Detection of ileocecal Crohn's disease using ultrasound as the primary imaging modality

Advances in the treatment of inflammatory bowel disease: Focus on polysaccharide nanoparticulate drug delivery systems

The complex pathogenesis of inflammatory bowel disease (IBD) explains the several hurdles for finding an efficient approach to cure it. Nowadays, therapeutic protocols aim to reduce inflammation during the hot phase or maintain remission during the cold phase. Nonetheless, these drugs suffer from severe side effects or poor efficacy due to low bioavailability in the inflamed region of the intestinal tract. New protocols based on antibodies that target proinflammatory cytokines are clinically relevant. However, besides being expensive, their use is associated with a primary nonresponse or a loss of response following a long administration period. Accordingly, many researchers exploited the physiological changes of the mucosal barrier for designing nanoparticulate drug delivery systems to target inflamed tissues. Others exploited biocompatibility and relative affordability of polysaccharides to test their intrinsic anti-inflammatory and healing properties in IBD models. This critical review updates state of the art on advances in IBD treatment. Data on using polysaccharide nanoparticulate drug delivery systems for IBD treatment are reviewed and discussed.

Clinical utility of small bowel ultrasound assessment of Crohn's disease in adults: a systematic scoping review

BACKGROUND

Ultrasound (US) is an alternative to magnetic resonance enterography, and has the potential to significantly reduce waiting times, expedite clinical decision-making and improve patient experience. Point of care US is an advantage of the US imaging modality, where same day scanning, interpretation and treatment decisions can be made.

AIM

To systematically scope the literature on point of care US use in small bowel Crohn's disease, generating a comprehensive list of factors relating to the current understanding of clinical utility of this imaging modality.

METHODS

Searches included MEDLINE, EMBASE, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, clinicaltrial.gov,'TRIP' and Epistemonikos. Reference lists of included studies were hand searched. Search terms were searched for as both keywords and subject headings (MeSH) as appropriate. Searches were performed with the 'suggested search terms' and 'explode' selection, and restricted to 'human', 'adult' and 'English language' publications. No date limits were applied to be as inclusive as possible. Two investigators conducted abstract and full-text review. No formal quality appraisal process was undertaken; however, quality of sources was considered when reporting findings. A narrative synthesis was conducted.

RESULTS

The review included 42 sources from the UK, Europe, Japan, Canada and the USA. Small bowel ultrasound (SBUS) has been shown to be as accurate in detecting the presence of small bowel Crohn's disease, is quicker, safer and more acceptable to patients, compared with magnetic resonance enterography. SBUS is used widely in central Europe and Canada but has not been embraced in the UK. Further research considering economic evaluation, clinical decision-making and exploration of perceived barriers to future implementation of SBUSs is required.

Use of Small Bowel Ultrasound to Predict Response to Infliximab Induction in Pediatric Crohn's Disease

GOAL

The goal of this study was to explore the utility of small bowel ultrasound (SBUS) as a noninvasive tool to assess induction response to infliximab (IFX) in pediatric Crohn's disease (CD).

BACKGROUND

Inflammatory bowel disease management has shifted to a treat-to-target and tight control strategy utilizing noninvasive serum and fecal markers to monitor disease activity in response to therapy. Bowel wall changes as seen on cross-sectional imaging may be a more accurate marker of treatment success.

MATERIALS AND METHODS

Pediatric patients with CD with small bowel involvement initiating IFX were prospectively enrolled. Clinical activity, biomarkers, and SBUS findings were evaluated at baseline (T0) and postinduction at week 14 (T1). The primary outcome was to describe the changes in SBUS parameters pre and post IFX induction and how they associate with clinical and biomarker response. Descriptive statistics summarized the data and univariate analysis tested associations.

RESULTS

All 13 CD patients achieved steroid-free clinical remission (P<0.001) and a decrease in C-reactive protein (P=0.01) postinduction. Bowel wall hyperemia (BWH) (P=0.01) and bowel segment length involved (P=0.07) decreased postinduction. Decrease in fecal calprotectin at T1 moderately correlated with a decrease in bowel segment length (r=0.57; P=0.04). No correlation was seen with a change in bowel wall thickness or BWH postinduction.

