1
|
Palmer A, Towbin AJ, Anton CG, Kocaoglu M, Zhang B, Whaley K, Debnath P, Dillman JR. MR enterography radiologic ulcers in newly diagnosed ileal Crohn disease in children: frequency, inter-radiologist agreement, and clinical correlation. Pediatr Radiol 2024:10.1007/s00247-024-06056-7. [PMID: 39292244 DOI: 10.1007/s00247-024-06056-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 09/04/2024] [Accepted: 09/06/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND Radiologic ulcers are increasingly recognized as an imaging finding of bowel wall active inflammation in Crohn disease (CD). OBJECTIVE To determine the frequency of ulcers at MR enterography (MRE) in children with newly diagnosed ileal CD, assess agreement between radiologists, and evaluate if their presence correlates with other imaging and clinical features of intestinal active inflammation. MATERIALS AND METHODS This retrospective study included 108 consecutive pediatric patients (ages 6-18 years) with newly diagnosed ileal CD that underwent clinical MRE prior to treatment initiation between January 2021 and December 2022. MRE examinations were independently reviewed by three pediatric radiologists who indicated the presence vs. absence of ulcers, ulcer severity (categorical depth), and ulcer extent (categorical number of ulcers). Maximum bowel wall thickness and length of disease were measured and averaged across readers. Patient demographics and clinical inflammatory markers were documented from electronic health records. Inter-radiologist agreement was assessed using Fleiss' kappa (k) statistics. Student's t-test was used to compare continuous variables. RESULTS Mean patient age was 13.9 years (67 [62%] boys). Radiologic ulcers were recorded in 64/108 (59.3%) cases by reader 1, 70/108 (64.8%) cases by reader 2, and 49/108 (45.4%) cases by reader 3 (k = 0.36). Based on majority consensus, radiologic ulcers were present in 60/108 (55.6%) participants. Inter-radiologist agreement for ulcer severity was k = 0.23, while ulcer extent was k = 0.66. There were significant differences in C-reactive protein, erythrocyte sedimentation rate, fecal calprotectin, albumin, maximum bowel wall thickness, and length of disease between patients without and with radiologic ulcers (P < 0.05). The sensitivity and specificity of MRE for detecting endoscopic ulcers were 66.7% (95% CI, 52.1-79.2%) and 69.2% (95% CI, 48.2-85.7%), respectively. CONCLUSION Radiologic ulcers are visible in children with newly diagnosed ileal CD, although inter-radiologist agreement is only fair. The presence of ulcers is associated with clinical laboratory inflammatory markers as well as other MRE findings of disease activity and is an additional imaging finding that can be used to evaluate intestinal inflammation.
Collapse
Affiliation(s)
- Andrew Palmer
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Christopher G Anton
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Murat Kocaoglu
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kaitlin Whaley
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Pradipta Debnath
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| |
Collapse
|
2
|
Grellier N, Kirchgesner J, Uzzan M, McLellan P, Stefanescu C, Lefevre JH, Treton X, Panis Y, Sokol H, Beaugerie L, Seksik P. Early ileal resection in Crohn's disease is not associated with severe long-term outcomes: The ERIC study. Aliment Pharmacol Ther 2024. [PMID: 39234950 DOI: 10.1111/apt.18247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/13/2024] [Accepted: 08/27/2024] [Indexed: 09/06/2024]
Abstract
BACKGROUND Early complicated Crohn's disease (CD) may require ileal resection as first-line treatment. AIM To evaluate the long-term outcomes of patients who underwent early ileal resection. METHODS We conducted a retrospective study in two inflammatory bowel diseases (IBD) referral centres, including patients with ileocaecal resection and segmental ileal resection within 5 years of CD diagnosis. Early resection was defined as within 6 months of diagnosis, intermediate resection between 6 months and 2 years, and late resection between 2 and 5 years. The primary outcome was the cumulative risk of a second ileal surgery. Secondary outcomes included the use of postoperative treatments and morphological recurrence after initial surgery (Rutgeerts score ≥i2, or recurrence on imaging). RESULTS Among 393 patients who underwent ileal resection within 5 years of diagnosis, 130, 128 and 135, respectively, had early, intermediate and late resection. The cumulative risk of second surgery at 10 years was not significantly different in the early resection group (25.0% [95% CI 17.4-35.2]), than the intermediate (16.8% [95% CI 10.5-26.2]; p = 0.17) or late resection group (22.7% [95% CI 15.1-33.3]; p = 0.83). The early resection group required fewer postoperative treatments than the late resection group with median survivals without treatments of 3.7 and 0.9 years, respectively (p = 0.002). Patients who had early resection had significantly less morphological recurrence than the late resection group (p = 0.02). CONCLUSION Early ileal resection in CD is not associated with a higher risk of a second resection. It may be associated with reduced use of medical treatments and fewer morphological recurrences.
