Ultrasonography of the colon in pediatric ulcerative colitis: a prospective, blind, comparative study with colonoscopy

Four intestinal ultrasound scores and bowel wall thickness alone correlated well with pediatric ulcerative colitis disease activity

OBJECTIVES

Intestinal ultrasound (IUS) is a noninvasive tool in ulcerative colitis (UC), but scoring systems have mostly been developed for adults, Crohn's disease, and flaring UC. Our aim was to evaluate the performance of bowel wall thickness (BWT) and four IUS scores in pediatric patients with newly diagnosed UC.

METHODS

Patients <18 years old with suspected UC were prospectively enrolled. Baseline IUS was done, and ulcerative colitis intestinal ultrasound score (UC-IUS), Milan criteria, simple pediatric activity ultrasound score (SPAUSS), and Civatelli Index were calculated. Mayo endoscopic segment subscore, pediatric ulcerative colitis activity index (PUCAI), and biomarkers were correlated with IUS using nonparametric and receiver operating characteristic analyses.

RESULTS

Fifty-two patients (56% male, median age 13.9 years, interquartile range [IQR] 11.2-16.3) with 206 colon segments were included. Patients who needed hospitalization (n = 27/52) had significantly worse IUS (BWT and all scores) compared to those not hospitalized. For all patients, IUS scores and BWT significantly correlated with baseline endoscopic, clinical, and biochemical disease activity (p = 0.32-0.67, p < 0.05). BWT (τb = 0.53), UC-IUS (τb = 0.55), and Milan (τb = 0.52) had the strongest endoscopic correlations. For differentiating between endoscopic disease severity, BWT, UC-IUS, and Milan, had the highest areas under the curve (0.89-0.93). Using BWT alone, a thinner cut-off had improved sensitivity while maintaining high specificity: ≥2.5 mm for moderate/severe endoscopic inflammation (sensitivity 66%; specificity 94%) and ≥3.5 mm for severe endoscopic inflammation (sensitivity 92%; specificity 86%).

CONCLUSIONS

BWT and all four IUS scores correlated well with endoscopic, clinical, and biochemical disease activity, and was another useful marker of severity in identifying patients needing hospitalization. Pediatric patients needed a thinner BWT cut-off, which should be accounted for when developing pediatric-specific scores. BWT alone may be just as clinically useful as composite US scores.

Differentiation of Active Ulcerative Colitis vs Noninflammatory Bowel Disease Proctitis by Transperineal Superb Microvascular Imaging

BACKGROUND

Transabdominal ultrasonography and transperineal ultrasonography (TPUS) appear correspond to colonoscopy (CS) for evaluating ulcerative colitis (UC) activity, but their utility in UC diagnosis remains unclear. This research compared the accuracy of TPUS and CS for assessing rectal activity and differentiating noninflammatory bowel disease proctitis from UC in pediatric cases.

METHODS

The study is a blinded, prospective, and controlled trial. Prospectively, values of fecal calprotectin (FCP) and findings of the TPUS and CS were compared between child cases of UC and non-IBD proctitis. Findings of rectal wall thickening (RWT), rectal wall flow (RWF) on power Doppler, and microvascular signal at wall circumference (MSWC) on monochrome superb microvascular imaging assessed using TPUS were compared with the CS.

RESULTS

Thirty patients with Mayo endoscopic subscore (MES) 0 to 1 UC, 57 with MES 2 to 3 UC, and 44 with proctitis were registered. Fecal calprotectin, RWF, and MSWC indicated significant differences among the groups (P < .05). Rectal wall thickening showed no significant difference between MES 0-1 and proctitis (P = .76). Rectal wall thickening and MSWC were independent predictors of endoscopic activity of UC, resulting in a sensitivity and specificity of 100% for RWT ≥4.5 mm and positive MSWC. Fecal calprotectin and RWF were independent predictors for differentiating MES 0 to 1 and proctitis, and FCP and RWT were independent predictors for differentiating MES 2 to 3 and proctitis. Sensitivity and specificity were 77.2% and 80.9%, respectively, for FCP >242.5 μg/g and RWF negative; and they were both 100% for RWT >4.1 mm and MSWC positive.