CONCLUSIONS

Our pilot study suggests that SBUS is a feasible, noninvasive tool to measure early treatment response to IFX. BWH, not bowel wall thickness, is the first parameter to change. Larger longitudinal studies are warranted to validate the utility of SBUS as part of a disease monitoring strategy.

The establishment of a regression model from four modes of ultrasound to predict the activity of Crohn's disease

To establish a multi-parametric regression model from four modes of ultrasound to predict the activity of Crohn's disease (CD) noninvasively. Score of 150 of the Crohn’s Disease Activity Index (CDAI) was taken as the cut-off value to divide the involved bowel segments of 51 patients into the active and inactive group. Eleven parameters from four modes of ultrasound (B-mode ultrasonography, color Doppler flow imaging, contrast-enhanced ultrasonography and shear wave elastography) were compared between the two groups to investigate the relationship between multimodal ultrasonic features and CD activity. P < 0.05 was considered statistically significant. Parameters with AUC larger than 0.5 was selected to establish the prediction model of CDAI. Totally seven ultrasound parameters (bowel wall thickness, mesenteric fat thickness, peristalsis, texture of enhancement, Limberg grade, bowel wall perforation and bowel wall stratification) were significantly different between active and inactive group. A regression model was established based on the seven parameters as followed: CDAI = 211.325 + 3.186BWT − 53.003BWS + 6.280BWP + 0.392MFT + 22.239PS + 79.012LG + 72.793TE. (R² = 0.72, P = 0.037). The multimodal ultrasound parametric regression model was designed to predict CDAI score invasively. The model has the potential to provide an alternative method for quantifying the CD activity.

Accuracy of point-of-care intestinal ultrasound for Crohn's disease

Background

Point-of-care ultrasound (POCUS), performed by a gastroenterologist, provides safe and convenient imaging allowing for immediate clinical decision in Crohn's disease. The minimum training required to gain competency, its accuracy and clinical utility requires evaluation.

Methods

In this pilot study, Crohn's disease activity and extent were assessed using POCUS (performed by a single gastroenterologist following the completion of 200 supervised scans), magnetic resonance enterography (MRE) and ileo-colonoscopy. The presence of complications was assessed by POCUS and MRE. Accuracy of POCUS was analysed with respect to MRE and ileo-colonoscopy. Agreement between modalities was assessed using kappa coefficient.

Results

Forty-two patients had a POCUS paired with MRE. Thirty-eight patients had a POCUS paired with ileo-colonoscopy. When compared to MRE, POCUS was accurate in the assessment of disease activity (sensitivity 87.5%, specificity 61.1%, ROC 0.74), extent (sensitivity 77.8%, specificity 83.3%, ROC 0.81) and complications (sensitivity 85.7%, specificity 94.3%, ROC 0.90). Agreement between POCUS and MRE was moderate (kappa estimates 0.50, P < 0.001, 0.61, P < 0.001 and 0.76, P < 0.001) for disease activity, extent and complications, respectively. When compared to ileo-colonoscopy, POCUS was accurate in the assessment of disease activity (sensitivity 72%, specificity 86%, ROC 0.79) and extent (sensitivity 85.7%, specificity 86%, ROC 0.86). For POCUS and ileo-colonoscopy, kappa estimates were 0.55, P < 0.001 for disease activity and 0.62, P < 0.001 for disease extent.

Conclusion

POCUS performed by a gastroenterologist after completion of limited training is accurate for assessing Crohn's disease activity, extent and the presence of complications.

Defining the ultrasound longitudinal natural history of newly diagnosed pediatric small bowel Crohn disease treated with infliximab and infliximab-azathioprine combination therapy

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.

Particularities of Crohn's disease in pediatric patients: current status and perspectives regarding imaging modalities

A consensus on the best imaging modality evaluating inflammatory bowel disease in the pediatric population is lacking and it is often unclear which modality to choose in specific clinical circumstances. Children with inflammatory bowel disease are exposed to ionizing radiation from multiple imaging studies performed at initial diagnosis, throughout treatment and during the follow-up period. This paper discusses the value of different imaging techniques in pediatric patients with inflammatory bowel disease and gives a review of the literature. In addition, particular features of inflammatory bowel disease in children including the predilection of affected segments in the gastrointestinal tract are highlighted. Based on current literature knowledge, we encourage an integrative approach to the interpretation of clinical and imaging data for diagnosis and follow-up in daily clinical settings.

