1
|
Arkenbosch JHC, van Ruler O, de Vries AC, van der Woude CJ, Dwarkasing RS. The role of MRI in perianal fistulizing disease: diagnostic imaging and classification systems to monitor disease activity. Abdom Radiol (NY) 2024:10.1007/s00261-024-04455-w. [PMID: 39180667 DOI: 10.1007/s00261-024-04455-w] [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: 04/03/2024] [Revised: 06/12/2024] [Accepted: 06/15/2024] [Indexed: 08/26/2024]
Abstract
Perianal fistulizing disease, commonly associated with Crohn's disease, poses significant diagnostic and therapeutic challenges due to its complex anatomy and high recurrence rates. Radiological imaging plays a pivotal role in the accurate diagnosis, classification, and management of this condition. This article reviews the current radiological modalities employed in the evaluation of perianal fistulizing disease, including magnetic resonance imaging (MRI), endoanal ultrasound, and computed tomography (CT). MRI, recognized as the gold standard, offers superior soft tissue contrast and multiplanar capabilities, facilitating detailed assessment of fistula tracts and associated abscesses. CT, although less detailed than MRI, remains valuable in acute settings for detecting abscesses and guiding drainage procedures. This article discusses the advantages and limitations of each modality, highlights the importance of standardized imaging protocols, and underscores the need for interdisciplinary collaboration in the management of perianal fistulizing disease. Future directions include advancements in imaging techniques and the integration of artificial intelligence to enhance diagnostic accuracy and treatment outcomes.
Collapse
Affiliation(s)
- Jeanine H C Arkenbosch
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Oddeke van Ruler
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Roy S Dwarkasing
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
| |
Collapse
|
2
|
Vuyyuru SK, Solitano V, Singh S, Hanzel J, Macdonald JK, Danese S, Peyrin Biroulet L, Ma C, Jairath V. Scoring Indices for Perianal Fistulising Crohn's Disease: A Systematic Review. J Crohns Colitis 2024; 18:836-850. [PMID: 38126903 DOI: 10.1093/ecco-jcc/jjad214] [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: 08/14/2023] [Revised: 11/20/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND AIMS In this systematic review we summarise existing scoring indices for assessing disease activity and quality of life in perianal fistulising Crohn's disease [PFCD], and highlight gaps in the literature. METHODS MEDLINE, EMBASE, and CENTRAL were searched from August 24, 2022, to identify studies evaluating clinical, radiological, or patient-reported outcome measures [PROMS] in PFCD. The primary objective was to identify all available scoring indices and describe the operating properties of these indices. RESULTS A total of 53 studies reported on the use of one clinical index [Perianal Disease Activity Index: PDAI], three PROMs, and 10 radiological indices; 25 studies evaluated the operating properties of these indices. The PDAI demonstrated content validity, construct validity, and responsiveness but criterion validity or reliability were not assessed. The Van Assche Index [VAI], modified VAI, and the Magnetic Resonance Index for Assessing Fistulas in Patients with CD [MAGNIFI-CD] were the most studied radiological indices. These indices demonstrated responsiveness and reliability. The VAI and MAGNIFI-CD demonstrated construct validity; criterion and content validity and feasibility have not been assessed. Among the three PROMs, the Crohn's Anal Fistula Quality of Life index demonstrated content and construct validity, inter-observer reliability, and responsiveness; criterion validity, intra-observer reliability, and feasibility have not been assessed for this index. CONCLUSIONS There are no fully valid, reliable, and responsive clinical disease or radiological indices for PFCD. Although the radiological indices demonstrated responsiveness and reliability, well-defined cut-offs for response and remission are lacking. Future research should focus on establishing standardised definitions and thresholds for outcomes.
Collapse
Affiliation(s)
- Sudheer K Vuyyuru
- Department of Medicine, Division of Gastroenterology, Schulich school of Medicine, Western University, London, ON, Canada
- Alimentiv Inc., 100 Dundas street, London, ON, Canada
| | - Virginia Solitano
- Department of Medicine, Division of Gastroenterology, Schulich school of Medicine, Western University, London, ON, Canada
- Alimentiv Inc., 100 Dundas street, London, ON, Canada
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Siddharth Singh
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Jurij Hanzel
- Alimentiv Inc., 100 Dundas street, London, ON, Canada
- Faculty of Medicine, University of Ljubljana, Department of Gastroenterology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Laurent Peyrin Biroulet
- Department of Gastroenterology, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- Inserm, NGERE, University of Lorraine, Nancy, France
- INFINY Institute, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- FHU-CURE, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- Groupe Hospitalier Privé Ambroise Paré - Hartmann, Paris IBD Center, Neuilly sur Seine, France
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC, Canada
| | - Christopher Ma
- Alimentiv Inc., 100 Dundas street, London, ON, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Vipul Jairath
- Department of Medicine, Division of Gastroenterology, Schulich school of Medicine, Western University, London, ON, Canada
- Alimentiv Inc., 100 Dundas street, London, ON, Canada
- Department of Epidemiology and Biostatistics and Robarts Research Institute, Western University, London, ON, Canada
| |
Collapse
|
3
|
Singh A, Midha V, Kochhar GS, Shen B, Sood A. Management of Perianal Fistulizing Crohn's Disease. Inflamm Bowel Dis 2023:izad195. [PMID: 37672347 DOI: 10.1093/ibd/izad195] [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: 02/20/2023] [Indexed: 09/08/2023]
Abstract
Perianal fistulizing Crohn's disease (CD) represents a severe phenotype of CD that is associated with significant morbidity and reduction in quality of life. Perianal fistulizing CD is caused by a complex interplay of genetic predisposition, immune dysregulation, gut dysbiosis, and various unknown physiological and mechanical factors. A multidisciplinary approach is hence required for optimal management . A detailed anatomical description and classification of perianal fistula, including comprehensive clinical, endoscopic, and radiological diagnostic workup, is an important prerequisite to treatment. For simple perianal fistulas, use of antibiotics and immunomodulators, with or without fistulotomy, are appropriate measures. The medical management of complex perianal fistula, on the other hand, requires adequate control of infection before initiation of therapy with immunomodulators. In active complex perianal fistula, anti-tumor necrosis factors remain the most accepted therapy, with concomitant use of antibiotics or immunomodulators enhancing the efficacy. For patients refractory to anti-tumor necrosis factors, treatment with anti-integrins, anti-interleukins, and small molecules is being evaluated. Mesenchymal stem cells, hyperbaric oxygen therapy, and exclusive enteral nutrition have also been investigated as adjunct therapies. Despite the expansion of the medical armamentarium, a large proportion of the patients require surgical interventions. In this review, we provide an up-to-date overview of the pathophysiology, clinical presentation, diagnosis, and medical management of perianal fistulizing CD. A brief overview of the surgical management of perianal fistulizing CD is also provided.
Collapse
Affiliation(s)
- Arshdeep Singh
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| | - Vandana Midha
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, India
| | - Gursimran Singh Kochhar
- Division of Gastroenterology, Hepatology and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Bo Shen
- Center for Interventional Inflammatory Bowel Disease, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| |
Collapse
|
4
|
Xiong Z, Zhou Z, Hao L, Li Y, Hu X, Hu D, Luo Y, Wang Y, Shen Y, Li Z. The relationship between perianal fistula activity and abdominal adipose tissue in Crohn’s disease: an observational study. Insights Imaging 2022; 13:156. [PMID: 36153465 PMCID: PMC9509502 DOI: 10.1186/s13244-022-01293-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 09/04/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objective
The aim of this study was to analyze the relationship between abdominal adipose tissue and perianal fistula activity in patients with Crohn's disease (CD) using cross-sectional imaging.
Methods
Patients with perianal fistulizing CD who underwent pelvic magnetic resonance imaging (MRI) and abdominal computed tomography (CT) were retrospectively enrolled. We scored the fistulas in each patient's MRI images based on Van Assche's classification. The area and density of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) (at the third, fourth, and fifth lumbar (L3, L4, and L5) levels were measured by averaging five slices of measurements at each vertebral level in CT images, and areas were further standardized by the lumbar height2 (heightL1-5). The VAT/SAT ratio (VSR) and VAT/Total adipose tissue (VA/TA) index were calculated. Based on MRI scores, patients were divided into two groups with low and high activity, and their clinical, MRI features, and CT parameters were compared. We evaluated patients with follow-up MRI and compared the differences in clinical and radiological indicators among patients with different outcomes.
Results
Overall, 136 patients were included, 77 in the low-activity group and 59 in the high-activity group. Patients in the high activity group had lower subcutaneous adipose index (all levels, p < 0.05) and visceral adipose index (L3 level, p < 0.01), but higher SAT and VAT density (all levels, p < 0.01), VSR (L5 level, p = 0.07) and VA/TA index (L5 level, p < 0.05).
Conclusion
There were differences in adipose tissue composition among CD patients with different active perianal fistulas.
Collapse
|
5
|
Gergely M, Deepak P. Tools for the Diagnosis and Management of Crohn's Disease. Gastroenterol Clin North Am 2022; 51:213-239. [PMID: 35595412 DOI: 10.1016/j.gtc.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Numerous tools have emerged over recent decades to aid in the increasingly complex management of patients with Crohn's disease (CD) beyond endoscopy, including video capsule endoscopy, magnetic resonance enterography, computed tomography enterography, a variety of biomarkers, and even wearable biosensors and smartphone applications. These tools have allowed for a more sophisticated and less invasive complementary approach to the evaluation of disease activity and treatment response in patients with CD. This article details the characteristics, practical application, and limitations of these various modalities and discusses how updated guidelines are now incorporating many of them into a treat-to-target strategy.
Collapse
Affiliation(s)
- Maté Gergely
- Division of Gastroenterology, Inflammatory Bowel Diseases Center, Washington University School of Medicine, 600 South Euclid Avenue, Campus Box 8124, Saint Louis, MO 63110, USA
| | - Parakkal Deepak
- Division of Gastroenterology, Inflammatory Bowel Diseases Center, Washington University School of Medicine, 600 South Euclid Avenue, Campus Box 8124, Saint Louis, MO 63110, USA.
| |
Collapse
|
6
|
Kucharzik T, Tielbeek J, Carter D, Taylor SA, Tolan D, Wilkens R, Bryant RV, Hoeffel C, De Kock I, Maaser C, Maconi G, Novak K, Rafaelsen SR, Scharitzer M, Spinelli A, Rimola J. ECCO-ESGAR Topical Review on Optimizing Reporting for Cross-Sectional Imaging in Inflammatory Bowel Disease. J Crohns Colitis 2022; 16:523-543. [PMID: 34628504 DOI: 10.1093/ecco-jcc/jjab180] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The diagnosis and follow up of patients with inflammatory bowel disease [IBD] requires cross-sectional imaging modalities, such as intestinal ultrasound [IUS], magnetic resonance imaging [MRI] and computed tomography [CT]. The quality and homogeneity of medical reporting are crucial to ensure effective communication between specialists and to improve patient care. The current topical review addresses optimized reporting requirements for cross-sectional imaging in IBD. METHODS An expert consensus panel consisting of gastroenterologists, radiologists and surgeons convened by the ECCO in collaboration with ESGAR performed a systematic literature review covering the reporting aspects of MRI, CT, IUS, endoanal ultrasonography and transperineal ultrasonography in IBD. Practice position statements were developed utilizing a Delphi methodology incorporating two consecutive rounds. Current practice positions were set when ≥80% of the participants agreed on a recommendation. RESULTS Twenty-five practice positions were developed, establishing standard terminology for optimal reporting in cross-sectional imaging. Assessment of inflammation, complications and imaging of perianal CD are outlined. The minimum requirements of a standardized report, including a list of essential reporting items, have been defined. CONCLUSIONS This topical review offers practice recommendations to optimize and homogenize reporting in cross-sectional imaging in IBD.