Collapse
Affiliation(s)
- N Grellier
- Department of Gastroenterology, Poitiers University Hospital, Poitiers, France
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - J Kirchgesner
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - M Uzzan
- Department of Gastroenterology, Mondor Hospital, Paris, France
| | - P McLellan
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - C Stefanescu
- Department of Gastroenterology and Nutrition Beaujon Hospital, Clichy, France
- Department of General and Digestive Surgery, Saint-Antoine Hospital, Paris, France
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly sur Seine, France
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Pare-Hartmann, Neuilly, France
| | - J H Lefevre
- Department of General and Digestive Surgery, Saint-Antoine Hospital, Paris, France
| | - X Treton
- Department of Gastroenterology and Nutrition Beaujon Hospital, Clichy, France
- Department of General and Digestive Surgery, Saint-Antoine Hospital, Paris, France
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly sur Seine, France
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Pare-Hartmann, Neuilly, France
| | - Y Panis
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly sur Seine, France
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Pare-Hartmann, Neuilly, France
| | - H Sokol
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - L Beaugerie
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| | - P Seksik
- Department of Gastroenterology, CRSA, Sorbonne Université, INSERM, APHP, Hôpital Saint-Antoine, Paris, France
| |
Collapse
|
3
|
Minordi LM, D’Angelo FB, Privitera G, Papa A, Larosa L, Laterza L, Scaldaferri F, Barbaro B, Carbone L, Pugliese D. Crohn's Disease: Radiological Answers to Clinical Questions and Review of the Literature. J Clin Med 2024; 13:4145. [PMID: 39064186 PMCID: PMC11277847 DOI: 10.3390/jcm13144145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/12/2024] [Accepted: 07/13/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Crohn's disease (CD) is a chronic, progressive inflammatory condition, involving primarily the bowel, characterized by a typical remitting-relapsing pattern. Despite endoscopy representing the reference standard for the diagnosis and assessment of disease activity, radiological imaging has a key role, providing information about mural and extra-visceral involvement. Methods: Computed Tomography and Magnetic Resonance Imaging are the most frequently used radiological techniques in clinical practice for both the diagnosis and staging of CD involving the small bowel in non-urgent settings. The contribution of imaging in the management of CD is reported on by answering the following practical questions: (1) What is the best technique for the assessment of small bowel CD? (2) Is imaging a good option to assess colonic disease? (3) Which disease pattern is present: inflammatory, fibrotic or fistulizing? (4) Is it possible to identify the presence of strictures and to discriminate inflammatory from fibrotic ones? (5) How does imaging help in defining disease extension and localization? (6) Can imaging assess disease activity? (7) Is it possible to evaluate post-operative recurrence? Results: Imaging is suitable for assessing disease activity, extension and characterizing disease patterns. CT and MRI can both answer the abovementioned questions, but MRI has a greater sensitivity and specificity for assessing disease activity and does not use ionizing radiation. Conclusions: Radiologists are essential healthcare professionals to be involved in multidisciplinary teams for the management of CD patients to obtain the necessary answers for clinically relevant questions.