Point of Care Ultrasound Accurately Distinguishes Inflammatory from Noninflammatory Disease in Patients Presenting with Abdominal Pain and Diarrhea

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.

Prospective cohort study of ultrasound-ultrasound and ultrasound-MR enterography agreement in the evaluation of pediatric small bowel Crohn disease

BACKGROUND

There is a paucity of published literature describing ultrasound (US)-US and US-MR enterography (MRE) inter-radiologist agreement in pediatric small bowel Crohn disease.

OBJECTIVE

To prospectively assess US-US and US-MRE inter-radiologist agreement in pediatric small bowel Crohn disease.

MATERIALS AND METHODS

Institutional Review Board approval and informed consent/assent were obtained for this HIPAA-compliant prospective cohort study of children with newly diagnosed distal small bowel Crohn disease (July 2012 to December 2014). Enrolled subjects (n = 29) underwent two small bowel US examinations performed by blinded independent radiologists both before and at multiple time points after initiation of medical therapy (231 unique US examinations, in total); 134 US examinations were associated with concurrent MRE. The MRE examination was interpreted by a third blinded radiologist. The following was documented on each examination: involved length of ileum (cm); maximum bowel wall thickness (mm); amount of bowel wall and mesenteric Doppler signal, and presence of stricture, penetrating disease and/or abscess. Inter-radiologist agreement was assessed with single-measure, three-way, mixed-model intra-class correlation coefficients (ICC) and prevalence-adjusted, bias-adjusted kappa statistics (κ). Numbers in brackets are 95% confidence intervals.

RESULTS

Ultrasound-US agreement was moderate for involved length (ICC: 0.41 [0.35-0.49]); substantial for maximum bowel wall thickness (ICC: 0.67 [0.64-0.70]); moderate for bowel wall Doppler signal (ICC: 0.53 [0.48-0.59]); slight for mesenteric Doppler signal (ICC: 0.25 [0.18-0.42]), and moderate to almost perfect for stricture (κ: 0.54), penetrating disease (κ: 0.80), and abscess (κ: 0.96). US-MRE agreement was moderate for involved length (ICC: 0.42 [0.37-0.49]); substantial for maximum bowel wall thickness (ICC: 0.66 [0.65-0.69]), and substantial to almost perfect for stricture (κ: 0.61), penetrating disease (κ: 0.72) and abscess (κ: 0.88).

CONCLUSION

Ultrasound-US agreement was similar to US-MRE agreement for assessing pediatric small bowel Crohn disease. Discrepancies in US-US and US-MRE reporting question the utility of US as an accurate, reproducible radiologic biomarker for assessing response to medical therapy and disease-related complications.

Monitoring disease activity and progression in Crohn's disease. A Swiss perspective on the IBD ahead 'optimised monitoring' recommendations

BACKGROUND AND AIMS

The structured IBD Ahead 'Optimised Monitoring' programme was designed to obtain the opinion, insight and advice of gastroenterologists on optimising the monitoring of Crohn's disease activity in four settings: (1) assessment at diagnosis, (2) monitoring in symptomatic patients, (3) monitoring in asymptomatic patients, and (4) the postoperative follow-up. For each of these settings, four monitoring methods were discussed: (a) symptom assessment, (b) endoscopy, (c) laboratory markers, and (d) imaging. Based on literature search and expert opinion compiled during an international consensus meeting, recommendations were given to answer the question 'which diagnostic method, when, and how often'. The International IBD Ahead Expert Panel advised to tailor this guidance to the healthcare system and the special prerequisites of each country. The IBD Ahead Swiss National Steering Committee proposes best-practice recommendations adapted for Switzerland.

METHODS

The IBD Ahead Steering Committee identified key questions and provided the Swiss Expert Panel with a structured literature research. The expert panel agreed on a set of statements. During an international expert meeting the consolidated outcome of the national meetings was merged into final statements agreed by the participating International and National Steering Committee members - the IBD Ahead 'Optimized Monitoring' Consensus.