Collapse
Affiliation(s)
- Torsten Kucharzik
- Department of Gastroenterology, Klinikum Lüneburg, University of Hamburg, Bögelstr. 1, 21339 Lüneburg, Germany
| | - Jeroen Tielbeek
- Department of Radiology, Spaarne Gasthuis, Boerhaavelaan 22, Haarlem, the Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hasomher, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Damian Tolan
- Radiology Department, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, UK
| | - Rune Wilkens
- Gastrounit, Division of Medicine, Hvidovre University Hospital, Copenhagen, Denmark; Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents and Adults, University of Copenhagen, Hvidovre Hospital, Copenhagen, Denmark
| | - Robert V Bryant
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia
| | - Christine Hoeffel
- Department of Abdominal Radiology, CHU Reims and CRESTIC, URCA, 51100 Reims, France
| | - Isabelle De Kock
- Department of Radiology, Ghent University Hospital, Ghent, Belgium
| | - Christian Maaser
- Outpatient Department of Gastroenterology, Department of Geriatrics, Klinikum Lüneburg, University of Hamburg, Bögelstr. 1, 21339 Lüneburg, Germany
| | - Giovanni Maconi
- Gastroenterology Unit, 'Luigi Sacco' University Hospital, Milan, Italy
| | - Kerri Novak
- Department of Radiology and Medicine, Division of Gastroenterology, University of Calgary, Alberta, Canada
| | - Søren R Rafaelsen
- Department of Radiology, University Hospital of Southern Denmark, Vejle, Denmark
| | - Martina Scharitzer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Jordi Rimola
- IBD unit, Radiology Department, Hospital Clínic Barcelona, Barcelona, Catalonia, Spain
| |
Collapse
|
7
|
Choshen S, Turner D, Pratt LT, Precel R, Greer ML, Castro DA, Assa A, Martínez-León MI, Herman-Sucharska I, Coppenrath E, Konen O, Davila J, Bekhit E, Alsabban Z, Focht G, Gavish M, Griffiths A, Cytter-Kuint R. Development and Validation of a Pediatric MRI-Based Perianal Crohn Disease (PEMPAC) Index-A Report from the ImageKids Study. Inflamm Bowel Dis 2022; 28:700-709. [PMID: 34151950 DOI: 10.1093/ibd/izab147] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND As part of the prospective multicenter ImageKids study, we aimed to develop and validate the pediatric MRI-based perianal Crohn disease (PEMPAC) index. METHODS Children with Crohn disease with any clinical perianal findings underwent pelvic magnetic resonance imaging at 21 sites globally. The site radiologist and 2 central radiologists provided a radiologist global assessment (RGA) on a 100 mm visual analog scale and scored the items selected by a Delphi group of 35 international radiologists and a review of the literature. Two weighted multivariable statistical models were constructed against the RGA. RESULTS Eighty children underwent 95 pelvic magnetic resonance imaging scans; 64 were used for derivation and 31 for validation. The following items were included: fistula number, location, length and T2 hyperintensity; abscesses; rectal wall involvement; and fistula branching. The last 2 items had negative beta scores and thus were excluded in a contending basic model. In the validation cohort, the full and the basic models had the same strong correlation with the RGA (r = 0.75; P < 0.01) and with the adult Van Assche index (VAI; r = 0.93 and 0.92; P < 0.001). The correlation of the VAI with the RGA was similar (r = 0.77; P < 0.01). The 2 models and the VAI had a similar ability to differentiate remission from active disease (area under the receiver operating characteristic curve, 0.91-0.94). The PEMPAC index had good responsiveness to change (area under the receiver operating characteristic curve, 0.89; 95% confidence interval, 0.69-1.00). CONCLUSIONS Using a blended judgmental and mathematical approach, we developed and validated an index for quantifying the severity of perianal disease in children with CD. The adult VAI may also be used with confidence in children.
Collapse
Affiliation(s)
- Sapir Choshen
- Pediatric Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Li-Tal Pratt
- Pediatric Imaging Unit, Imaging Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Precel
- Pediatric Imaging Unit, Imaging Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Mary-Louise Greer
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Denise A Castro
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.,Department of Diagnostic Radiology, Kingston Health Science Centre, Queen's University, Kingston, Canada
| | - Amit Assa
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Diagnostic Imaging, Schneider Children's Hospital, Petach-Tikva, Israel
| | | | | | | | - Osnat Konen
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Diagnostic Imaging, Schneider Children's Hospital, Petach-Tikva, Israel
| | - Jorge Davila
- Department of Medical Imaging, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Elhamy Bekhit
- Department of Medicine and Radiology, The Royal Children's Hospital, Melbourne, Australia
| | - Zehour Alsabban
- Department of Radiology, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Gili Focht
- The Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Matan Gavish
- School of Computer Science and Engineering, The Hebrew University, Jerusalem, Israel
| | - Anne Griffiths
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Canada
| | - Ruth Cytter-Kuint
- Radiology Department, Shaare Zedek Medical Center, Jerusalem, Israel
| |
Collapse
|
8
|
Queiroz NSF, Garcia KS, Miranda EF, Kotze PG. Patient-Reported Outcomes Measures in Perianal Fistulizing Crohn's Disease. Rev Recent Clin Trials 2022; 17:RRCT-EPUB-122860. [PMID: 35469573 DOI: 10.2174/1574887117666220425125424] [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: 09/04/2021] [Revised: 01/06/2022] [Accepted: 01/10/2022] [Indexed: 06/14/2023]
Abstract
Perianal fistulizing Crohn's disease (PFCD) is a disabling complication of Crohn's disease (CD) that can significantly impact on patients' quality of life (QoL) and often requires multidisciplinary care. Clinical trials assessing the efficacy of medical and surgical interventions for fistulas usually evaluate outcomes such as closure of fistula tracts or radiologic healing. However, these traditional outcome assessments fail in capturing the impact of the disease from patients' perspectives. In this context, regulatory authorities have increasingly encouraged the inclusion of validated patient-reported outcomes (PRO) that assess disease activity and reveal how a patient functions and feels. This recent trend towards patient-centered care aims to ensure that improvements in efficacy outcomes are accompanied by meaningful benefits to patients. The aim of this review is to discuss currently available PRO measures (PROMS) for the assessment of PFCD to provide to physicians appropriate tools aiming to optimize patient care and disseminate the use of these instruments in clinical practice.
Collapse
Affiliation(s)
| | - Karoline Soares Garcia
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Eron Fabio Miranda
- Colorectal Surgery Unit, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
- Health Sciences Postgraduate Program, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| |
Collapse
|
9
|
Alyami A, Hoad CL, Tench C, Bannur U, Clarke C, Latief K, Argyriou K, Lobo A, Lung P, Baldwin-Cleland R, Sahnan K, Hart A, Limdi JK, Mclaughlin J, Atkinson D, Parker GJM, O’Connor JPB, Little RA, Gowland PA, Moran GW. Quantitative Magnetic Resonance Imaging in Perianal Crohn's Disease at 1.5 and 3.0 T: A Feasibility Study. Diagnostics (Basel) 2021; 11:2135. [PMID: 34829482 PMCID: PMC8624877 DOI: 10.3390/diagnostics11112135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/08/2021] [Accepted: 11/12/2021] [Indexed: 01/06/2023] Open
Abstract
Perianal Crohn's Disease (pCD) is a common manifestation of Crohn's Disease. Absence of reliable disease measures makes disease monitoring unreliable. Qualitative MRI has been increasingly used for diagnosing and monitoring pCD and has shown potential for assessing response to treatment. Quantitative MRI sequences, such as diffusion-weighted imaging (DWI), dynamic contrast enhancement (DCE) and magnetisation transfer (MT), along with T2 relaxometry, offer opportunities to improve diagnostic capability. Quantitative MRI sequences (DWI, DCE, MT and T2) were used in a cohort of 25 pCD patients before and 12 weeks after biological therapy at two different field strengths (1.5 and 3 T). Disease activity was measured with the Perianal Crohn's Disease Activity index (PDAI) and serum C-reactive protein (CRP). Diseased tissue areas on MRI were defined by a radiologist. A baseline model to predict outcome at 12 weeks was developed. No differences were seen in the quantitative MR measured in the diseased tissue regions from baseline to 12 weeks; however, PDAI and CRP decreased. Baseline PDAI, CRP, T2 relaxometry and surgical history were found to have a moderate ability to predict response after 12 weeks of biological treatment. Validation in larger cohorts with MRI and clinical measures are needed in order to further develop the model.
Collapse
Affiliation(s)
- Ali Alyami
- Department of Diagnostic Radiography Technology, College of Applied Medical Sciences, Jazan University, Jazan 45142, Saudi Arabia;
- Translational Medical Sciences Academic Unit, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham NG7 2UH, UK;
- National Institute of Health Research Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK; (C.L.H.); (C.T.); (P.A.G.)
| | - Caroline L. Hoad
- National Institute of Health Research Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK; (C.L.H.); (C.T.); (P.A.G.)
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham NG7 2QX, UK
| | - Christopher Tench
- National Institute of Health Research Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK; (C.L.H.); (C.T.); (P.A.G.)