Collapse
Affiliation(s)
- Laura Maria Minordi
- UOC di Radiologia Addomino-Pelvica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Largo Francesco Vito, 1, 00168 Roma, Italy; (F.B.D.)
| | - Francesca Bice D’Angelo
- UOC di Radiologia Addomino-Pelvica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Largo Francesco Vito, 1, 00168 Roma, Italy; (F.B.D.)
| | - Giuseppe Privitera
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20122 Milan, Italy;
| | - Alfredo Papa
- Unità Operativa Semplice Dipartimentale Day Hospital (UOSD DH) Medicina Interna e Malattie dell’Apparato Digerente, Fondazione Policlinico Universitario “A. Gemelli” Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Luigi Larosa
- UOC di Radiologia Addomino-Pelvica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Largo Francesco Vito, 1, 00168 Roma, Italy; (F.B.D.)
| | - Lucrezia Laterza
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario “A. Gemelli” Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Catholic University of Rome, 00168 Rome, Italy; (L.L.); (F.S.); (D.P.)
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy
| | - Franco Scaldaferri
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario “A. Gemelli” Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Catholic University of Rome, 00168 Rome, Italy; (L.L.); (F.S.); (D.P.)
| | - Brunella Barbaro
- UOC di Radiologia Addomino-Pelvica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Largo Francesco Vito, 1, 00168 Roma, Italy; (F.B.D.)
| | - Luigi Carbone
- UOC Pronto Soccorso, Medicina d’Urgenza e Medicina Interna, Ospedale Isola Tiberina Gemelli Isola, 00186 Rome, Italy;
| | - Daniela Pugliese
- CEMAD Digestive Disease Center, Fondazione Policlinico Universitario “A. Gemelli” Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Catholic University of Rome, 00168 Rome, Italy; (L.L.); (F.S.); (D.P.)
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, L. Go A. Gemelli 8, 00168 Rome, Italy
- UOS Gastroenterologia, Ospedale Isola Tiberina Gemelli Isola, 00186 Rome, Italy
| |
Collapse
|
4
|
Chavoshi M, Zamani S, Kolahdoozan S, Radmard AR. Diagnostic value of MR and CT enterography in post-operative recurrence of Crohn's disease: a systematic review and meta-analysis. Abdom Radiol (NY) 2024:10.1007/s00261-024-04394-6. [PMID: 38829393 DOI: 10.1007/s00261-024-04394-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/17/2024] [Accepted: 05/17/2024] [Indexed: 06/05/2024]
Abstract
Post-operative recurrence is a critical issue in the surveillance of Crohn's disease after ileocecal resection. This meta-analysis aims to assess the diagnostic yield of enterography techniques in post-operative recurrence of Crohn's disease. A systematic electronic bibliographic databases search was conducted. The inclusion criteria of original articles were: Utilized MR enterography or CT enterography after ileocolonic resection; Documented recurrence by ileo-colonoscopy (Rutgeerts' score ≥ i2); Provided crude data of diagnostic performance. A random-effect method was used for analysis. Relative risk and diagnostic value of each imaging feature were calculated. Eleven studies (11 populations and 589 patients) were included (4 CTE and 7 MRE with 248 and 341 patients, respectively). The pooled sensitivity and specificity of the enterography were 91% (95% CI: 0.85-0.95) and 75% (95% CI: 0.56-0.87), respectively. The pooled sensitivity and specificity of CTE were 93% (95% CI: 0.87-0.96) and 67% (95% CI: 0.35-0.90), respectively. MRE revealed pooled sensitivity and specificity of 90% (95% CI: 0.78-0.96) and 78% (95% CI: 0.57-0.90), respectively. The inter-study heterogeneity was low for sensitivity (I2 = 29%, p-value = 0.17) and high for specificity (I2 = 85%, p-value < 0.01). Wall enhancement, anastomosis wall thickening, anastomosis stenosis, pre-anastomotic dilatation, penetrating lesion, comb sign, and perivisceral edema were significantly higher in POR patients. Wall thickening and penetrating lesion were the most sensitive (81%) and specific (97%) findings, respectively. MRE and CTE exhibit high sensitivity and acceptable specificity (especially MRE) for detection of recurrence in Crohn's disease which makes them an effective initial screening tool and reserves ileo-colonoscopy for those patients with inconclusive enterography results.