CONCLUSIONS

Transperineal ultrasonography with mSMI may enable the evaluation of rectal activity and differentiation of UC from non-IBD proctitis with accuracy comparable to endoscopy.

Bedside Intestinal Ultrasound Predicts Disease Severity and the Disease Distribution of Pediatric Patients With Inflammatory Bowel Disease: A Pilot Cross-sectional Study

BACKGROUND

Intestinal ultrasound (IUS) is a noninvasive tool to assess bowel inflammation. There is a paucity of data on its accuracy in pediatric patients.

AIM

The aim of this study is to evaluate the diagnostic performance of bowel wall thickness (BWT) measured using IUS compared with endoscopic disease activity in children suspected of having inflammatory bowel disease (IBD).

METHODS

We conducted a single-center cross-sectional pilot study of pediatric patients suspected to have previously undiagnosed IBD. Endoscopic inflammation was graded using segmental scores of the Simple Endoscopic Score for Crohn's Disease (SES-CD) and the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) and classified as having healthy, mild, or moderate/severe disease activity. Association between BWT and endoscopic severity was assessed using the Kruskal-Wallis test. The diagnostic performance of BWT to detect active disease at endoscopy was evaluated using the area under the receiver operating characteristic curve; sensitivity and specificity were calculated.

RESULTS

In all, 174 bowel segments in 33 children were assessed by IUS and ileocolonoscopy. An elevated median BWT was associated with increased bowel segment disease severity, classified by the SES-CD (P < .001) and the UCEIS (P < .01). Using a cutoff value of 1.9 mm, we found that the BWT had an area under the receiver operating characteristic curve of 0.743 (95% CI, 0.67-0.82), a sensitivity of 64% (95% CI, 53%-73%), and a specificity of 76% (95% CI, 65%-85%) to detect inflamed bowel.

CONCLUSION

Increasing BWT is associated with increasing endoscopic activity in pediatric IBD. Our study suggests that the optimal BWT cutoff value for detecting active disease may be less than that seen in adults. Additional pediatric studies are needed.

Intestinal ultrasound in inflammatory bowel disease: New kid on the block

Intestinal ultrasound is an emerging technique for diagnosing and monitoring patients with inflammatory bowel disease (IBD). It is a simple, non-invasive, inexpensive, safe and reliable tool for monitoring patients with IBD. This technique has good diagnostic accuracy in the assessment of the extent and severity of IBD and its complications. The most commonly used parameters are bowel wall thickness, color Doppler flow, bowel wall stratification and peri-bowel inflammation. Various scoring systems have been developed utilizing the above parameters to monitor patients with IBD. It is a good tool to monitor response to therapy and follow-up for post-operative recurrence. Early response on intestinal ultrasound (IUS) predicts long-term clinical remission and mucosal healing in patients with Crohn's disease. In patients with ulcerative colitis (UC), the response to IUS can be assessed as early as two weeks. Recent data has emerged to predict the response to corticosteroids and colectomy in patients with acute severe UC. Point of care IUS in the outpatient clinic is an excellent tool to follow-up patients and guide clinical decision-making and has good acceptability among patients. It is an underutilized technique in spite of its appeal and the availability of evidence. Underutilization can be attributed to the lack of awareness, expertise and training centres. This review discusses the technical details and the evidence to support the use of IUS in IBD. We aim to increase awareness and use of intestinal ultrasound and build local expertise and data.

Ultrasound in Pediatric Inflammatory Bowel Disease-A Review of the State of the Art and Future Perspectives

Inflammatory bowel disease (IBD) comprises a group of relapsing, chronic diseases of the gastrointestinal tract that, in addition to adults, can affect children and adolescents. To detect relapses of inflammation, these patients require close observation, frequent follow-up, and therapeutic adjustments. While reference standard diagnostics include anamnestic factors, laboratory and stool sample assessment, performing specific imaging in children and adolescents is much more challenging than in adults. Endoscopic and classic cross-sectional imaging modalities may be invasive and often require sedation for younger patients. For this reason, intestinal ultrasound (IUS) is becoming increasingly important for the non-invasive assessment of the intestine and its inflammatory affection. In this review, we would like to shed light on the current state of the art and provide an outlook on developments in this field that could potentially spare these patients more invasive follow-up procedures.