- Division of Clinical Neurosciences, Clinical Neurology, University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK
| | - Uday Bannur
- Department of Radiology, Queens Medical Centre Campus, Nottingham University Hospitals, Nottingham NG7 2UH, UK; (U.B.); (C.C.); (K.L.)
| | - Christopher Clarke
- Department of Radiology, Queens Medical Centre Campus, Nottingham University Hospitals, Nottingham NG7 2UH, UK; (U.B.); (C.C.); (K.L.)
| | - Khalid Latief
- Department of Radiology, Queens Medical Centre Campus, Nottingham University Hospitals, Nottingham NG7 2UH, UK; (U.B.); (C.C.); (K.L.)
| | - Konstantinos Argyriou
- Translational Medical Sciences Academic Unit, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham NG7 2UH, UK;
| | - Alan Lobo
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK;
| | - Philip Lung
- Department of Radiology, St Mark’s Hospital and Academic Institute, London North West Healthcare NHS Trust, London HA1 3UJ, UK; (P.L.); (R.B.-C.)
| | - Rachel Baldwin-Cleland
- Department of Radiology, St Mark’s Hospital and Academic Institute, London North West Healthcare NHS Trust, London HA1 3UJ, UK; (P.L.); (R.B.-C.)
| | - Kapil Sahnan
- Fistula Research Unit, St Mark’s Hospital and Academic Institute, London North West Healthcare NHS Trust, London HA1 3UJ, UK; (K.S.); (A.H.)
| | - Ailsa Hart
- Fistula Research Unit, St Mark’s Hospital and Academic Institute, London North West Healthcare NHS Trust, London HA1 3UJ, UK; (K.S.); (A.H.)
| | - Jimmy K. Limdi
- Department of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Greater Manchester, Crumpsall M8 5RB, UK;
| | - John Mclaughlin
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford M6 8HD, UK;
| | - David Atkinson
- Centre for Medical Imaging, University College London, London W1W 7TS, UK;
| | - Geoffrey J. M. Parker
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London WC1V 6LJ, UK;
- Bioxydyn Limited, Manchester M15 6SZ, UK
| | - James P. B. O’Connor
- Quantitative Biomedical Imaging Laboratory, Division of Cancer Science, University of Manchester, Manchester M13 9PL, UK (R.A.L.)
| | - Ross A. Little
- Quantitative Biomedical Imaging Laboratory, Division of Cancer Science, University of Manchester, Manchester M13 9PL, UK (R.A.L.)
| | - Penny A. Gowland
- National Institute of Health Research Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK; (C.L.H.); (C.T.); (P.A.G.)
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham NG7 2QX, UK
| | - Gordon W. Moran
- Translational Medical Sciences Academic Unit, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham NG7 2UH, UK;
- National Institute of Health Research Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK; (C.L.H.); (C.T.); (P.A.G.)
| |
Collapse
|
10
|
Adegbola SO, Dibley L, Sahnan K, Wade T, Verjee A, Sawyer R, Mannick S, McCluskey D, Bassett P, Yassin N, Warusavitarne J, Faiz O, Phillips R, Tozer PJ, Norton C, Hart AL. Development and initial psychometric validation of a patient-reported outcome measure for Crohn's perianal fistula: the Crohn's Anal Fistula Quality of Life (CAF-QoL) scale. Gut 2021; 70:1649-1656. [PMID: 33272978 PMCID: PMC8355881 DOI: 10.1136/gutjnl-2019-320553] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 08/22/2020] [Accepted: 10/29/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Crohn's perianal fistulas are challenging for patients and clinicians. Many do not respond to available treatments and despite recommendations by a global consensus, there are currently no specific patient-derived quality of life tools to measure response to treatment. We present a new validated patient-reported outcome measure (PROM) for this complicated disease phenotype. METHODS A draft questionnaire was generated using unstructured qualitative patient interviews on the experience of living with Crohn's perianal fistula, a nationwide multidisciplinary consensus exercise, a systematic review of outcomes assessing medical/surgical/combined treatment and a patient and public involvement day. Psychometric properties were assessed including construct validity (by comparison with the Hospital Anxiety and Depression Scale (HADS) and the UK Inflammatory Bowel Disease Questionnaire (UK-IBDQ)), and reliability and responsiveness was assessed by test-retest analysis. RESULTS Data from 211 patients contributed to development of a final 28-item questionnaire. The Crohn's Anal Fistula Quality of Life (CAF-QoL) demonstrated good internal consistency (Cronbach's alpha 0.88), excellent stability (intraclass correlation 0.98) and good responsiveness and construct validity, with positive correlation with the UK-IBDQ and HADS. CONCLUSION The CAF-QoL scale is ready for use as a PROM in research and clinical practice. It complements objective clinical evaluation of fistula by capturing impact on the patient.
Collapse
Affiliation(s)
- Samuel O Adegbola
- Surgery and Cancer, Imperial College London, London, UK .,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Lesley Dibley
- Faculty of Education, Health and Human Sciences, University of Greenwich, London, UK
| | - Kapil Sahnan
- Surgery and Cancer, Imperial College London, London, UK,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Tiffany Wade
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Azmina Verjee
- CAF-QoL Patient and Public Involvement Team, London, UK
| | - Rachel Sawyer
- CAF-QoL Patient and Public Involvement Team, London, UK
| | | | | | - Paul Bassett
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Nuha Yassin
- Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Janindra Warusavitarne
- Surgery and Cancer, Imperial College London, London, UK,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Omar Faiz
- Surgery and Cancer, Imperial College London, London, UK,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Robin Phillips
- Surgery and Cancer, Imperial College London, London, UK,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Phil J Tozer
- Surgery and Cancer, Imperial College London, London, UK,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Ailsa L Hart
- Surgery and Cancer, Imperial College London, London, UK,Robin Phillips Fistula Research Unit, St Mark's Hospital and Academic Institute, London, UK
| |
Collapse
|
11
|
Caron B, D'Amico F, Danese S, Peyrin-Biroulet L. Endpoints for Perianal Crohn's Disease Trials: Past, Present and Future. J Crohns Colitis 2021; 15:1387-1398. [PMID: 33550374 DOI: 10.1093/ecco-jcc/jjab026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Since the 1980s, many studies have evaluated the efficacy of therapies to improve the outcomes of patients with perianal Crohn's disease. We performed a systematic review to describe the evolution of endpoints in perianal fistulizing Crohn's disease. Efficacy outcomes, definitions and measurement tools were assessed. METHODS Electronic databases were searched up to November 1, 2020. All published randomized placebo-controlled trials enrolling patients with perianal fistula and Crohn's disease were eligible for inclusion. Ongoing randomized clinical trials were also described. RESULTS Nineteen randomized controlled trials were included. Clinical efficacy endpoints were reported in all trials. Clinical response was the most frequent primary endpoint [6/19 studies, 31.6%], followed by clinical remission in four studies [21%]. Clinical response was defined as closure of at least 50% of fistulas, while remission was defined as closure of all fistulas. A combined clinical and radiological primary endpoint was used to assess fistula healing in four studies [21%]. The Perianal Disease Activity Index was a primary endpoint in only one study [5.5%]. In addition, eight ongoing controlled trials were identified. Combined clinical and radiological remission was the most frequent primary endpoint in these studies [4/8, 50%]. CONCLUSION In this systematic review, significant changes in outcomes used in randomized clinical trials of perianal Crohn's disease were observed. Radiological endpoints are increasingly used in perianal fistulizing Crohn's disease trials.
Collapse
Affiliation(s)
- Bénédicte Caron
- Department of Gastroenterology and Inserm NGERE U1256, Nancy University Hospital, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Ferdinando D'Amico
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Gastroenterology, IBD Center, Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Gastroenterology, IBD Center, Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, Nancy University Hospital, University of Lorraine, Vandoeuvre-lès-Nancy, France
| |
Collapse
|
12
|
Vasudevan A, Bruining DH, Loftus EV, Faubion W, Ehman EC, Raffals L. Approach to medical therapy in perianal Crohn's disease. World J Gastroenterol 2021; 27:3693-3704. [PMID: 34321838 PMCID: PMC8291021 DOI: 10.3748/wjg.v27.i25.3693] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/13/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023] Open
Abstract
Perianal Crohn's disease remains a challenging condition to treat and can have a substantial negative impact on quality of life. It often requires combined surgical and medical interventions. Anti-tumor necrosis factor (anti-TNF) therapy, including infliximab and adalimumab, remain preferred medical therapies for perianal Crohn's disease. Infliximab has been shown to be efficacious in improving fistula closure rates in randomized controlled trials. Clinicians can be faced with a number of questions relating to the optimal use of anti-TNF therapy in perianal Crohn's disease. Specific issues include evaluation for the presence of perianal sepsis, the treatment target of therapy, the ideal time to commence treatment, whether additional medical therapy should be used in conjunction with anti-TNF therapy, and the duration of treatment. This article will discuss key studies which can assist clinicians in addressing these matters when they are considering or have already commenced anti-TNF therapy for the treatment of perianal Crohn's disease. It will also discuss current evidence regarding the use of vedolizumab and ustekinumab in patients who are failing to achieve a response to anti-TNF therapy for perianal Crohn's disease. Lastly, new therapies such as local injection of mesenchymal stem cell therapy will be discussed.
Collapse
Affiliation(s)
- Abhinav Vasudevan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - Edward V Loftus Jr
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - William Faubion
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| | - Eric C Ehman
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, United States
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
| |
Collapse
|
13
|
Hashash JG, Mourad FH. Perianal Fistulizing Crohn's Disease: No Shortcuts to a Deep Understanding of the Disease. Dig Dis Sci 2021; 66:1392-1393. [PMID: 32833159 DOI: 10.1007/s10620-020-06549-z] [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: 12/09/2022]
Affiliation(s)
- Jana G Hashash
- Division of Gastroenterology, American University of Beirut, Beirut, Lebanon.
| | - Fadi H Mourad
- Division of Gastroenterology, American University of Beirut, Beirut, Lebanon
| |
Collapse
|
14
|
Lee T, Kamm MA, Bell S, Lust M, Brown S, Niewiadomski O, Basnayake C, Wright E, D'Souza B, Woods R, Wei SC, Connell W, Thompson A, Yong E, Ding NS. Long-term outcomes of perianal fistulizing Crohn's disease in the biologic era. JGH OPEN 2020; 5:235-241. [PMID: 33553661 PMCID: PMC7857282 DOI: 10.1002/jgh3.12475] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/21/2020] [Accepted: 11/30/2020] [Indexed: 11/08/2022]
Abstract
Background and Aim While the advent of biologic therapy has led to improved outcomes in perianal fistulizing Crohn's disease (pfCD), loss of response is common. Previous studies suggest that patients who achieve radiological healing (with healing of underlying tracts on magnetic resonance imaging [MRI]) have a longer duration of response. The aim of this study was to characterize MRI outcomes of pfCD at a specialist inflammatory bowel disease (IBD) unit and compare the long-term clinical outcomes between patients achieving MRI and clinical healing. Methods A retrospective analysis of perianal fistulizing Crohn's patients treated at one specialist IBD unit was performed. Records were reviewed for patient demographics, disease history, clinical assessments, investigation results, and disease flares. Clinical remission was defined as closure of all baseline fistula openings. Radiological healing was defined as the absence of any T2-hyperintense sinuses, tracts, or collections. The primary end-point was rate of MRI healing. The secondary outcome was defined as flare-free period (time between clinical or radiological healing and patients' first signs/symptoms requiring therapy escalation). Results A total of 93 patients were included, with a median follow-up of 4.8 years (interquartile range, 2.4-6 years). Of 44 patients, 22 (50%) achieved clinical remission, while 15 of 93 (16%) achieved radiological healing. Of 22 patients, 10 (45%) with clinical remission had a subsequent disease flare (median time of 7 months) compared with 3 of 15 (20%) patients with MRI healing (median time of 3.6 years). Radiological healing was associated with a significantly longer flare-free period (P = 0.01). Conclusion Radiological healing occurs less commonly but represents a deeper form of healing, associated with improved long-term clinical outcomes.