Collapse
Affiliation(s)
- Mohammadreza Chavoshi
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Zamani
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shadi Kolahdoozan
- Digestive Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Reza Radmard
- Department of Radiology, Tehran University of Medical Sciences, Shariati Hospital, 14117, North Kargar St., Tehran, Iran.
| |
Collapse
|
5
|
Hammoudi N, Sachar D, D'Haens G, Reinisch W, Kotze PG, Vermeire S, Schölmerich J, Kamm MA, Griffiths A, Panes J, Ghosh S, Siegel CA, Bemelman W, O'Morain C, Steinwurz F, Fleshner P, Mantzaris GJ, Sands B, Abreu MT, Dotan I, Turner D, Dignass A, Allez M. Outcomes and Endpoints of Postoperative Recurrence in Crohn's Disease: Systematic Review and Consensus Conference. J Crohns Colitis 2024; 18:943-957. [PMID: 38112601 DOI: 10.1093/ecco-jcc/jjad205] [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: 09/18/2023] [Revised: 10/24/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Outcomes after ileocolonic resection in Crohn's disease [CD] are heterogeneous, and a clear definition of postoperative recurrence remains to be determined. Our Endpoints Working Group of the International Organization for the study of Inflammatory Bowel Disease [IOIBD] aimed to standardise postoperative outcomes, to discuss which endpoints should be used for postoperative clinical trials, and to define those which could be used in trials or registries. METHODS Based on a systematic review of the literature, recommendations and statements were drafted and sent to all IOIBD members for a first round of voting. Recommendations and statements were revised based on the voters' comments during a consensus hybrid conference open to all IOIBD members. If no agreement was reached after two rounds of voting, the statement was excluded. RESULTS In the systematic review, 3071 manuscripts were screened of which 434 were included. Sixteen recommendations were identified, of which 11 were endorsed. Recommendations and statements include that endoscopy remains the gold standard and should be used as a short-term primary endpoint in both observational cohorts and randomised controlled trials. Clinical symptoms classically used in clinical trials for luminal CD are not reliable in this specific situation. For that reason, longer-term endpoints should be based on the evidence of macroscopic inflammation assessed by imaging techniques, endoscopy, or as reflected by the presence of complications. CONCLUSIONS Agencies recommend the use of clinical evaluations, as in the case of luminal CD, and do not recognise primary endpoints based solely on endoscopy. This consensus has led to agreement on the need to define postoperative endoscopy-based and/or imaging-based endpoints.
Collapse
Affiliation(s)
- Nassim Hammoudi
- Department of Gastroenterology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - David Sachar
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Geert D'Haens
- Department of Gastroenterology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Walter Reinisch
- Department Internal Medicine III, Division Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria
| | | | - Severine Vermeire
- Department of Gastroenterology & Hepatology, University Hospital Leuven, Leuven, Belgium
| | | | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, and Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anne Griffiths
- IBD Centre, SickKids Hospital, University of Toronto, Toronto, ON, Canada
| | - Julian Panes
- Formerly Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Subrata Ghosh
- APC Microbiome Ireland, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Corey A Siegel
- IBD Center, Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, USA
| | - Willem Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Colm O'Morain
- Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Flavio Steinwurz
- Department of Gastroenterology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Bruce Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maria T Abreu
- Department of Medicine, Division of Gastroenterology, Crohn's and Colitis Center, Leonard M. Miller School of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medica Center, Petah-Tikva, Israel and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Axel Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Goethe-University, Frankfurt Am Main, Germany
| | - Matthieu Allez
- Department of Gastroenterology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| |
Collapse
|
6
|
Fasulo E, D’Amico F, Osorio L, Allocca M, Fiorino G, Zilli A, Parigi TL, Danese S, Furfaro F. The Management of Postoperative Recurrence in Crohn's Disease. J Clin Med 2023; 13:119. [PMID: 38202126 PMCID: PMC10779955 DOI: 10.3390/jcm13010119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/20/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease with different phenotypes of presentation, inflammatory, penetrating, or stricturing disease, that significantly impacts patient well-being and quality of life. Despite advances in medical therapy, surgery sometimes represents the only treatment to address complications, such as strictures, fistulas, or abscesses. Minimizing postoperative recurrence (POR) remains a major challenge for both clinicians and patients; consequently, various therapeutic strategies have been developed to prevent or delay POR. The current review outlines an updated overview of POR management. We focused on diagnostic assessment, which included endoscopic examination, biochemical analyses, and cross-sectional imaging techniques, all crucial tools used to accurately diagnose this condition. Additionally, we delved into the associated risk factors contributing to POR development. Furthermore, we examined recent advances in the prophylaxis and treatment of POR in CD.