RESULTS

A systematic assessment of symptoms, endoscopy findings, and laboratory markers with special emphasis on faecal calprotectin is deemed necessary even in symptom-free patients. The choice of recommended imaging methods is adapted to the specific situation in Switzerland and highlights the importance of ultrasonography and magnetic resonance imaging besides endoscopy.

CONCLUSION

The recommendations stress the importance of monitoring disease activity on a regular basis and by objective parameters, such as faecal calprotectin and endoscopy with detailed documentation of findings. Physicians should not rely on symptoms only and adapt the monitoring schedule and choice of options to individual situations.

Ultrasonographic imaging of inflammatory bowel disease in pediatric patients

Inflammatory bowel disease (IBD) is one of the most common chronic gastrointestinal diseases in pediatric patients. Choosing the optimal imaging modality for the assessment of gastrointestinal disease in pediatric patients can be challenging. The invasiveness and patient acceptance, the radiation exposure and the quality performance of the diagnostic test need to be considered. By reviewing the literature regarding imaging in inflammatory bowel disease the value of ultrasound in the clinical management of pediatric patients is highlighted. Transabdominal ultrasound is a useful, noninvasive method for the initial diagnosis of IBD in children; it also provides guidance for therapeutic decisions and helps to characterize and predict the course of the disease in individual patients. Ultrasound techniques including color Doppler imaging and contrast-enhanced ultrasound are promising imaging tools to determine disease activity and complications. Comparative studies between different imaging methods are needed.

Contrast-enhanced ultrasonography (CEUS) vs. MRI of the small bowel in the evaluation of Crohn's disease activity

PURPOSE

The presence of disease activity in Crohn's disease (CD) is one of the main parameters used to establish whether optimal therapy should be drug therapy or surgery. However, a major problem in monitoring CD is the common mismatch between the patient's symptoms and imaging objective signs of disease activity. Bowel ultrasonography (US) has emerged as a low-cost, noninvasive technique in the diagnosis and follow-up of patients with CD. Accordingly, the use of contrast-enhanced US (CEUS) has made possible an evaluation of the vascular enhancement pattern, similar to the use of magnetic resonance imaging (MRI). The aim of our study was to evaluate the role of CEUS in comparison with small-bowel MRI for assessing Crohn's disease activity.

MATERIALS AND METHODS

We prospectively enrolled 30 consecutive patients with known CD. Clinical and laboratory data were compared with imaging findings obtained from MRI and CEUS of the small bowel. MRI was performed with a 1.5-T system using phased-array coils and biphasic orally administered contrast agent prior to and after gadolinium chelate administration. We performed US with a 7.5-MHz linear-array probe and a second-generation contrast agent. The parameters analysed in both techniques were the following: lesion length, wall thickness, layered wall appearance, comb sign, fibroadipose proliferation, presence of enlarged lymph nodes and stenosis. We classified parietal enhancement curves into two types in relation to the contrast pattern obtained with the time-intensity curves at MRI and CEUS: (1) quick washin, quick washout, (2) slow washin, plateau with a slow washout.

RESULTS

Comparison between Crohn's disease activity index (CDAI) and MRI showed a low correlation, with an rho=0.398; correlation between CDAI-laboratory data and CEUS activity was low, with rho=0.354; correlation between MRI activity and CEUS activity was good, with rho = 0.791; high correlation was found between CEUS and MRI of the small bowel when assessing wall-thickness, lymph nodes and comb sign; good correlation was fund when assessing layered wall appearance, disease extension and fibroadipose proliferation. At MRI, time-intensity curves for 12/30 patients were active, compared with for 14/30 patients at CEUS; therefore there was a poor correlation between curve on CEUS and curve on MRI (r=0.167; p=0.36).

CONCLUSIONS

The use of CEUS can be recommended if there is a discrepancy between MRI and clinical/laboratory parameters. MRI of the small bowel remains the most accurate method for evaluating disease activity.