Single measurement of bowel wall thickness using intestinal ultrasonography in children with ulcerative colitis

BACKGROUND

Endoscopic monitoring of disease activity in patients with ulcerative colitis (UC) is important. However, frequent colonoscopic examinations are difficult to perform because of their invasiveness, especially in children. Bowel wall thickness (BWT) measurement using intestinal ultrasonography and fecal calprotectin (FC) measurement are useful noninvasive evaluation methods.

METHODS

We retrospectively analyzed BWT and FC levels and evaluated the Mayo endoscopic subscore (MES) using colonoscopy in pediatric patients with UC during the same period. The BWT was evaluated using the maximum BWT (mBWT), which was the maximum value of each colonic BWT; the sum of BWT (sBWT), which was the sum of each colonic BWT; and the sum of the adjusted BWT (saBWT), which was corrected using sBWT.

RESULTS

In 54 procedures from 40 patients, FC, mBWT, sBWT, and saBWT were significantly different between MES 0-1 and MES 2. The agreement between BWT and MES 2 was 193 out of 216 segments (89.4%). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FC were 68.8%, 84.2%, 64.7%, 86.5%, and 79.6% respectively, while those of saBWT were 81.2%, 89.5%, 76.5%, 91.9%, 87.0%, respectively.

CONCLUSIONS

BWT in each colonic segment, particularly saBWT, was more useful than FC for detecting moderate colonic inflammation (MES 2) in pediatric patients with UC. Therefore, intestinal ultrasonography may be helpful in the less invasive management of pediatric patients with UC.

NIMBUS study protocol: a single-centre feasibility study of non-invasive monitoring with bowel ultrasound in paediatric inflammatory bowel disease

INTRODUCTION

Incidence of inflammatory bowel disease (IBD) is increasing in childhood and treatment increasingly targets mucosal healing. Monitoring bowel inflammation requires endoscopy or MRI enterography which are invasive, expensive and have long waiting lists.We aim to examine the feasibility of a non-invasive monitoring tool-bowel ultrasound (BUS)-in children with IBD and explore correlations with inflammatory markers and disease activity measures. Some BUS criteria have been found to correlate with these markers; however, this has not been validated in children.We aim to examine the feasibility of BUS for monitoring inflammation in this population; highlighting useful parameters for this purpose. We aim to inform a larger scale randomised controlled trial using BUS.

METHODS AND ANALYSIS

This prospective observational feasibility study will be carried out over 24 months at the Noah's Ark Children's Hospital for Wales, Cardiff; with the endpoint recruitment of 50 participants. Children aged 2-18 years with a modified Porto criteria diagnosis of IBD will be included.Patients without IBD or who have previously undergone IBD-related surgery will be excluded; as will families unable to give informed consent.Ultrasound scan images and reports will be collected, as well as laboratory results and clinical outcomes.The primary aim will assess the feasibility of targeted BUS for disease monitoring; including recruitment statistics. The secondary aims will involve data collection and correlation analysis for targeted ultrasound parameters, biomarkers, disease activity scores and prediction of changes in treatment. The statistical methods will include: feasibility metrics, descriptive statistics, cross-tabulation and χ2 analysis, correlation analysis, regression analysis.

ETHICS AND DISSEMINATION

Ethical approval is granted by NHS Research Ethics Committee. The sponsor is Cardiff and Vale University Health Board. We will publish the results in a peer-reviewed medical journal.

TRIAL REGISTRATION NUMBER

NCT05673278.

Point-of-Care Intestinal Ultrasound in Pediatric Inflammatory Bowel Disease

PURPOSE OF REVIEW

Intestinal ultrasound (IUS) is an emerging non-invasive point-of-care tool utilized by pediatric gastroenterologists for accurately detecting and monitoring inflammatory bowel disease (IBD) activity. In this article, we reviewed the evidence supporting and technique to perform IUS for children with IBD.