Collapse
Affiliation(s)
- Tanya Lee
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Michael A Kamm
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Sally Bell
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Mark Lust
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Steve Brown
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Ola Niewiadomski
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Chamara Basnayake
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Emily Wright
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Basil D'Souza
- Department of Colorectal Surgery St Vincent's Hospital Melbourne Victoria Australia
| | - Rodney Woods
- Department of Colorectal Surgery St Vincent's Hospital Melbourne Victoria Australia
| | - Shu Chen Wei
- Department of Internal Medicine National Taiwan University Hospital and College of Medicine Taipei Taiwan
| | - William Connell
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Alexander Thompson
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Eric Yong
- Department of Radiology St Vincent's Hospital Melbourne Victoria Australia
| | - Nik Sheng Ding
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| |
Collapse
|
15
|
Wang WG, Lu WZ, Yang CM, Yu KQ, He HB. Modified Van Assche magnetic resonance imaging-based score for assessing the clinical status of anal fistulas. Medicine (Baltimore) 2020; 99:e20075. [PMID: 32384475 PMCID: PMC7440082 DOI: 10.1097/md.0000000000020075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The modified Van Assche magnetic resonance imaging (MRI)-based score is a feasible system to assess the clinical status of anal fistulas in Crohn disease. In this study, we evaluated this score's association with clinical status in patients with anal fistulas (AFs).We included all patients with AF who underwent contrast-enhanced pelvic MRI and surgery between January 2011 and December 2016. The score was evaluated retrospectively preoperatively and 1, 3, and 6 months postoperatively. Univariate and multivariate analyses of the risk factors for AF recurrence were also performed.We retrospectively analyzed data for 104 patients. Twelve (11.5%) patients developed AF recurrence. We classified patients' preoperative clinical status into three grades: 52 (50.0%) grade A, 31 (29.8%) grade B, and 21 (20.2%) grade C. The preoperative MRI-based score was significantly correlated with patients' preoperative clinical status grade (Pearson correlation: 0.547; P < .001). The 3 preoperative clinical status grades showed significant (F = 23.303, P < .001) tendencies for associations with lower respective MRI-based scores. The incidence of AF recurrence decreased with the MRI-based score to 1-month postoperatively, then gradually increased (F = 60.863, P = .000). Long duration of disease, prior interventions, and high MRI-based score were independent risk factors for AF recurrence.The MRI-based score objectively assessed the clinical status and disease activity of patients with AFs, with a high score being associated with severe clinical status and long recovery time.
Collapse
Affiliation(s)
- Wei-Guo Wang
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University
| | - Wen-Zhu Lu
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University
| | - Chun-Mei Yang
- Department of Integrated Traditional Chinese and Western Medicine, Cheng Du Shang Jin Nan Fu Hospital, Chengdu, Sichuan Province, China
| | - Ke-Qiang Yu
- Department of Integrated Traditional Chinese and Western Medicine, Cheng Du Shang Jin Nan Fu Hospital, Chengdu, Sichuan Province, China
| | - Hong-Bo He
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University
| |
Collapse
|
16
|
Halligan S, Tolan D, Amitai MM, Hoeffel C, Kim SH, Maccioni F, Morrin MM, Mortele KJ, Rafaelsen SR, Rimola J, Schmidt S, Stoker J, Yang J. ESGAR consensus statement on the imaging of fistula-in-ano and other causes of anal sepsis. Eur Radiol 2020; 30:4734-4740. [PMID: 32307564 PMCID: PMC7431441 DOI: 10.1007/s00330-020-06826-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 03/19/2020] [Indexed: 12/15/2022]
Abstract
Objectives To develop imaging guidelines for patients with fistula-in-ano and other causes of anal sepsis. Methods An expert group of 13 members of the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) used a modified Delphi process to vote on a series of consensus statements relating to the imaging of patients with potential anal sepsis. Participants first completed a questionnaire to gather practice information and to help frame the statements posed. Results In the first round of voting, the expert group scored 51 statements of which 45 (88%) achieved immediate consensus. The remaining 6 statements were redrafted following input from the expert group and consensus achieved for all during a second round of voting, including an additional statement drafted. No statement was rejected due to a lack of consensus. After redrafting to improve clarity, 53 individual statements were presented. Conclusion These expert consensus statements can be used to guide appropriate indication, acquisition, interpretation and reporting of medical imaging for patients with potential fistula-in-ano and other causes of anal sepsis. Key Points • Medical imaging, notably magnetic resonance imaging, is used widely for the diagnosis and monitoring of fistula-in-ano and other causes of anal and perianal sepsis. • While the indexed medical literature is clear that diagnostic accuracy is potentially excellent, this depends on competent image acquisition and interpretation. • In order to facilitate this, the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) has produced expert consensus guidelines regarding the imaging of fistula-in-ano and related conditions. Electronic supplementary material The online version of this article (10.1007/s00330-020-06826-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- S Halligan
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK.
| | - D Tolan
- Department of Radiology, St James's University Hospital, Leeds Teaching Hospitals Trust, Leeds, UK
| | - M M Amitai
- Department of Radiology, Sackler Faculty of Medicine, Tel Aviv University, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - C Hoeffel
- Department of Radiology, Hôpital Robert-Debré, Reims, France
| | - S H Kim
- Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, South Korea
| | - F Maccioni
- Department of Radiological Sciences, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - M M Morrin
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - K J Mortele
- Division of Abdominal Imaging, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - S R Rafaelsen
- Colorectal Centre of Excellence, University Hospital of Southern Denmark, Vejle, Denmark
| | - J Rimola
- Radiology Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - S Schmidt
- Department of Radiology, University Hospital, CHUV, Lausanne, Switzerland
| | - J Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - J Yang
- Department of Radiology, Concord Hospital, Sydney, Australia
| |
Collapse
|
17
|
Predictors of long-term outcomes of radiologically defined perianal fistulizing Crohn's disease treated with antitumor necrosis factor-alpha agents based on Parks' classification. Eur J Gastroenterol Hepatol 2020; 32:187-192. [PMID: 31851087 DOI: 10.1097/meg.0000000000001634] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Perianal fistulizing Crohn's disease (PFCD) leads to significant disability. Data assessing healing of complex PFCD based on pelvic MRI using Parks' classification remains sparse. We aimed to assess the frequency of closure of fistula tract on MRI in patients treated with antitumor necrosis factor alpha antagonists and identify predictors of poor response. MATERIALS AND METHODS We retrospectively identified patients registered in the Saudi Inflammatory Bowel Disease Information System registry, who were diagnosed as PFCD based on MRI and treated with infliximab or adalimumab. Fistulae were classified based on Parks' classification and response to treatment was determined as full, partial, or no response, after at least 12 months of treatment. RESULTS Out of 960 patients, 61 had complex PFCD that required treatment with an anti-TNF agent. The median age was 27 years (range: 14-69 years) and the median duration of disease was 6.2 ± 5.8 years. A full response to treatment was achieved in 27 (44.4%), whereas 10 patients (16.3%) had partial response and 24 (39.3%) had no response. On univariable analysis, a statistically significant association was observed between poor fistula response and low BMI, rectal involvement, fistulae classification, and the presence of an abscess. According to multivariable regression, only low BMI predicted poor fistulae outcome (odds ratio = 1.37, 95% confidence interval: 0.69-0.98). CONCLUSION Less than half of this cohort of patients with PFCD achieved complete radiological fistula healing with anti-TNF therapy. Low BMI appears to be the only predictor of poor outcome.
Collapse
|
18
|
|
19
|
Lee T, Yong E, Ding NS. Radiological outcomes in perianal fistulizing Crohn's disease: A systematic review and meta-analysis. JGH OPEN 2019; 4:340-344. [PMID: 32514434 PMCID: PMC7273731 DOI: 10.1002/jgh3.12295] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 12/01/2019] [Indexed: 12/17/2022]
Abstract
Perianal fistulas are a common and debilitating manifestation of Crohn's disease. Since the advent of biological agents, patient outcomes appear to have improved. While rates of clinical response and remission are well characterized in literature, magnetic resonance imaging (MRI) outcomes remain less so. This is despite previous studies demonstrating the persistence of fistula tracts on MRI, in spite of clinical healing, suggesting radiological markers of improvement may be more accurate. The aims of this study were to systematically review the literature for all studies reporting on MRI outcomes following biological therapy and to compare rates of radiological healing to clinical remission. A search was performed according to the Preferred Reporting Items For Systematic Reviews and Meta‐Analysis (PRISMA) guidelines. Nine articles were included, with a total sample size of 259 patients. Of these 259 patients, 47% achieved clinical remission following induction therapy and 42% following a median of 52 weeks' maintenance therapy. Out of the 259 patients, 7% achieved radiological healing in the short term and 25% in the long term. The odds ratio of MRI versus clinical healing was 0.10 (95% confidence interval [CI], 0.02–0.39) and 0.43 (95% CI, 0.26–0.71), respectively, at those corresponding time points. MRI healing of perianal fistulizing Crohn's, while arguably a more accurate assessment of treatment response, is significantly less common than clinical remission. Heterogeneity exists in the definition of radiological and clinical response, leading to variation in reported rates. Further studies, directly comparing the long‐term outcomes of patients achieving clinical remission and MRI healing are required, to better inform the role of MRI follow up in clinical practice.