Crohn's disease imaging: a review

Crohn's disease is a chronic granulomatous inflammatory disease of the gastrointestinal tract, which can involve almost any segment from the mouth to the anus. Typically, Crohn's lesions attain segmental and asynchronous distribution with varying levels of seriousness, although the sites most frequently involved are the terminal ileum and the proximal colon. A single gold standard for the diagnosis of CD is not available and the diagnosis of CD is confirmed by clinical evaluation and a combination of endoscopic, histological, radiological, and/or biochemical investigations. In recent years, many studies have been performed to investigate the diagnostic potential of less invasive and more patient-friendly imaging modalities in the evaluation of Crohn's disease including conventional enteroclysis, ultrasonography, color-power Doppler, contrast-enhanced ultrasonography, multidetector CT enteroclysis, MRI enteroclysis, and 99mTc-HMPAO-labeled leukocyte scintigraphy. The potential diagnostic role of each imaging modality has to be considered in different clinical degrees of the disease, because there is no single imaging technique that allows a correct diagnosis and may be performed with similar results in every institution. The aim of this paper is to point out the advantages and limitations of the various imaging techniques in patients with suspected or proven Crohn's disease.

Inflammatory bowel disease: value in diagnosis and management of MDCT-enteroclysis and 99mTc-HMPAO labeled leukocyte scintigraphy

OBJECTIVES

The aims of this study are: (a) to evaluate the reliability of Multidetector Computed Tomography Enteroclysis (MDCT-E) and (99m)Tc-HMPAO labeled leukocyte scintigraphy (TLLS), in inflammatory bowel disease, (b) to test the accuracy of the two techniques with regard to their histological results, (c) to define how each technique can influence the natural course of inflammatory bowel disease (IBD), (d) to assess the potential value of the two techniques combined.

MATERIALS AND METHODS

Thirty-seven patients with suspected IBD underwent MDCT-E and TLLS. We made a separate assessment of the results shown by the two methods and then compared and contrasted the histological results of the two. The latter, however, were either disappointing or not available in 15 patients who, for this reason, had to be dismissed from the study. As result, the number of participants eventually dropped to 22 subjects: 12 women, 10 men with an average age of 44 years.

RESULTS

MDCT-E and TLLS were successful in all patients. Sensitivity, specificity, and efficiency values have been reported as follows: MDCT-E: 62%, 100%, 64%,100%, 11%, respectively. TLLS: 90%, 100%, 91%, 100%, 33%, respectively. The two methods combined: 95%, 100%, 95%, 100%, 50%, respectively.

CONCLUSIONS

The two techniques can be employed in different stages of the natural course of the disease. In our experience, TLLS proved itself to be useful in the diagnosis of the disease and the assessment of its development. Conversely, MDCT-E proved itself to be more reliable in identifying the seat and the extent of the disease inside and outside the bowel wall as well as potential intra-peritoneal and extra-intestinal complications. The combined use of the two methods represents the Criterion Standard for diagnosing IBD with imaging.

Faecal chitinase 3-like-1: a novel biomarker of disease activity in paediatric inflammatory bowel disease

BACKGROUND

Chitinase 3-like-1 (CHI3L1) is up-regulated in the inflamed mucosa of inflammatory bowel disease (IBD).

AIM

To evaluate the usefulness of a faecal CHI3L1 assay, as a reliable marker for predicting the severity of paediatric IBD.

METHODS

Faecal samples were obtained from ulcerative colitis (UC, n = 94), Crohn's disease (CD, n = 87), and healthy individuals (n = 56). The faecal CHI3L1 and calprotectin levels were determined by ELISA. For endoscopic evaluation, the sum of the Matts' score for UC and the simple endoscopic score for CD (SES-CD) were used. Ileal lesions were evaluated by ultrasonography.

RESULTS

Faecal CHI3L1 levels were significantly elevated in active UC (median 366.6 ng/g, n = 44) and active CD (median 632.7 ng/g, n = 48) patients, as compared with healthy individuals (median 2.2 ng/g, n = 56). In UC patients, the faecal CHI3L1 levels were positively correlated with the sum of the Matts' score (r = 0.73, P < 0.01, n = 42). In CD patients, there was a significant correlation between faecal CHI3L1 levels and endoscopic activity as determined by the SES-CD scoring system (r = 0.61, P < 0.01, n = 25). The faecal CHI3L1 levels of patients with wall thickening of their small intestine were significantly higher than those of healthy controls or patients without wall thickening. The cutoff value of 13.7 ng/g for fecal CHI3L1(the 95th percentile of the control value) predicted active lesions in IBD patients with a sensitivity of 84.7% and a specificity of 88.9%.

