Considerations in Imaging Among Emergency Department Patients With Inflammatory Bowel Disease

Persistently High Rates of Abdominal Computed Tomography Imaging Among Patients With Inflammatory Bowel Disease Who Present to the Emergency Department

Background

Recent guidelines recommended judicious use of abdominal computed tomography (CT) in the emergency department (ED) for inflammatory bowel disease. Trends in CT utilization over the last decade, including since the implementation of these guidelines, remain unknown.

Methods

We performed a single-centre, retrospective study between 2009 and 2018 to assess trends in CT utilization within 72 h of an ED encounter. Changes in the annual rates of CT imaging among adults with IBD were estimated by Poisson regression and CT findings by Cochran-Armitage or Cochran-Mantel Haenszel tests.

Results

A total of 3000 abdominal CT studies were performed among 14,783 ED encounters. CT utilization increased annually by 2.7% in Crohn’s disease (CD) (95% confidence interval [CI], 1.2 to 4.3; P = 0.0004), 4.2% in ulcerative colitis (UC) (95% CI, 1.7 to 6.7; P = 0.0009) and 6.3% in IBD unclassifiable (95% CI, 2.5 to 10.0; P = 0.0011). Among encounters with gastrointestinal symptoms, 60% with CD and 33% with UC underwent CT imaging in the final year of the study. Urgent CT findings (obstruction, phlegmon, abscess or perforation) and urgent penetrating findings alone (phlegmon, abscess or perforation) comprised 34% and 11% of CD findings, and 25% and 6% of UC findings, respectively. The CT findings remained stable overtime for both CD (P = 0.13) and UC (P = 0.17).

Conclusion

Our study demonstrated persistently high rates of CT utilization among patients with IBD who presented to the ED over the last decade. Approximately one third of scans demonstrated urgent findings, with a minority demonstrating urgent penetrating findings. Future studies should aim to identify patients in whom CT imaging is most appropriate.

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

BACKGROUND

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

GOAL

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk Factors for and Frequency of CT Scans, Steroid Use, and Repeat Visits in Inflammatory Bowel Disease Patients Seen at a Single-Center Emergency Department: A Retrospective Cohort Study

Patients with inflammatory bowel disease often present to the emergency department due to the chronic relapsing nature of the disease. Previous studies have shown younger patients to have an increased frequency of emergency department visits, resulting in repeated exposure to imaging studies and steroids, both of which are associated with risks. We performed a retrospective cohort analysis of inflammatory bowel disease patients seen at Houston Methodist Hospital’s emergency department from January 2014 to December 2017 using ICD codes to identify patients with Crohn’s disease, ulcerative colitis, or indeterminate colitis from the electronic medical record. Data were collected on demographics, medications, and imaging. Five hundred and fifty-nine patients were randomly selected for inclusion. Older age was associated with decreased risk of CT scan or steroid use. Patients with ulcerative colitis compared to Crohn’s had decreased risk of CT scan, while there was an increased risk of CT in patients on a biologic, immunomodulator, or when steroids were given. Steroid use was also more common in those with inflammatory bowel disease as the primary reason for the visit. Patients in our study frequently received steroids and had CT scans performed. The increased risk of CT in those on a biologic, immunomodulator, or steroids suggests more severe disease may contribute. Guidelines are needed to reduce any unnecessary corticosteroid use and limit repeat CT scans in young inflammatory bowel disease patients to decrease the risk of radiation-associated malignancy over their lifetime.

Optotheranostic Nanosystem with Phone Visual Diagnosis and Optogenetic Microbial Therapy for Ulcerative Colitis At-Home Care

Ulcerative colitis (UC) is a relapsing disorder characterized by chronic inflammation of the intestinal tract. However, the home care of UC based on remote monitoring, due to the operational complexity and time-consuming procedure, restrain its widespread applications. Here we constructed an optotheranostic nanosystem for self-diagnosis and long-acting mitigations of UC at home. The system included two major modules: (i) A disease prescreening module mediated by smartphone optical sensing. (ii) Disease real-time intervention module mediated by an optogenetic engineered bacteria system. Recombinant Escherichia coli Nissle 1917 (EcN) secreted interleukin-10 (IL-10) could downregulate inflammatory cascades and matrix metalloproteinases; it is a candidate for use in the therapeutic intervention of UC. The results showed that the Detector was able to analyze, report, and share the detection results in less than 1 min, and the limit of detection was 15 ng·mL^-1. Besides, the IL-10-secreting EcN treatment suppressed the intestinal inflammatory response in UC mice and protected the intestinal mucosa against injury. The optotheranostic nanosystems enabled solutions to diagnose and treat disease at home, which promotes a mobile health service development.