Collapse
Affiliation(s)
- Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Ferdinando D’Amico
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20089 Milan, Italy
| | - Laura Osorio
- Gastroenterologist Hospital Pablo Tobon Uribe, Medellín 050010, Colombia;
| | - Mariangela Allocca
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Gionata Fiorino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Alessandra Zilli
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Tommaso Lorenzo Parigi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
- Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Federica Furfaro
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| |
Collapse
|
7
|
Furfaro F, D'Amico F, Zilli A, Craviotto V, Aratari A, Bezzio C, Spinelli A, Gilardi D, Radice S, Saibeni S, Papi C, Peyrin-Biroulet L, Danese S, Fiorino G, Allocca M. Noninvasive Assessment of Postoperative Disease Recurrence in Crohn's Disease: A Multicenter, Prospective Cohort Study on Behalf of the Italian Group for Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2023; 21:3143-3151. [PMID: 36521739 DOI: 10.1016/j.cgh.2022.11.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 11/19/2022] [Accepted: 11/28/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS Colonoscopy (CS) is the gold standard to assess postoperative recurrence (POR) in Crohn's disease (CD). However, CS is invasive and may be poorly tolerated by patients. The aim of this study was to prospectively assess the diagnostic accuracy of a noninvasive approach in detecting POR, using the endoscopic Rutgeerts' score (RS) as the reference standard. METHODS Consecutive patients with CD who underwent ileo-cecal resection were prospectively enrolled in 3 referral Italian centers. Patients underwent CS and bowel ultrasound within 1 year of surgery. Uni- and multivariable analyses were used to assess the correlation between noninvasive parameters and endoscopic recurrence, defined by a RS ≥2. RESULTS Ninety-one patients were enrolled. Sixty patients (66%) experienced endoscopic POR. The multivariable analysis identified bowel wall thickness (BWT) per 1-mm increase (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.21-4.89; P = .012), the presence of mesenteric lymph nodes (OR, 15.63; 95% CI, 1.48-164.54; P = .022), and fecal calprotectin (FC) values ≥50 mcg/g (OR, 8.58; 95% CI, 2.45-29.99; P < .001) as independent predictors for endoscopic recurrence. The presence of lymph nodes or the combination of BWT ≥3 mm and FC values ≥50 mcg/g correctly classified 56% and 75% of patients, with less than 5% of patients falsely classified as having endoscopic recurrence. Conversely, the combination of BWT <3 mm and FC <50 mcg/g correctly classified 74% of patients with only 4.5% of patients falsely classified as not having endoscopic recurrence. CONCLUSIONS A noninvasive approach combining bowel ultrasound and FC can be used with confidence for detecting POR in patients with CD without the requirement for CS.
Collapse
Affiliation(s)
- Federica Furfaro
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy
| | - Ferdinando D'Amico
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Alessandra Zilli
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy
| | | | | | - Cristina Bezzio
- Gastroenterology Unit, Rho Hospital, Rho (MI), ASST Rhodense, Garbagnate Milanese, Italy
| | | | | | - Simona Radice
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy
| | - Simone Saibeni
- Gastroenterology Unit, Rho Hospital, Rho (MI), ASST Rhodense, Garbagnate Milanese, Italy
| | - Claudio Papi
- IBD Unit, San Filippo Neri Hospital, Rome, Italy
| | - Laurent Peyrin-Biroulet
- University of Lorraine, CHRU-Nancy, Department of Gastroenterology, Nancy, France; University of Lorraine, Inserm, NGERE, Nancy, France
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy.