CONCLUSION

Faecal CHI3L1 assays may be useful for predicting the severity and activity of mucosal inflammation in IBD.

Fecal calprotectin is a useful marker for disease activity in pediatric patients with inflammatory bowel disease

BACKGROUND

Studies evaluating the correlation between endoscopic disease activity and noninvasive markers are scarce in inflammatory bowel disease (IBD).

AIM

The aim of this study is to evaluate the accuracy of the fecal calprotectin (FC) assay as a marker of disease activity of IBD, as determined by an extensive endoscopic scoring system.

METHODS

Thirty-five children and adolescents with IBD [17 with ulcerative colitis (UC) and 18 with Crohn's disease (CD)] and 28 healthy volunteers were enrolled. FC levels were determined by ELISA. The sum of Matts' score for UC and the simple endoscopic score for Crohn's disease (SES-CD) were used. The ileal lesions were evaluated by ultrasonography.

RESULTS

In UC patients, there was a strong correlation between FC levels and the sum of Matts' score (r=0.838, p<0.01). FC levels were significantly elevated in endoscopically active patients (median 1,562.5 μg/g) as compared to patients in endoscopic remission (median 38.9 μg/g) or healthy controls (median 19.9 μg/g). In CD patients, there was a strong correlation between FC levels and the SES-CD score (r=0.760, p<0.01). The FC levels were significantly higher in endoscopically active patients (median 2,037.5 μg/g) than in endoscopically inactive patients (median 172.5 μg/g) or healthy controls (median 19.9 μg/g), respectively. The FC levels of patients with ileal wall thickening (median 2,225.0 μg/g) were significantly higher than healthy controls (median 19.9 μg/g) and patients lacking ileal wall thickening (median 17.5 μg/g), respectively.

CONCLUSIONS

The FC assay is a useful marker for the detection of mucosal inflammation in pediatric IBD patients.

Ultrasound and inflammatory bowel disease

Transabdominal bowel sonography is a fast, efficient, and cheap way of examining the intestines. It is also virtually hazard-free and well accepted by patients. During the last 20 years, it has been established as a procedure for detecting bowel disease early in the diagnostic workup. Although rather unspecific, the method is sensitive for detection of bowel disease and can be applied to find the extent and location of inflammatory bowel disease. In patients with known ulcerative colitis and Crohn disease, it can also be used for follow-up because it is easily repeatable and radiation-free. Because it can be applied to find both intraluminal and peri-intestinal pathological features, it is a particularly valuable tool for the detection of complications of Crohn disease as stenosis, fistulas, and abscesses. Neither B-mode nor Doppler techniques have been proven obviously useful in categorizing disease activity, but new techniques using intravenous contrast might come closer to solving this question. Finally, recent longitudinal studies using transabdominal bowel sonography show that it can also give important prognostic information and be used for monitoring the effect of therapy.

Bowel ultrasound in Crohn's disease: surgical perspective

BACKGROUND

Bowel ultrasound has been proven to be a useful tool in the management of Crohn's disease, particularly in the assessment of intra-abdominal complications, most of which require surgery.

MATERIALS AND METHODS

The National Library of Medicine has been searched for articles on the use of bowel ultrasound in Crohn's disease focusing on aspects of interest to the surgeon.

RESULTS AND CONCLUSIONS

Several studies have demonstrated that bowel ultrasound may be useful to reduce the risk of unnecessary laparotomy in patients presenting acute abdomen with suspected chronic inflammatory bowel disease. Bowel ultrasound has been proven to be of value in the follow-up of Crohn's disease patients since allowing early diagnosis of intra-abdominal complications and, therefore, optimising the diagnostic and surgical approach. At followup, bowel ultrasound may accurately diagnose early postoperative complications and long-term disease recurrence. In patients submitted to conservative surgery, ultrasonography reveals changes in diseased bowel walls that may be predictive of recurrence of the disease, and hence determinant in the choice of medical treatment.