Collapse
Affiliation(s)
- Tanya Lee
- St Vincent's Clinical School University of Melbourne Melbourne Victoria Australia
| | - Eric Yong
- Department of Radiology St Vincent's Hospital Melbourne Victoria Australia
| | - Nik S Ding
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia
| |
Collapse
|
20
|
van Rijn KL, Lansdorp CA, Tielbeek JAW, Nio CY, Buskens CJ, D'Haens GRAM, Löwenberg M, Stoker J. Evaluation of the modified Van Assche index for assessing response to anti-TNF therapy with MRI in perianal fistulizing Crohn's disease. Clin Imaging 2019; 59:179-187. [PMID: 31821976 DOI: 10.1016/j.clinimag.2019.10.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/04/2019] [Accepted: 10/03/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Structured evaluation of magnetic resonance imaging (MRI) is important to guide clinical decisions of perianal fistulas in Crohn's disease (CD) patients. PURPOSE To evaluate the recently developed modified Van Assche index to assess clinical responses to anti-tumor necrosis factor (TNF) therapy in patients with perianal fistulizing CD. METHODS A search of medical records identified patients with fistulizing perianal CD who underwent baseline and follow-up MRI while receiving anti-TNF treatment. Patients were divided into clinical responders and non-responders based on physician's assessment. MRI-scans were scored using the original and modified Van Assche index and scores between baseline and follow-up were compared within clinical responders and non-responders. RESULTS Thirty cases were included (48% female, median age 27 years). Clinical responders (n = 16) had a median modified Van Assche score of 9.6 (IQR 5.8-12.7) at baseline and 5.8 (IQR 3.5-8.5) at follow-up (p = 0.008). In non-responders (n = 14), corresponding scores were 7.7 (IQR 5.8-13.5) and 8.2 (IQR 5.8-11.5) (p = 0.624). In clinical responders, 6/16 showed no drop in modified Van Assche score at follow-up. Scores obtained with the original Van Assche index dropped between baseline and follow-up in clinical responders (13.0 vs. 9.6, p = 0.011), whereas no decrease was observed in non-responders (11.5 vs. 11.5, p = 0.324). CONCLUSIONS While the modified Van Assche index overall decreases significantly in patients with perianal fistulas responding to anti-TNF treatment, one third of responders had unaltered scores at follow-up. Also, outcomes were comparable to the original Van Assche index. Further optimization of the modified Van Assche index is needed before application in larger studies.
Collapse
Affiliation(s)
- Kyra L van Rijn
- Amsterdam UMC, University of Amsterdam, Department of Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, the Netherlands.
| | - Corine A Lansdorp
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jeroen A W Tielbeek
- Amsterdam UMC, University of Amsterdam, Department of Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, the Netherlands
| | - C Yung Nio
- Amsterdam UMC, University of Amsterdam, Department of Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, the Netherlands
| | - Christianne J Buskens
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Meibergdreef 9, the Netherlands
| | - Geert R A M D'Haens
- Amsterdam UMC, University of Amsterdam, Department of Gastroenterology and Hepatology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Mark Löwenberg
- Amsterdam UMC, University of Amsterdam, Department of Gastroenterology and Hepatology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jaap Stoker
- Amsterdam UMC, University of Amsterdam, Department of Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, the Netherlands
| |
Collapse
|
21
|
Hindryckx P, Jairath V, Zou G, Feagan BG, Sandborn WJ, Stoker J, Khanna R, Stitt L, van Viegen T, Shackelton LM, Taylor SA, Santillan C, Mearadji B, D'Haens G, Richard MP, Panes J, Rimola J. Development and Validation of a Magnetic Resonance Index for Assessing Fistulas in Patients With Crohn's Disease. Gastroenterology 2019; 157:1233-1244.e5. [PMID: 31336124 DOI: 10.1053/j.gastro.2019.07.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 07/12/2019] [Accepted: 07/16/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS There is no validated magnetic resonance imaging (MRI) index for assessment of perianal fistulas in patients with Crohn's disease (CD). We developed and internally validated a new instrument. METHODS We used paired baseline and week-24 MRI scans from 160 participants in a randomized placebo-controlled trial of stem cell therapy for patients with perianal fistulizing CD. Four radiologists scored disease activity using index items identified during previous studies and exploratory items. Reliability was assessed using intraclass correlation coefficients. We developed an index using backward elimination linear regression analysis, in which potential independent variables were items having intraclass correlation coefficients of at least 0.4 and the dependent variable was perianal fistulizing disease activity, measured on a 100-mm visual analogue scale. The final model was internally validated using the .632 bootstrap method to correct model optimism and quantify calibration accuracy. We evaluated responsiveness of the index by assessing longitudinal validity and estimating standardized effect sizes. RESULTS We developed the magnetic resonance novel index for fistula imaging in CD (MAGNIFI-CD) using 6 items. The optimism-corrected R2 of the model was 0.71, which was comparable to R2 for the original sample (0.74). The calibration slope for the model was 0.98. Compared with the original and modified versions of the Van Assche Index, the MAGNIFI-CD had improved operating characteristics. Estimates of intraclass correlation coefficients for MAGNIFI-CD, the modified Van Assche Index, and Van Assche Index were 0.85 (95% confidence interval [CI], 0.77-0.90), 0.81 (95% CI, 0.74-0.86), and 0.81 (95% CI, 0.71-0.86) for intra-rater reliability, and 0.74 (95% CI, 0.63-0.80), 0.67 (95% CI, 0.55-0.75) and 0.68 (95% CI, 0.56-0.77) for inter-rater reliability. Corresponding standardized effect size estimates were 1.02 (95% CI, 0.65-1.39), 0.84 (95% CI, 0.48-1.21), and 0.68 (95% CI, 0.33-1.03). CONCLUSIONS We developed an index called the MAGNIFI-CD, which is based on 6 items. It assesses MRI data and determines perianal fistulizing CD activity with improved operating characteristics compared to previous indices. This index may be used as an outcome measure in clinical trials comparing treatment effects in patients with perianal fistulizing CD. Although the performance of the MAGNIFI-CD indicates its stability and reasonable external validity, external validation is needed.
Collapse
Affiliation(s)
- Pieter Hindryckx
- Robarts Clinical Trials, Inc, London, Ontario, Canada; Department of Gastroenterology, University of Ghent, Ghent, Belgium
| | - Vipul Jairath
- Robarts Clinical Trials, Inc, London, Ontario, Canada; Department of Medicine, Division of Gastroenterology, University of Western Ontario, London, Ontario, Canada; Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada.
| | - Guangyong Zou
- Robarts Clinical Trials, Inc, London, Ontario, Canada; Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - Brian G Feagan
- Robarts Clinical Trials, Inc, London, Ontario, Canada; Department of Medicine, Division of Gastroenterology, University of Western Ontario, London, Ontario, Canada; Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - William J Sandborn
- Robarts Clinical Trials, Inc, London, Ontario, Canada; Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Reena Khanna
- Robarts Clinical Trials, Inc, London, Ontario, Canada; Department of Medicine, Division of Gastroenterology, University of Western Ontario, London, Ontario, Canada
| | - Larry Stitt
- Robarts Clinical Trials, Inc, London, Ontario, Canada; Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | | | | | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Cynthia Santillan
- Department of Radiology, University of California San Diego, La Jolla, California
| | - Banafsche Mearadji
- Department of Radiology and Nuclear Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Geert D'Haens
- Robarts Clinical Trials, Inc, London, Ontario, Canada; Inflammatory Bowel Disease Centre, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Julian Panes
- Department of Gastroenterology, Hospital Clínic de Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain
| |
Collapse
|
22
|
Sturm A, Maaser C, Calabrese E, Annese V, Fiorino G, Kucharzik T, Vavricka SR, Verstockt B, van Rheenen P, Tolan D, Taylor SA, Rimola J, Rieder F, Limdi JK, Laghi A, Krustiņš E, Kotze PG, Kopylov U, Katsanos K, Halligan S, Gordon H, González Lama Y, Ellul P, Eliakim R, Castiglione F, Burisch J, Borralho Nunes P, Bettenworth D, Baumgart DC, Stoker J. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 2: IBD scores and general principles and technical aspects. J Crohns Colitis 2019; 13:273-284. [PMID: 30137278 DOI: 10.1093/ecco-jcc/jjy114] [Citation(s) in RCA: 215] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Andreas Sturm
- Department of Gastroenterology, DRK Kliniken Berlin I Westend, Berlin, Germany
| | - Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Emma Calabrese
- Department of Systems Medicine, University of Rome, Tor Vergata, Italy
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic & American Hospital, Dubai, UAE
| | - Gionata Fiorino
- Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | | | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven and CHROMETA - Translational Research in Gastrointestinal Disorders, KU Leuven, Belgium
| | - Patrick van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, Groningen, The Netherlands
| | - Damian Tolan
- Clinical Radiology, St James's University Hospital, Leeds, UK
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester; Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Andrea Laghi
- Department of Clinical and Surgical Translational Medicine, Sapienza - University of Rome, Rome, Italy
| | - Eduards Krustiņš
- Department of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Paraná PUCPR, Curitiba, Brazil
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Hannah Gordon
- Section of Gastroenterology & Hepatology, Royal London Hospital, London, UK
| | - Yago González Lama
- Department of Gastroenterology, University Hospital Puerta De Hierro, Majadahonda Madrid, Spain
| | - Pierre Ellul
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Fabiana Castiglione
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital; Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Paula Borralho Nunes
- Department of Anatomic Pathology, Hospital Cuf Descobertas; Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, Münster, Germany
| | - Daniel C Baumgart
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Center AMC, University of Amsterdam, Amsterdam, The Netherlands
| | | |
Collapse
|
23
|
|
24
|
Williams G, Williams A, Tozer P, Phillips R, Ahmad A, Jayne D, Maxwell-Armstrong C. The treatment of anal fistula: second ACPGBI Position Statement - 2018. Colorectal Dis 2018; 20 Suppl 3:5-31. [PMID: 30178915 DOI: 10.1111/codi.14054] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 02/16/2018] [Indexed: 02/08/2023]
Abstract
It is over 10 years since the first ACPGBI Position Statement on the management of anal fistula was published in 2007. This second edition is the result of scrutiny of the literature published during this time; it updates the original Position Statement and reviews the published evidence surrounding treatments for anal fistula that have been developed since the original publication.
Collapse
Affiliation(s)
- G Williams
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - A Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - P Tozer
- St Mark's Hospital, Harrow, London, UK
| | | | - A Ahmad
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Jayne
- University of Leeds, Leeds, UK
| | - C Maxwell-Armstrong
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| |
Collapse
|
25
|
Gallego JC, Echarri A. Role of magnetic resonance imaging in the management of perianal Crohn's disease. Insights Imaging 2018; 9:47-58. [PMID: 29143190 PMCID: PMC5825308 DOI: 10.1007/s13244-017-0579-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 09/05/2017] [Accepted: 09/26/2017] [Indexed: 12/18/2022] Open
Abstract
Perianal fistulas are a major problem in many patients with Crohn's disease. These are usually complex fistulas that adversely affect patients' quality of life, and their clinical management is difficult. Medical treatment sometimes achieves cessation of discharge and closure of the external opening; however, it is difficult to assess the status of the rest of the fistula tract. Magnetic resonance imaging is the method of choice with which to evaluate the condition of perianal fistulas and allows for assessment of the status of inaccessible areas. Magnetic resonance imaging also allows the clinician to evaluate other perianal manifestations of Crohn's disease that differ from the fistulas. This imaging technique is therefore a fundamental means of patient monitoring. When used in conjunction with assessment of the patient's morphological findings, it provides information that allows for both quantification of disease severity and evaluation of the response to treatment. New types of magnetic resonance sequences are emerging, such as diffusion, perfusion, and magnetisation transfer. These sequences may serve as biomarkers because they provide information reflecting the changes taking place at the molecular level. This will help to shape a new scenario in the early assessment of the response to treatments such as anti-tumour necrosis factor drugs. TEACHING POINTS • MRI is the method of choice with which to evaluate perianal fistulas. • In perianal Crohn's disease, MRI is a fundamental means of patient monitoring. • The usefulness of the Van Assche score for patient monitoring remains unclear. • New MRI sequences' diffusion, perfusion, and magnetisation transfer may serve as biomarkers.