RECENT FINDINGS

IUS technique can visualize the colon from the distal sigmoid until the cecum and the terminal ileum without the need for bowel preparation, fasting, or sedation in children with IBD. IUS has been shown to be accurate to endoscopy in children with ulcerative colitis and Crohn's disease. IUS may be the most accurate biomarker to follow as a marker of treatment response that is predictive of endoscopic outcomes in children with IBD. Multiple studies have demonstrated that IUS can be performed at the point-of-care for IBD activity assessment in children. Recent studies have demonstrated the accuracy of IUS to endoscopy and magnetic resonance enterography with an ability to be repeated as a monitor of treatment response for tight control monitoring.

Predicting Treatment Response in Inflammatory Bowel Diseases: Cross-Sectional Imaging Markers

Therapeutic options for inflammatory bowel diseases (IBD) have largely expanded in the last decades, both in Crohn's disease and ulcerative colitis, including multiple biological drugs targeting different inflammation pathways. However, choosing the best treatment and timing for each patient is still an undeniable challenge for IBD physicians due to the marked heterogeneity among patients and disease behavior. Therefore, early prediction of the response to biological drugs becomes of utmost importance, allowing prompt optimization of therapeutic strategies and thus paving the way towards precision medicine. In such a context, researchers have recently focused on cross-sectional imaging techniques (intestinal ultrasound, computed tomography, and magnetic resonance enterography) in order to identify predictive markers of response or non-response to biologic therapies. In this review, we aim to summarize data about imaging factors that may early predict disease behavior during biological treatment, potentially helping to define more precise and patient-tailored strategies.

The Role of Noninvasive Surrogates of Inflammation in Monitoring Pediatric Inflammatory Bowel Diseases: The Old and the New

Effectiveness of limited available therapies for pediatric inflammatory bowel disease has reached stagnation. Previous non-invasive monitoring strategies have relied upon cumbersome tools to evaluate clinical symptoms and biochemical markers that do not reflect endoscopic activity or respond quickly to treatments. Novel, patient-centric, and highly accurate, monitoring strategies with a focus on intestinal ultrasound for a direct, precise monitoring of activity to achieve disease modification are now possible. Ultimately, research on the optimal tight control monitoring strategies, individualized to each pediatric inflammatory bowel disease patient, are in development and offer a hope to potential therapeutic ceiling breakthrough on the horizon.

Basic practices for gastrointestinal ultrasound

The standard diagnostic modalities for gastrointestinal (GI) diseases have long been endoscopy and barium enema. Recently, trans-sectional imaging modalities, such as computed tomography and magnetic resonance imaging, have become increasingly utilized in daily practice. In transabdominal ultrasonography (US), the bowel sometimes interferes with the observation of abdominal organs. Additionally, the thin intestinal walls and internal gas can make structures difficult to identify. However, under optimal US equipment settings, with identification of the sonoanatomy and knowledge of the US findings of GI diseases, US can be used effectively to diagnose GI disorders. Thus, the efficacy of GIUS has been gradually recognized, and GIUS guidelines have been published by the World Federation for Ultrasound in Medicine and Biology and the European Federation of Societies for Ultrasound in Medicine and Biology. Following a systematic scanning method according to the sonoanatomy and precisely estimating the layered wall structures by employing color Doppler make diagnosing disease and evaluating the degree of inflammation possible. This review describes current GIUS practices from an equipment perspective, a procedure for systematic scanning, typical findings of the normal GI tract, and 10 diagnostic items in an attempt to help medical practitioners effectively perform GIUS and promote the use of GIUS globally.

Intestinal ultrasound as a non-invasive tool to monitor inflammatory bowel disease activity and guide clinical decision making

Intestinal ultrasound (IUS) is a non-invasive, real-time, cross-sectional imaging tool that can be used at the point-of-care to assess disease activity in patients with Crohn’s disease or ulcerative colitis. IUS promotes quick and impactful treatment decisions that can modify disease progression and enhance patient compliance. This review will summarize the technical aspects of IUS, the evidence to support the use of IUS in disease activity monitoring, the comparison of IUS to current standard of care monitoring modalities such as colonoscopy and calprotectin, and the optimal positioning of IUS in a tight-control monitoring strategy.

Diagnostic accuracy of different cross-sectional imaging techniques for disease location and activity in Crohn's disease and external validation and comparison of MARIAs and IBUS-SAS

PURPOSE

The comparative accuracy of cross-sectional imaging techniques for evaluating Crohn's disease (CD) remains uncertain. This study aimed to assess diagnostic accuracy of disease location and activity in different cross-sectional images and validate and compare International Bowel Ultrasound Segmental Activity Score (IBUS-SAS) and Simplified Magnetic Resonance Index of Activity (MARIAs).