Colonic diseases: the value of US examination

The colon is affected by a number of diseases, mainly inflammatory, ischemic, and neoplastic conditions. Depending upon clinical indications endoscopy, US, CT, or other radiological methods are used for evaluation. The fact that US is frequently used as the initial imaging method in patients with non-specific clinical symptoms allows for greater influence in further diagnostic evaluation and with treatment, provided the investigator is familiar with the features of different intestinal diseases. This article will describe the anatomical characteristics of the colon, the US technique for examination of the colon, and the typical US features of the more common diagnoses of the colon.

[Significance of ultrasonography of the terminal ileum in moderate Crohn's disease]

BACKGROUND/AIM

Crohn's disease (CD) is a chronic granulomatous inflammatory disease of unknown etiology, involving any part of the gastrointestinal tract, and frequently followed by extraintestinal manifestations. The use of ultrasonography plays a significant role in diagnosing this disease, as well as in monitoring the effects of the therapy. The aim of this study was to assess the use of ultrasonographic diagnostics in the patients with moderate serious and the mild form of CD.

METHODS

The study involved 30 patients both sexes with CD of moderate form determined using the standard diagnostics, according to the Crohn's Disease Activity Index--CDAI ranging from 220-400. The patients were divided into two groups with CDAI > 320 (Ia), and CDAI between 220 and 320 (Ib), respectively. The Control group was made of 19 patients with the mildly active stage of the disease and the CDAI values in the range from 100-220. The patients were submitted to an ultrasonographic examination of the terminal ileum affected with CD in order to determine the length of the affected segment of intestine, the thickness of the wall, the changes of the structure of the wall, the changes of the surrounding mesenterium with the enlarged lymph nodes. CD complications, abscesses, and enteroenteral fistulas were investigated, too.

RESULTS

The comparison of the ultrasonographic findings of the three groups revealed that more serious clinical-laboratory image of CD significantly correlated with the higher length of the affected segment (p < 0.001), higher thickness of the wall (p < 0.001), the higher number and the larger lymph nodes of the mesenterium (p < 0.001). Only the most serious patients were found to have abscess of the ileocecal area (Ia - 40%). There was no difference found between the groups regarding the occurrence of enteroenteral fistulas.

CONCLUSION

Considering the obtained results and data from the literature, it could be concluded that an ultrasonographic examination of the ileocecal area plays an important role in the diagnostic procedure in the management of a patient with CD. Of particular significance is the possibility to use this examination in monitoring the effects of the therapy in patients with CD.

Evaluating bowel wall vascularity in Crohn’s disease: a comparison of dynamic MRI and wideband harmonic imaging contrast-enhanced low MI ultrasound

This was a prospective comparison of dynamic MRI (1.5 T) and echo-signal enhanced ultrasound in evaluating vascularization in thickened bowel walls cases of Crohn's disease. Twenty-one patients with histologically confirmed Crohn's disease and bowel wall diameters >5 mm were examined by MRI and ultrasound (US). MR sequences: T1w fl2D, T2w, FLASH T1w post-contrast media (CM) applications with fat saturation were used. Dynamic Turbo-FLASH T1w sequences were acquired in the area of maximal thickening of the ileal wall every 1.5 s post-CM application for a total duration of 1 min. US was performed after the application of 1.2 ml of echo-signal enhancer. Contrast uptake was measured by the semiquantitative score and brightness analysis in regions of interest (ROI). Clinical and laboratory findings including Crohn's disease activity indices were documented; MRI and US parameters were correlated. The length of sonographically documented lesions (122+/-75 mm) correlated significantly with the length of thickened bowel segments in MRI (128+/-76 mm; r=0.466; P=0.033). The maximum percent signal enhancement in the terminal ileum at ultrasound (217.5+/-100.1%) showed a high correlation with the findings of MRI (262+/-108%; r=0.623; P=0.003). With both methods, a plateau phase was observed. US and MRI are capable of evaluating local vascularization in the bowel wall objectively.

Mimics of Appendicitis: Alternative Nonsurgical Diagnoses with Sonography and CT

OBJECTIVE

Our objective was to illustrate the imaging features of alternative nonsurgical disorders in patients presenting with clinical signs of appendicitis.

CONCLUSION

This article illustrates the sonographic and CT features of various appendicitis-mimicking conditions that are self-limiting or that can be treated conservatively. A correct imaging diagnosis of these disorders may prevent a nontherapeutic appendectomy and unnecessary hospitalization.