Collapse
Affiliation(s)
- Jose C Gallego
- Department of Radiology, Complexo Hospitalario Universitario de Ferrol, Av. da Residencia s/n, 15405, Ferrol, Spain.
| | - Ana Echarri
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ferrol, Ferrol, Spain
| |
Collapse
|
26
|
Lefrançois P, Zummo-Soucy M, Olivié D, Billiard JS, Gilbert G, Garel J, Visée E, Manchec P, Tang A. Diagnostic performance of intravoxel incoherent motion diffusion-weighted imaging and dynamic contrast-enhanced MRI for assessment of anal fistula activity. PLoS One 2018; 13:e0191822. [PMID: 29370278 PMCID: PMC5784995 DOI: 10.1371/journal.pone.0191822] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 01/11/2018] [Indexed: 12/14/2022] Open
Abstract
Objective To evaluate intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) sequences for quantitative characterization of anal fistula activity. Methods This retrospective study was approved by the institutional review board. One hundred and two patients underwent MRI for clinical suspicion of anal fistula. Forty-three patients with demonstrable anal fistulas met the inclusion criteria. Quantitative analysis included measurement of DCE and IVIM parameters. The reference standard was clinical activity based on medical records. Statistical analyses included Bayesian analysis with Markov Chain Monte Carlo, multivariable logistic regression, and receiver operating characteristic analyses. Results Brevity of enhancement, defined as the time difference between the wash-in and wash-out, was longer in active than inactive fistulas (p = 0.02). Regression coefficients of multivariable logistic regression analysis revealed that brevity of enhancement increased and normalized perfusion area under curve decreased with presence of active fistulas (p = 0.03 and p = 0.04, respectively). By cross-validation, a logistic regression model that included quantitative perfusion parameters (DCE and IVIM) performed significantly better than IVIM only (p < 0.001). Area under the curves for distinguishing patients with active from those with inactive fistulas were 0.669 (95% confidence interval [CI]: 0.500, 0.838) for a model with IVIM only, 0.860 (95% CI: 0.742, 0.977) for a model with IVIM and brevity of enhancement, and 0.921 (95% CI: 0.846, 0.997) for a model with IVIM and all DCE parameters. Conclusion The inclusion of brevity of enhancement measured by DCE-MRI improved assessment of anal fistula activity over IVIM-DWI only.
Collapse
Affiliation(s)
- Philippe Lefrançois
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Mathieu Zummo-Soucy
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Damien Olivié
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Jean-Sébastien Billiard
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Guillaume Gilbert
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
- MR Clinical Science, Philips Healthcare Canada, Markham, Ontario, Canada
| | - Juliette Garel
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Emmanuel Visée
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
- Centre Hospitalier Départemental de Vendée, Les Oudairies, La Roche-Sur-Yon, France
| | - Perrine Manchec
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
- Norimagerie, 1,3 chemin du Penthod, Caluire et Cuire, France
| | - An Tang
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
- * E-mail:
| |
Collapse
|
27
|
Abstract
Perianal fistulizing Crohn's disease has a major negative effect on patient quality of life and is a predictor of poor long-term outcomes. Factors involved in the pathogenesis of perianal fistulizing Crohn's disease include an increased production of transforming growth factor β, TNF and IL-13 in the inflammatory infiltrate that induce epithelial-to-mesenchymal transition and upregulation of matrix metalloproteinases, leading to tissue remodelling and fistula formation. Care of patients with perianal Crohn's disease requires a multidisciplinary approach. A complete assessment of fistula characteristics is the basis for optimal management and must include the clinical evaluation of fistula openings, endoscopic assessment of the presence of proctitis, and MRI to determine the anatomy of fistula tracts and presence of abscesses. Local injection of mesenchymal stem cells can induce remission in patients not responding to medical therapies, or to avoid the exposure to systemic immunosuppression in patients naive to biologics in the absence of active luminal disease. Surgery is still required in a high proportion of patients and should not be delayed when criteria for drug failure is met. In this Review, we provide an up-to-date overview on the pathogenesis and diagnosis of fistulizing Crohn's disease, as well as therapeutic strategies.
Collapse
|
28
|
Samaan MA, Puylaert CAJ, Levesque BG, Zou GY, Stitt L, Taylor SA, Shackelton LM, Vandervoort MK, Khanna R, Santillan C, Rimola J, Hindryckx P, Nio CY, Sandborn WJ, D'Haens G, Feagan BG, Jairath V, Stoker J. The development of a magnetic resonance imaging index for fistulising Crohn's disease. Aliment Pharmacol Ther 2017; 46:516-528. [PMID: 28653753 DOI: 10.1111/apt.14190] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 10/29/2016] [Accepted: 05/24/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is the gold standard for assessment of perianal fistulising Crohn's disease (CD). The Van Assche index is the most commonly used MRI fistula index. AIMS To assess the reliability of the Van Assche index, and to modify the instrument to improve reliability and create a novel index for fistulising CD. METHODS A consensus process developed scoring conventions for existing Van Assche index component items and new items. Four experienced radiologists evaluated 50 MRI images in random order on three occasions. Reliability was assessed by estimates of intraclass correlation coefficients (ICCs). Common sources of disagreement were identified and recommendations made to minimise disagreement. A mixed effects model used a 100 mm visual anologue scale (VAS) for global severity as outcome and component items as predictors to create a modified Van Assche index. RESULTS Intraclass correlation coefficients (95% confidence intervals) for intra-rater reliability of the original and modified Van Assche indices and the VAS were 0.86 (0.81-0.90), 0.90 (0.86-0.93) and 0.86 (0.82-0.89). Corresponding ICCs for inter-rater reliability were 0.66 (0.52-0.76), 0.67 (0.55-0.75) and 0.58 (0.47-0.66). Sources of disagreement included number, location, and extension of fistula tracts, and rectal wall involvement. A modified Van Assche index (range 0-24) was created that included seven component items. CONCLUSIONS Although "almost perfect" intra-rater reliability was observed for the assessment of MRI images for fistulising CD using the Van Assche index, inter-rater reliability was considerably lower. Our modification of this index should result in a more optimal instrument.
Collapse
Affiliation(s)
- M A Samaan
- Department of Gastroenterology, Guy's & St Thomas' Hospital, London, UK.,Robarts Clinical Trials, Inc, London, Canada
| | - C A J Puylaert
- Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - B G Levesque
- Department of Gastroenterology, University of California San Diego, La Jolla, CA, USA.,Robarts Clinical Trials, Inc, San Diego, CA, USA
| | - G Y Zou
- Robarts Clinical Trials, Inc, London, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, Canada
| | - L Stitt
- Robarts Clinical Trials, Inc, London, Canada
| | - S A Taylor
- Department of Medical Imaging, University College London, London, UK
| | | | | | - R Khanna
- Robarts Clinical Trials, Inc, London, Canada.,Department of Medicine, University of Western Ontario, London, Canada
| | - C Santillan
- Department of Radiology, University of California San Diego, La Jolla, CA, USA
| | - J Rimola
- Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - P Hindryckx
- Robarts Clinical Trials, Inc, London, Canada.,Department of Gastroenterology, University Hospital of Ghent, Ghent, Belgium
| | - C Y Nio
- Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - W J Sandborn
- Department of Gastroenterology, University of California San Diego, La Jolla, CA, USA.,Robarts Clinical Trials, Inc, San Diego, CA, USA
| | - G D'Haens
- Department of Gastroenterology, Academic Medical Centre, Amsterdam, The Netherlands.,Robarts Clinical Trials, BV, Amsterdam, The Netherlands
| | - B G Feagan
- Robarts Clinical Trials, Inc, London, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, Canada.,Department of Medicine, University of Western Ontario, London, Canada
| | - V Jairath
- Robarts Clinical Trials, Inc, London, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, Canada.,Department of Medicine, University of Western Ontario, London, Canada
| | - J Stoker
- Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| |
Collapse
|
29
|
Thomassin L, Armengol-Debeir L, Charpentier C, Bridoux V, Koning E, Savoye G, Savoye-Collet C. Magnetic resonance imaging may predict deep remission in patients with perianal fistulizing Crohn's disease. World J Gastroenterol 2017; 23:4285-4292. [PMID: 28694669 PMCID: PMC5483503 DOI: 10.3748/wjg.v23.i23.4285] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 04/03/2017] [Accepted: 05/09/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To evaluate the imaging course of Crohn’s disease (CD) patients with perianal fistulas on long-term maintenance anti-tumor necrosis factor (TNF)-α therapy and identify predictors of deep remission.
METHODS All patients with perianal CD treated with anti-TNF-α therapy at our tertiary care center were evaluated by magnetic resonance imaging (MRI) and clinical assessment. Two MR examinations were performed: at initiation of anti-TNF-α treatment and then at least 2 years after. Clinical assessment (remission, response and non-response) was based on Present’s criteria. Rectoscopic patterns, MRI Van Assche score, and MRI fistula activity signs (T2 signal and contrast enhancement) were collected for the two MR examinations. Fistula healing was defined as the absence of T2 hyperintensity and contrast enhancement on MRI. Deep remission was defined as the association of both clinical remission, absence of anal canal ulcers and healing on MRI. Characteristics and imaging patterns of patients with and without deep remission were compared by univariate and multivariate analyses.
RESULTS Forty-nine consecutive patients (31 females and 18 males) were included. They ranged in age from 14-70 years (mean, 33 years). MRI and clinical assessment were performed after a mean period of exposure to anti-TNF-α therapy of 40 ± 3.7 mo. Clinical remission, response and non-response were observed in 53.1%, 20.4%, and 26.5% of patients, respectively. Deep remission was observed in 32.7% of patients. Among the 26 patients in clinical remission, 10 had persisting inflammation of fistulas on MRI (T2 hyperintensity, n = 7; contrast enhancement, n = 10). Univariate analysis showed that deep remission was associated with the absence of rectal involvement and the absence of switch of anti-TNF-α treatment or surgery requirement. Multivariate analysis demonstrated that only the absence of rectal involvement (OR = 4.6; 95%CI: 1.03-20.5) was associated with deep remission.
