Is there a role of magnetic resonance imaging in deciding to stop anti-tumor necrosis factor treatment in ileal Crohn's disease?

Clinical utilization of magnetic resonance enterography in small bowel Crohn's disease management: a retrospective tertiary centre experience

BACKGROUND

Magnetic resonance enterography (MRE) is the mainstay imaging modality in the evaluation of small bowel Crohn's disease (CD) activity and its associated complications. Few studies have assessed the indications for ordering it and its association with management changes. The objective was to identify the current clinical utilization of MRE and associated management changes in patients with established small bowel CD.

METHODS

A retrospective audit was conducted on all patients with established CD who underwent MRE at a tertiary centre from November 2014 to December 2017. Clinical indications, radiological findings and management changes were obtained from patient records.

RESULTS

A total of 220 patients underwent a total of 287 MRE examinations. The most common indications for ordering MREs were based on patient symptoms (n = 204, 71.1%) and routine disease surveillance (n = 57, 19.9%). The most common radiological findings were inflammation (n = 156, 54.4%) and strictures (n = 98, 34.1%). Management changes post MRE occurred in 152 of 287 (53%) cases. Of the 152 patients, 87 (57.2%) had changes in medical management, 40 (26.3%) had surgical or endoscopic intervention and 25 (16.4%) had both medical and surgical management changes. Management changes following MRE in patients with new or concerning symptoms were significantly higher than in surveillance patients (OR 4.1, P = 0.000003).

CONCLUSION

This study provides a foundation for understanding the current utilization of MRE in small bowel CD at a tertiary centre. However, its role in altering management particularly within surveillance patients is yet to be defined. Future prospective trials are required to better delineate its role and develop an algorithm for small bowel CD management.

A review of magnetic resonance enterography-based indices for quantification of Crohn's disease inflammation

Magnetic resonance enterography (MRE) is a leading radiological modality in Crohn's disease (CD) and is used together with laboratory findings and endoscopic examinations for the evaluation of patients during initial diagnosis and follow up. Over the years, there has been great progress in the understanding of CD and there is a continuous strive to achieve better monitoring of patients and to develop new modalities which will predict disease course and thus help in clinical decisions making. An objective evaluation of CD using a quantification score is not a new concept and there are different clinical, endoscopies, radiological and combined indices which are used in clinical practice. Such scores are a necessity in clinical trials on CD for evaluation of disease response, however, there is no consensus of the preferred MRE score and they are not routinely used. This review presents MRE-based indices in use in the last decade: the Magnetic Resonance Index of Activity (MaRIA), the Clermont score, the Crohn's Disease Magnetic Resonance Imaging (MRI) Index (CDMI), the Magnetic Resonance Enterography Global Score (MEGS) and the Lemann index. We compare the different indices and evaluate the clinical research that utilized them. The aim of this review is to provide a reference guide for researchers and clinicians who incorporate MRE indices in their work. When devising future indices, accumulated data of the existing indices must be taken into account, as each of the current indices has its own strengths and weakness.

Monitoring of small bowel Crohn's disease

In recent years, the therapeutic paradigm in Crohn's disease has shifted from a mere symptom-oriented approach, to aiming to healing of the underlying inflammation and prevention of long-term structural complications. Such 'treat-to-target' approach may allow for a more stable disease course with less hospitalizations, lower requirement for surgery and improved quality of life. In Crohn's disease, the small bowel is affected in the majority of patients; frequently, Crohn's involves only the small bowel, which remains inaccessible to conventional ileocolonoscopic techniques. Thus, non-invasive monitoring techniques are crucial for accurate disease assessment. Areas covered: This review addresses the indications and clinical implications of non-invasive small bowel monitoring modalities (magnetic resonance enterography, intestinal ultrasound, capsule endoscopy) in the assessment and management of Crohn's disease. Expert commentary: This review addresses the limitations of the current knowledge and future areas of research, including the possible utilization of transmural healing as an imaging target and the need to establish clear quantitative target values to guide treatment by imaging findings in Crohn's disease.