certolizumab pegol are moderately effective. Oral tacrolimus could be used in patients failing anti-TNF therapy. Definite surgical repair is only of consideration in the absence of luminal inflammation. CONCLUSIONS Based on a multidisciplinary approach, items relevant for fistula management were identified and algorithms on diagnosis and treatment of pCD were developed.
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Affiliation(s)
- Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Robarts Research Institute, Amsterdam, The Netherlands
| | - Willem Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael A Kamm
- St. Vincent's Hospital and University of Melbourne, Melbourne, Australia
| | - Jaap Stoker
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Reena Khanna
- Robarts Research Institute, London, Ontario, Canada University of Western Ontario, London, Ontario, Canada
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Julián Panés
- Department of Gastroenterology, Hospital Clinic Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Gert van Assche
- Department of Gastroenterology, University of Leuven, Leuven, Belgium
| | - Zhanju Liu
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Ailsa Hart
- APRG, Imperial College, London, UK IBD Unit, St. Mark's Hospital, London, UK
| | - Barrett G Levesque
- Robarts Research Institute, San Diego, CA, USA Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Robarts Research Institute, Amsterdam, The Netherlands
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