CONCLUSION Deep remission is achieved in approximately one third of patients on maintenance anti-TNF-α therapy. Absence of rectal involvement is predictive of deep remission.
Collapse
|
30
|
Bezzio C, Bryant RV, Manes G, Maconi G, Saibeni S. New horizons in the imaging of perianal Crohn's disease: transperineal ultrasonography. Expert Rev Gastroenterol Hepatol 2017; 11:523-530. [PMID: 28319427 DOI: 10.1080/17474124.2017.1309285] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
perianal disease, most commonly manifest as fistula or abscess formation, affects up to 40% of patients with crohn's disease. perianal crohn's disease is disabling, associated with poor outcomes, and represents a therapeutic challenge for physicians. correct diagnosis and classification of perianal disease is the first crucial step for appropriate multidisciplinary management. Areas covered: A literature search was performed of the PubMed database using the terms 'transperineal ultrasonography', 'transperineal ultrasound', 'perianal disease', 'perianal fistula', 'perianal abscess', 'magnetic resonance', 'endoanal ultrasonography', 'endoscopic ultrasound' in combination with 'Crohn's disease'. A comprehensive review of the relative advantages and disadvantages of the various methods of evaluation of perianal Crohn's disease is provided. A particular focus is placed on transperineal ultrasonography, including historical and technical factors, advantages and limitations, and its current role in practice. An algorithm for integration of transperineal ultrasound into the management of perianal Crohn's disease into clinical practice is proposed, along with future areas research. Expert commentary: Transperineal ultrasound is a simple, safe, cheap and reliable imaging technique for evaluation of perianal Crohn's disease, which should be used more frequently in clinical practice.
Collapse
Affiliation(s)
- Cristina Bezzio
- a Gastroenterology Unit , Rho Hospital, ASST Rhodense , Garbagnate Milanese , Italy
| | - Robert V Bryant
- b Department of Gastroenterology and Hepatology , Royal Adelaide Hospital , Adelaide , Australia
| | - Gianpiero Manes
- a Gastroenterology Unit , Rho Hospital, ASST Rhodense , Garbagnate Milanese , Italy
| | - Giovanni Maconi
- c Gastroenterology Unit , Sacco Hospital, ASST Fatebenefratelli-Sacco , Milano , Italy
| | - Simone Saibeni
- a Gastroenterology Unit , Rho Hospital, ASST Rhodense , Garbagnate Milanese , Italy
| |
Collapse
|
31
|
Panes J, Jairath V, Levesque BG. Advances in Use of Endoscopy, Radiology, and Biomarkers to Monitor Inflammatory Bowel Diseases. Gastroenterology 2017; 152:362-373.e3. [PMID: 27751880 DOI: 10.1053/j.gastro.2016.10.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 10/07/2016] [Accepted: 10/11/2016] [Indexed: 02/07/2023]
Abstract
Crohn's disease and ulcerative colitis are heterogeneous inflammatory bowel diseases, and therapeutic requirements vary among patients. We have a limited capacity to predict disease progression for individual patients, therefore it is important that they are evaluated for the presence of active disease when symptoms are mild or even absent, when patients are more likely to respond to new treatment interventions. It then is important to monitor responses to treatment, to quickly identify those therapies that are ineffective, modify or change therapy, and avoid disease complications. Studies are underway to assess the effects of different monitoring strategies. Because of the heavy burden of severe inflammatory bowel disease on patients' health and quality of life, and the association between intestinal healing and disease progression in high-risk patients, a treat-to-target strategy (based on tissue healing) is likely to be optimal.
Collapse
Affiliation(s)
- Julian Panes
- Department of Gastroenterology Hospital Clinic of Barcelona, Institud d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
| | - Vipul Jairath
- Department of Medicine, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
| | - Barrett G Levesque
- Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
| |
Collapse
|
32
|
Jairath V, Levesque BG, Vande Casteele N, Khanna R, Mosli M, Hindryckx P, Travis S, Duijvestein M, Rimola J, Panes J, D'Haens G, Sandborn WJ, Feagan BG. Evolving Concepts in Phases I and II Drug Development for Crohn's Disease. J Crohns Colitis 2017; 11:246-255. [PMID: 27487793 DOI: 10.1093/ecco-jcc/jjw137] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/16/2016] [Accepted: 06/29/2016] [Indexed: 02/08/2023]
Abstract
The highest attrition rates during drug development programmes occur at the proof of concept stage. Given the large number of molecules under development for Crohn's disease, a need exists to improve the efficiency of early drug development by fast-tracking promising agents and terminating ineffective ones. Multiple opportunities are available to achieve these goals, including the use of more responsive outcome measures, and the incorporation of sophisticated pharmacokinetic modelling and/or highly specific pharmacodynamic markers into exposure-based dosing regimens and novel trial designs. In this article we review these strategies and propose an integrated paradigm of early drug development in Crohn's disease.
Collapse
Affiliation(s)
- Vipul Jairath
- Department of Medicine, University of Western Ontario, London, ON, Canada.,Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Barrett G Levesque
- Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Niels Vande Casteele
- Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA.,KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Reena Khanna
- Department of Medicine, University of Western Ontario, London, ON, Canada.,Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada
| | - Mahmoud Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Pieter Hindryckx
- Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,University Hospital of Ghent, Ghent, Belgium
| | - Simon Travis
- Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Marjolijn Duijvestein
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jordi Rimola
- Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Julian Panes
- Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Geert D'Haens
- Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - William J Sandborn
- Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Brian G Feagan
- Department of Medicine, University of Western Ontario, London, ON, Canada .,Robarts Clinical Trials Inc., Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada
| |
Collapse
|
33
|
Tutein Nolthenius CJ, Bipat S, Mearadji B, Spijkerboer AM, Ponsioen CY, Montauban van Swijndregt AD, Stoker J. MRI characteristics of proctitis in Crohn's disease on perianal MRI. Abdom Radiol (NY) 2016; 41:1918-30. [PMID: 27315072 PMCID: PMC5018025 DOI: 10.1007/s00261-016-0802-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose Multiple features have been described for assessing inflammation in Crohn’s disease (CD) in MR enterography, but have not been validated in perianal magnetic resonance imaging (MRI). Retrospectively, we studied which MRI features are valuable in assessing proctitis. Materials and methods CD patients (≥18 years) who underwent colonoscopy (reference standard) and perianal fistula MRI within 8 weeks were included. Seventeen MRI features were blindly scored by three observers and correlated to endoscopy (regression analysis). Reproducibility (multirater kappa, intraclass correlation coefficient) was determined for all three observer pairs. MRI features were considered relevant when significantly correlated to endoscopy for ≥2 observers, and reproducibility was ≥0.40 for ≥2 observer pairs. Results Perianal MRI of 58 CD patients were included. Wall thickness, rectal mural fat, creeping fat, and size of mesorectal lymph nodes showed a significant correlation with endoscopy for ≥2 observers (p = 0.000–0.023, p = 0.011–0.172, p = 0.007–0.011 and p = 0.000–0.005, respectively) with a kappa/intraclass correlation coefficient of ≥0.60 for ≥2 observer pairs. Perimural T2 signal and perimural enhancement significantly correlated to endoscopy (all p values ≤0.05) for all three observers and the reproducibility was ≥0.40 for ≥2 observer pairs. Mural T2 signal and degree and pattern of T1 enhancement showed significant correlation to endoscopy for two observers, but with poor to moderate reproducibility. Conclusion Wall thickness, mural fat, and mesorectal features (perimural T2 signal, perimural enhancement, creeping fat, and size of mesorectal lymph nodes) had significant correlation to endoscopy and were reproducible in diagnosing proctitis. Some established luminal features in MRE were considered not useful.
Collapse
Affiliation(s)
- Charlotte J Tutein Nolthenius
- Department of Radiology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
- Department of Radiology, OLVG, PO Box 99550, 1090 HM, Amsterdam, The Netherlands.
| | - Shandra Bipat
- Department of Radiology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Banafsche Mearadji
- Department of Radiology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Anje M Spijkerboer
- Department of Radiology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 DE, Amsterdam, The Netherlands
| | | | - Jaap Stoker
- Department of Radiology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| |
Collapse
|
34
|
Gecse KB, Sebastian S, Hertogh GD, Yassin NA, Kotze PG, Reinisch W, Spinelli A, Koutroubakis IE, Katsanos KH, Hart A, van den Brink GR, Rogler G, Bemelman WA. Results of the Fifth Scientific Workshop of the ECCO [II]: Clinical Aspects of Perianal Fistulising Crohn's Disease-the Unmet Needs. J Crohns Colitis 2016; 10:758-65. [PMID: 26826183 DOI: 10.1093/ecco-jcc/jjw039] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 01/26/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Perianal fistulas affect up to one-third of Crohn's patients during the course of their disease. Despite the considerable disease burden, current treatment options remain unsatisfactory. The Fifth Scientific Workshop [SWS5] of the European Crohn's and Colitis Organisation [ECCO] focused on the pathophysiology and clinical impact of fistulas in the disease course of patients with Crohn's disease [CD]. METHODS The ECCO SWS5 Working Group on clinical aspects of perianal fistulising Crohn's disease [pCD] consisted of 13 participants, gastroenterologists, colorectal surgeons, and a histopathologist, with expertise in the field of inflammatory bowel diseases. A systematic review of literature was performed. RESULTS Four main areas of interest were identified: natural history of pCD, morphological description of fistula tracts, outcome measures [including clinical and patient-reported outcome measures, as well as magnetic resonance imaging] and randomised controlled trials on pCD. CONCLUSIONS The treatment of perianal fistulising Crohn's disease remains a multidisciplinary challenge. To optimise management, a reliable classification and proper trial endpoints are needed. This could lead to standardised diagnosis, treatment, and follow-up of Crohn's perianal fistulas and the execution of well-designed trials that provide clear answers. The prevalence and the natural history of pCD need further evaluation.