| | - Gionata Fiorino
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Mariangela Allocca
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| |
Collapse
|
8
|
Dragoni G, Allocca M, Myrelid P, Noor NM, Hammoudi N, Rivière P, Panis Y, Ferrante M. Results of the Eighth Scientific Workshop of ECCO: Diagnosing Postoperative Recurrence of Crohn's Disease After an Ileocolonic Resection With Ileocolonic Anastomosis. J Crohns Colitis 2023; 17:1373-1386. [PMID: 37070339 DOI: 10.1093/ecco-jcc/jjad055] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Indexed: 04/19/2023]
Abstract
Despite the introduction of potent biologic therapies, many patients with Crohn's disease [CD] still require an ileocolonic resection [ICR] during the course of their disease. Furthermore, the need of redo ICR has not decreased over the past few decades, highlighting the need for better strategies to prevent and treat postoperative recurrence [POR]. The first step to develop such a strategy would be to define and standardise the description of POR with adequate diagnostic instruments. In this article, we will describe the different methodologies used to report POR [endoscopic, histological, radiological, biochemical, clinical, and surgical], and review their potential benefits and limitations, as well as the optimal timing of evaluation.
Collapse
Affiliation(s)
- Gabriele Dragoni
- IBD Referral Center, Department of Gastroenterology, Careggi University Hospital, Florence, Italy
- Gastroenterology Research Unit, Department of Experimental and Clinical Biochemical Sciences 'Mario Serio', University of Florence, Florence, Italy
| | - Mariangela Allocca
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Nurulamin M Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Nassim Hammoudi
- Gastroenterology Department, Hôpital Saint-Louis - APHP, Université Paris Cité, INSERM U1160, Paris, France
| | - Pauline Rivière
- Department of Gastroenterology and Hepatology, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, CHU de Bordeaux, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Yves Panis
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Chronic Diseases and Metabolism [CHROMETA], KU Leuven, Leuven, Belgium
| |
Collapse
|
9
|
Carretero C, Bojorquez A, Eliakim R, Lazaridis N. Updates in the diagnosis and management of small-bowel Crohn's disease. Best Pract Res Clin Gastroenterol 2023; 64-65:101855. [PMID: 37652654 DOI: 10.1016/j.bpg.2023.101855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 07/06/2023] [Accepted: 08/01/2023] [Indexed: 09/02/2023]
Affiliation(s)
- Cristina Carretero
- Gastroenterology Department, Clínica Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IDISNA), Clínica Universidad de Navarra. Pio XII 36, 31004, Pamplona, Spain.
| | - Alejandro Bojorquez
- Gastroenterology Department, Clínica Universidad de Navarra, Clínica Universidad de Navarra. Pio XII 36, 31004, Pamplona, Spain.
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tek-Aviv, Israel.
| | - Nikolaos Lazaridis
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive Health, London, United Kingdom; Saint Luke's Hospital, Small Bowel Service, Agias Sofias 18, 54622, Thessaloniki, Greece.
| |
Collapse
|
10
|
Replacing Endoscopy with Magnetic Resonance Enterography for Mucosal Activity Assessment in Terminal Ileal Crohn’s Disease: Are We There Yet? Diagnostics (Basel) 2023; 13:diagnostics13061061. [PMID: 36980368 PMCID: PMC10046927 DOI: 10.3390/diagnostics13061061] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023] Open
Abstract
Crohn’s disease (CD) is a chronic immune mediated disorder that most commonly affects the small bowel and/or the large bowel. Treatment targets in CD include mucosal healing assessed via ileocolonoscopy and transmural healing assessed through cross-sectional imaging modalities such as magnetic resonance enterography (MRE). More recently, histological healing in CD has emerged as a treatment target, though it is made cumbersome given its reliance on frequent endoscopic examinations. With expert guidelines now recommending regular objective assessments as part of a treat-to-target approach, accurate non-invasive assessment will become increasingly critical. MRE has an established role in the assessment of small bowel CD, with growing data supportive of its ability in detecting disease activity at mucosal and histological levels. This could therefore potentially reduce the need for serial endoscopic assessment. Thus, this review will assess the capacity of individual MRE parameters and MRE indices for detecting mucosal and histological small bowel CD activity. Furthermore, challenging scenarios, such as CD activity detection in post-operative clinical scenarios and abnormal findings in the context of a normal ileocolonoscopy, will be explored.