Point-of-Care Ultrasound Diagnosis of a Crohn's Disease-Related Intraabdominal Abscess in the Emergency Department

The emergency department (ED) diagnosis of Crohn’s disease (CD)-associated complications is typically established with abdominopelvic computed tomography imaging. Ultrasonography has been suggested as an effective alternative modality for diagnosing several CD complications, including intraabdominal abscesses. We report the identification of a CD-related intraabdominal abscess by emergency physician (EP)-performed point-of-care ultrasound (POCUS). This case highlights the feasibility of EPs integrating POCUS into the clinical decision-making for patients with inflammatory bowel disease in the ED.

Sonographic assessment of inflammatory bowel disease in the emergency department: A case series and review of the literature

The use of sonography for diagnosing inflammatory bowel disease (IBD) has been reported in the radiology literature but is not common practice in the hands of emergency physicians (EPs). We present a series of three cases where IBD was managed by an EP using point-of-care ultrasonography (POCUS), and discuss the sonographic features of IBD including bowel wall thickening, increased blood flow on color Doppler, infiltration of surrounding fatty tissue, and presence of intraperitoneal fluid. Complications such as bowel strictures and peri-colic abscess are also described. We suggest that the use of POCUS for the assessment of IBD patients in the ED may expedite both diagnosis and treatment, as well as minimize the use of additional imaging.

The management of emergency hospital visits for inflammatory bowel diseases: A French national expert consensus report

BACKGROUND

Management of inflammatory bowel diseases (IBD) in the emergency department is often suboptimal.

AIMS

To develop a national consensus checklist of indicators to facilitate decision-making in emergency departments concerning hospitalisation and referral for abdominopelvic computed tomography (CT).

METHODS

A Delphi survey was used to obtain consensus on a checklist of clinical and biological variables. 119 healthcare professionals experienced in treating IBD were invited to participate. Panellists were provided with a literature survey and invited to agree or disagree with items on a prototype checklist. Two successive rounds of voting were organised.

RESULTS

The prototype checklist included fifteen clinical or laboratory indicators for hospitalisation or CT. Four indicators were not retained in the Delphi process and four additional indicators added. The final indicators retained were: abdominal signs/symptoms of disease exacerbation, intravenous morphine titration, fever, vomiting, dehydration, recent intestinal surgery, ano-perineal abscess, bowel obstruction, haemodynamic instability, anaemia, acute kidney failure and elevated C-reactive protein. Consensus for the retained indicators was >88%.

CONCLUSIONS

Use of this consensus checklist for the management of IBD in the emergency department may help improve standards of care and thus reduce the burden of these diseases.

Gastrointestinal perforation: clinical and MDCT clues for identification of aetiology

Gastrointestinal tract (GIT) perforation is a common medical emergency associated with considerable mortality, ranging from 30 to 50%. Clinical presentation varies: oesophageal perforations can present with acute chest pain, odynophagia and vomiting, gastroduodenal perforations with acute severe abdominal pain, while colonic perforations tend to follow a slower progression course with secondary bacterial peritonitis or localised abscesses. A subset of patients may present with delayed symptoms, abscess mimicking an abdominal mass, or with sepsis.

Direct multidetector computed tomography (MDCT) findings support the diagnosis and localise the perforation site while ancillary findings may suggest underlying conditions that need further investigation following primary repair of ruptured bowel. MDCT findings include extraluminal gas, visible bowel wall discontinuity, extraluminal contrast, bowel wall thickening, abnormal mural enhancement, localised fat stranding and/or free fluid, as well as localised phlegmon or abscess in contained perforations.

The purpose of this article is to review the spectrum of MDCT findings encountered in GIT perforation and emphasise the MDCT and clinical clues suggestive of the underlying aetiology and localisation of perforation site.