Collapse
Affiliation(s)
- Krisztina B Gecse
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Shaji Sebastian
- Inflammatory Bowel Disease Unit, Hull & East Yorkshire NHS Trust, Hull, UK
| | - Gert de Hertogh
- Department of Pathology, University of Leuven, Leuven, Belgium
| | - Nuha A Yassin
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, London, UK
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Paraná, Curitiba, PR, Brazil
| | - Walter Reinisch
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Antonino Spinelli
- Colorectal Surgery Unit, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | | | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Medicine, School of Health Sciences, Ioannina, Greece
| | - Ailsa Hart
- Inflammatory Bowel Disease Unit, St Mark's Hospital, London, UK
| | - Gijs R van den Brink
- Department of Gastroenterology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerhard Rogler
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
35
|
Marzo M, Felice C, Pugliese D, Andrisani G, Mocci G, Armuzzi A, Guidi L. Management of perianal fistulas in Crohn’s disease: An up-to-date review. World J Gastroenterol 2015; 21:1394-1403. [PMID: 25663759 PMCID: PMC4316082 DOI: 10.3748/wjg.v21.i5.1394] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 11/17/2014] [Accepted: 12/16/2014] [Indexed: 02/06/2023] Open
Abstract
Perianal disease is one of the most disabling manifestations of Crohn’s disease. A multidisciplinary approach of gastroenterologist, colorectal surgeon and radiologist is necessary for its management. A correct diagnosis, based on endoscopy, magnetic resonance imaging, endoanal ultrasound and examination under anesthesia, is crucial for perianal fistula treatment. Available medical and surgical therapies are discussed in this review, including new local treatment modalities that are under investigation.
Collapse
|
36
|
Garros A, Siproudhis L, Tchoundjeu B, Rohou T, Brochard C, Wallenhorst T, Bretagne JF, Bouguen G. Magnetic resonance imaging and clinical assessments for perianal Crohn's disease: gain and limits. Dig Liver Dis 2014; 46:1072-6. [PMID: 25192603 DOI: 10.1016/j.dld.2014.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/26/2014] [Accepted: 08/01/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Assessment of perianal Crohn's disease remains challenging. European Crohn's and Colitis Organisation (ECCO) recommend magnetic resonance imaging (MRI) as a gold standard, but both accuracy and advantages remain limited compared to systematic clinical assessment. The aim of this study was to define their actual diagnostic value. METHODS We performed a retrospective analysis of a prospective database of consecutive patients with perianal Crohn's disease assessed by magnetic resonance imaging and clinical examination from 2006 to 2012. At each outpatient visit, perianal activity (Perianal Disease Activity Index) and perianal phenotype (Cardiff-Hughes classification) were noted. MRI was interpreted according to Cardiff-Hughes and Van Assche classifications. RESULTS Overall, 122 combined evaluations were assessed in 70 patients. Radiological imaging failed to show superficial ulcerations in 20/21 patients (95%) and severe ulcerations in 13/15 patients (87%). It consistently failed to diagnose anal stenosis (n=21, 100%). For fistulising lesions, the global agreement between the two methods was 71/122 (58%) in assessing complex fistulas. Clinical assessment underestimated 44/68 (65%) of multiple or ramified fistula tracts. Clinical examination failed to diagnose half of the radiological abscesses. CONCLUSIONS Current ECCO guidelines should be applied with some caution because of the low sensitivity of MRI for the diagnosis of non-fistulising perianal disease. Combining clinical and MRI assessments improves diagnostic accuracy.
Collapse
Affiliation(s)
- Aurélien Garros
- Department of Hepato-Gastroenterology, University Hospital of Rennes, Pontchaillou, France
| | - Laurent Siproudhis
- Department of Hepato-Gastroenterology, University Hospital of Rennes, Pontchaillou, France; INSERM U991, University of Rennes 1, Rennes, France.
| | - Belinda Tchoundjeu
- Department of Hepato-Gastroenterology, University Hospital of Rennes, Pontchaillou, France
| | - Tanguy Rohou
- Department of Radiology, University Hospital of Rennes, Pontchaillou, France
| | - Charlène Brochard
- Department of Hepato-Gastroenterology, University Hospital of Rennes, Pontchaillou, France
| | - Timothée Wallenhorst
- Department of Hepato-Gastroenterology, University Hospital of Rennes, Pontchaillou, France
| | - Jean-François Bretagne
- Department of Hepato-Gastroenterology, University Hospital of Rennes, Pontchaillou, France
| | - Guillaume Bouguen
- Department of Hepato-Gastroenterology, University Hospital of Rennes, Pontchaillou, France; INSERM U991, University of Rennes 1, Rennes, France
| |
Collapse
|
37
|
Gecse KB, Bemelman W, Kamm MA, Stoker J, Khanna R, Ng SC, Panés J, van Assche G, Liu Z, Hart A, Levesque BG, D'Haens G. A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease. Gut 2014; 63:1381-92. [PMID: 24951257 DOI: 10.1136/gutjnl-2013-306709] [Citation(s) in RCA: 248] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To develop a consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease (pCD), based on best available evidence. METHODS Based on a systematic literature review, statements were formed, discussed and approved in multiple rounds by the 20 working group participants. Consensus was defined as at least 80% agreement among voters. Evidence was assessed using the modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. RESULTS Highest diagnostic accuracy can only be established if a combination of modalities is used. Drainage of sepsis is always first line therapy before initiating immunosuppressive treatment. Mucosal healing is the goal in the presence of proctitis. Whereas antibiotics and thiopurines have a role as adjunctive treatments in pCD, anti-tumour necrosis factor (anti-TNF) is the current gold standard. The efficacy of infliximab is best documented although adalimumab and certolizumab pegol are moderately effective. Oral tacrolimus could be used in patients failing anti-TNF therapy. Definite surgical repair is only of consideration in the absence of luminal inflammation. CONCLUSIONS Based on a multidisciplinary approach, items relevant for fistula management were identified and algorithms on diagnosis and treatment of pCD were developed.
Collapse
Affiliation(s)
- Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Robarts Research Institute, Amsterdam, The Netherlands
| | - Willem Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael A Kamm
- St. Vincent's Hospital and University of Melbourne, Melbourne, Australia
| | - Jaap Stoker
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Reena Khanna
- Robarts Research Institute, London, Ontario, Canada University of Western Ontario, London, Ontario, Canada
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Julián Panés
- Department of Gastroenterology, Hospital Clinic Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Gert van Assche
- Department of Gastroenterology, University of Leuven, Leuven, Belgium
| | - Zhanju Liu
- Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Ailsa Hart
- APRG, Imperial College, London, UK IBD Unit, St. Mark's Hospital, London, UK
| | - Barrett G Levesque
- Robarts Research Institute, San Diego, CA, USA Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Robarts Research Institute, Amsterdam, The Netherlands
| | | | | |
Collapse
|
38
|
Vanbeckevoort D, Bielen D, Vanslembrouck R, Van Assche G. Magnetic resonance imaging of perianal fistulas. Magn Reson Imaging Clin N Am 2014; 22:113-23. [PMID: 24238135 DOI: 10.1016/j.mric.2013.07.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Perianal fistulization is the result of a chronic inflammation of the perianal tissues. A wide spectrum of clinical manifestations, ranging from simple to complex fistulas, can be seen, the latter especially in patients with Crohn disease. Failure to detect secondary tracks and hidden abscesses may lead to therapeutic failure, such as insufficient response to medical treatment and relapse after surgery. Currently, magnetic resonance (MR) imaging is the preferred technique for evaluating perianal fistulas and associated complications. Initially used most often in the preoperative setting, MR imaging now also plays an important role in evaluating the response to medical therapy.
Collapse
Affiliation(s)
- Dirk Vanbeckevoort
- Department of Radiology, University Hospitals Leuven, Herestraat 49, Leuven B-3000, Belgium.
| | | | | | | |
Collapse
|
39
|
MRI-based score helps in assessing the severity and in follow-up of pediatric patients with perianal Crohn disease. J Pediatr Gastroenterol Nutr 2014; 58:252-7. [PMID: 24121148 DOI: 10.1097/mpg.0000000000000199] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The radiologic healing of perianal fistulizing Crohn disease (PfCD) lags behind the clinical healing. Contrast-enhanced pelvic magnetic resonance imaging (MRI) is the radiologic study of choice used to diagnose PfCD in children. The aim was to study whether the various MRI-based radiologic parameters and score can help in staging and follow-up of patients with PfCD. METHODS We performed a retrospective chart review of children with PfCD who underwent contrast-enhanced MRI of the pelvis. The demographic profile, clinical status, and laboratory data of the patients at the time of each MRI examination were noted. Based on the clinical status of the patient at the time of MRI examinations, the MRIs were classified into 3 groups: severe disease, mild-to-moderate disease, and asymptomatic. Each MRI examination was reviewed by a radiologist, who was blinded to the clinical status of the patient. RESULTS Of the radiologic parameters, the number of fistulas, the complexity of fistulas, and the number of abscesses were significantly lower in the asymptomatic group compared with the mild-to-moderate and severe disease groups. The Van Assche MRI-based score was significantly lower in the asymptomatic group compared with the mild-to-moderate disease (P = 0.01) and the severe disease group (P = 0.002). The percentage increase in fistula activity after gadolinium administration was significantly lower in the asymptomatic group compared with the mild-to-moderate disease (P = 0.026) and severe disease (P = 0.019) groups. The MRI-based scores were significantly higher in the MRI examinations performed at diagnosis compared with those that were performed while the patients were receiving the treatment (P = 0.017). CONCLUSIONS The Van Assche MRI score and the percentage increase in fistula activity after gadolinium administration help in assessing the severity perianal Crohn disease. The Van Assche MRI score may be helpful in documenting healing during therapy of perianal Crohn disease.
Collapse
|
40
|
Di Nardo G, Aloi M, Oliva S, Civitelli F, Casciani E, Cucchiara S. Investigation of small bowel in pediatric Crohn's disease. Inflamm Bowel Dis 2012; 18:1760-76. [PMID: 22275336 DOI: 10.1002/ibd.22885] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Accepted: 12/28/2011] [Indexed: 12/16/2022]
Abstract
Investigation of the small bowel has been traditionally a challenge for pediatric gastroenterologists due to its location, anatomical tortuosity, and invasiveness of the available techniques. Recently, there has been a remarkable improvement in imaging and endoscopic tools aimed at exploring successfully the small intestine in inflammatory bowel disease. The former are represented by ultrasonography (either alone or with administration of oral contrast agents) and by magnetic resonance: both have provided accurate methods to detect structural bowel changes, diminishing patient discomfort and precluding radiation hazard. The use of traditional radiologic techniques such as fluoroscopy have been markedly reduced due to radiation exposure and inability to depict transmural inflammation or extraluminal complications. Among the novel endoscopic tools, capsule endoscopy and balloon-assisted enteroscopy have tremendously opened new diagnostic and therapeutic perspectives, by allowing the direct visualization of small intestinal mucosa and, through enteroscopy, histological diagnosis as well as therapeutic interventions such as stricture dilation and bleeding treatment. These endoscopic techniques should always be preceded by imaging of the intestine in order to identify strictures. This review describes the most recent progress with the employment of novel imaging and endoscopic methodologies for investigating the small bowel in children with suspected or established Crohn's disease.
Collapse
Affiliation(s)
- Giovanni Di Nardo
- Department od Pediatrics and Infantile Neuropsychiatry, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, University Hospital Umberto I, Rome, Italy
| | | | | | | | | | | |
Collapse
|