Collapse
|
11
|
Nancey S, Fumery M, Faure M, Boschetti G, Gay C, Milot L, Roblin X. Use of imaging modalities for decision-making in inflammatory bowel disease. Therap Adv Gastroenterol 2023; 16:17562848231151293. [PMID: 36777362 PMCID: PMC9912556 DOI: 10.1177/17562848231151293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/27/2022] [Indexed: 02/11/2023] Open
Abstract
Cross-sectional magnetic resonance enterography (MRE) and intestinal ultrasonography (IUS) provide valuable and noninvasive information to accurately assess disease activity, severity, and extent; detect complications; and monitor the response to treatment, as well as predict the postoperative recurrence of Crohn's disease and a negative disease course. Therefore, both imaging modalities are emerging as pivotal diagnostic tools to achieve the emerging therapeutic target of transmural healing associated with better disease outcomes. Despite its numerous potential advantages over endoscopy and even MRE and its good availability, IUS is still widely underused to monitor and manage inflammatory bowel disease (IBD) patients and help in making clinical decisions in routine practice. This situation is clearly due to the absence of validated, reliable, and responsive indices, as well as the lack of trained gastroenterologists and radiologists, as IUS is a component of radiologist expertise in several countries but not yet integrated into the training program of gastroenterologists. However, there is an increasing body of evidence in the literature that IUS and MRE are both becoming essential imaging resources to help clinicians in making reliable decisions. Here, we discuss the up-to-date evidence about the usefulness and performance of cross-sectional imaging, focusing on the ability of bowel US and MRE to aid clinical decision-making for the optimal management and monitoring of IBD.
Collapse
Affiliation(s)
| | - Mathurin Fumery
- Department of Gastroenterology, University
Hospital of Amiens, Amiens, France
| | | | - Gilles Boschetti
- Department of Gastroenterology, Lyon Sud
Hospital, Hospices Civils de Lyon, University Claude Bernard Lyon 1,
Pierre-Bénite, France,INSERM U1111, CIRI, Lyon, France
| | - Claire Gay
- Department of Gastroenterology, Lyon Sud
Hospital, Hospices Civils de Lyon, University Claude Bernard Lyon 1,
Pierre-Bénite, France
| | - Laurent Milot
- Department of Radiology, Hospices Civils de
Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Xavier Roblin
- Department of Gastroenterology, Immunology,
University Hospital of Saint-Etienne, Saint-Etienne, France
| |
Collapse
|
12
|
Vieujean S, Louis E. Precision medicine and drug optimization in adult inflammatory bowel disease patients. Therap Adv Gastroenterol 2023; 16:17562848231173331. [PMID: 37197397 PMCID: PMC10184262 DOI: 10.1177/17562848231173331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/16/2023] [Indexed: 05/19/2023] Open
Abstract
Inflammatory bowel diseases (IBD) encompass two main entities including ulcerative colitis and Crohn's disease. Although having a common global pathophysiological mechanism, IBD patients are characterized by a significant interindividual heterogeneity and may differ by their disease type, disease locations, disease behaviours, disease manifestations, disease course as well as treatment needs. Indeed, although the therapeutic armamentarium for these diseases has expanded rapidly in recent years, a proportion of patients remains with a suboptimal response to medical treatment due to primary non-response, secondary loss of response or intolerance to currently available drugs. Identifying, prior to treatment initiation, which patients are likely to respond to a specific drug would improve the disease management, avoid unnecessary side effects and reduce the healthcare expenses. Precision medicine classifies individuals into subpopulations according to clinical and molecular characteristics with the objective to tailor preventative and therapeutic interventions to the characteristics of each patient. Interventions would thus be performed only on those who will benefit, sparing side effects and expense for those who will not. This review aims to summarize clinical factors, biomarkers (genetic, transcriptomic, proteomic, metabolic, radiomic or from the microbiota) and tools that could predict disease progression to guide towards a step-up or top-down strategy. Predictive factors of response or non-response to treatment will then be reviewed, followed by a discussion about the optimal dose of drug required for patients. The time at which these treatments should be administered (or rather can be stopped in case of a deep remission or in the aftermath of a surgery) will also be addressed. IBD remain biologically complex, with multifactorial etiopathology, clinical heterogeneity as well as temporal and therapeutic variabilities, which makes precision medicine especially challenging in this area. Although applied for many years in oncology, it remains an unmet medical need in IBD.
Collapse
Affiliation(s)
- Sophie Vieujean
- Hepato-Gastroenterology and Digestive Oncology, University Hospital CHU of Liège, Liège, Belgium
| | | |
Collapse
|
13
|
Battat R. Serum Monitoring of Recurrence in Post-Operative Crohn's Disease: Have We Arrived? J Crohns Colitis 2022; 16:1795-1796. [PMID: 35737583 DOI: 10.1093/ecco-jcc/jjac077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Robert Battat
- Jill Roberts Center for Inflammatory Bowel Disease, Division of Gastroenterology and Hepatology, New York Presbyterian Hospital/Weill-Cornell Medical College, New York, NY, USA
| |
Collapse
|
14
|
Wang Y, Zhang R, Mao R, Li X. Inflammatory bowel disease cross-sectional imaging: What's new? United European Gastroenterol J 2022; 10:1179-1193. [PMID: 36461914 PMCID: PMC9752287 DOI: 10.1002/ueg2.12343] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/13/2022] [Indexed: 12/07/2022] Open
Abstract
Cross-sectional imaging-ultrasonography, computed tomography enterography, and magnetic resonance enterography-is a routine and indispensable tool for patients with Crohn's disease (CD) that helps to detect or monitor disease characteristics before, during, and after CD treatment. New emerging radiological technologies may have further clinical applications in the management of CD. In this review article, we focus on the latest developments in cross-sectional imaging in CD research, including its role in intra- and extra-luminal lesion detection, intestinal inflammation and fibrosis grading, therapeutic response assessment and outcome prediction, postoperative recurrence detection and prediction, and the gut-brain axis.
Collapse
Affiliation(s)
- Yang‐di Wang
- Department of RadiologyThe First Affiliated Hospital, Sun Yat‐Sen UniversityGuangzhouPeople's Republic of China
| | - Ruo‐nan Zhang
- Department of RadiologyThe First Affiliated Hospital, Sun Yat‐Sen UniversityGuangzhouPeople's Republic of China
| | - Ren Mao
- Department of GastroenterologyThe First Affiliated Hospital, Sun Yat‐Sen UniversityGuangzhouPeople's Republic of China
| | - Xue‐hua Li
- Department of RadiologyThe First Affiliated Hospital, Sun Yat‐Sen UniversityGuangzhouPeople's Republic of China
| |
Collapse
|
15
|
Bachour SP, Baker ME, Click B. Reply. Clin Gastroenterol Hepatol 2022; 20:2925-2926. [PMID: 35149221 DOI: 10.1016/j.cgh.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Salam P Bachour
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Mark E Baker
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio
| | - Benjamin Click
- Department of Gastroenterology and Hepatology Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
16
|
Contemporary Management of Postoperative Crohn's Disease after Ileocolonic Resection. J Clin Med 2022; 11:jcm11226746. [PMID: 36431223 PMCID: PMC9693828 DOI: 10.3390/jcm11226746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/12/2022] [Accepted: 11/12/2022] [Indexed: 11/17/2022] Open
Abstract
Surgery remains an important treatment modality in the multidisciplinary management of patients with Crohn's disease (CD). To illustrate the recent advances in the management of postoperative CD we outline the contemporary approach to treatment: diagnosing disease recurrence using endoscopy or noninvasive methods and risk stratification underlying decisions to institute treatment. Endoscopic scoring indices are being refined to guide treatment decisions by accurately estimating the risk of recurrence based on endoscopic appearance. The original Rutgeerts score has been modified to separate anastomotic lesions from lesions in the neoterminal ileum. Two further indices, the REMIND score and the POCER index, were recently developed with the same intention. Noninvasive monitoring for recurrence using a method with high negative predictive value has the potential to simplify management algorithms and only perform ileocolonoscopy in a subset of patients. Fecal calprotectin, intestinal ultrasound, and magnetic resonance enterography are all being evaluated for this purpose. The use of infliximab for the prevention of postoperative recurrence is well supported by data, but management decisions are fraught with uncertainty for patients with previous exposure to biologics. Data on the use of ustekinumab and vedolizumab for postoperative CD are emerging, but controlled studies are lacking.
Collapse
|