METHODS

CD patients were retrospectively included from August 2018 to May 2021. We compared accuracy of B-mode intestinal ultrasound (B-IUS), computed tomography enterography (CTE), and magnetic resonance enterography (MRE) for the identification of disease location. Meanwhile, disease activity was compared on B-IUS, color Doppler imaging, CTE, and MRE. ROC analyses were used to validate MARIAs and IBUS-SAS. Spearman rank correlation was performed to evaluate the relationships between MARIAs/IBUS-SAS and CDAI, SES-CD, and inflammatory indicators.

RESULTS

A total of 115 CD patients were evaluated. The diagnostic accuracy of MRE in detecting small bowel disease was superior to that of B-IUS/CTE, showing sensitivity (89.3%), specificity (71.4%), and AUC (0.820). B-IUS had the highest sensitivity (81.2%), specificity (84.8%), and AUC (0.830) for detecting terminal ileal lesions. The diagnostic accuracy for colonic disease and disease activity was not significantly different among these techniques. In the validation of IBUS-SAS, the AUC was 0.860, with an optimal cutoff value to predict active disease of 46.7. MARIAs and IBUS-SAS showed no significant differences in the correlations of CDAI, SES-CD, and inflammatory indicators.

CONCLUSION

MRE and B-IUS are more sensitive for detecting small bowel CD and terminal ileal CD, respectively. IBUS-SAS has potential for precisely defining CD activity.

Intestinal Ultrasound to Assess Ulcerative Colitis Disease Activity in Children: External Validation and Comparison of 2 Intestinal Ultrasound Activity Indices

BACKGROUND

There is currently no consensus on the definition of an abnormal intestinal ultrasound (IUS) for children with ulcerative colitis (UC). This cross-sectional study aimed to externally validate and compare 2 existing IUS indices in children with UC.

METHODS

Children undergoing colonoscopy for UC assessment underwent IUS the day before colonoscopy, assessed with the Mayo endoscopic subscore. The UC-IUS index and the Civitelli index were compared with the Mayo endoscopic score in the ascending, transverse, and descending colon. The area under the receiver-operating characteristic curve for detecting a Mayo endoscopic score ≥2 of both scores was compared and sensitivity and specificity were calculated.

RESULTS

A total of 35 UC patients were included (median age 15 years, 39% female). The area under the receiver-operating characteristic curve was higher for the UC-IUS index in the ascending colon (0.82 [95% confidence interval (CI), 0.67-0.97] vs 0.76 [95% CI, 0.59-0.93]; P = .046) and transverse colon (0.88 [95% CI, 0.76-1.00] vs 0.77 [95% CI, 0.60-0.93]; P = .01). In the descending colon, there was no difference (0.84 [95% CI, 0.70-0.99] vs 0.84 [95% CI, 0.70-0.98]). The optimal cutoff for the UC-IUS was <1 point to rule out a Mayo endoscopic score ≥2 (sensitivity: 88%, 100%, and 90% in the ascending, transverse, and descending colon, respectively) and a Mayo endoscopic score ≥2 could be detected using a cutoff of >1 (specificity: 84%, 83%, and 87%, respectively). For the Civitelli index, in our cohort, the optimal cutoff was <1 to rule out a Mayo endoscopic score ≥2 (sensitivity 75%, 65%, and 80%, respectively) and a cutoff >1 to detect a Mayo endoscopic score ≥2 (specificity 89%, 89%, and 93%, respectively).

CONCLUSIONS

In this cohort, the UC-IUS index performed better than the Civitelli index. The UC-IUS index had both a high sensitivity and specificity in this cohort, when using 1 point as cutoff for a Mayo endoscopic score ≥2.

Intestinal Ultrasound in Pediatric Inflammatory Bowel Disease: Promising, but Work in Progress

Intestinal ultrasound (IUS) is increasingly used and promulgated as a noninvasive monitoring tool for children with inflammatory bowel disease because other diagnostic modalities such as colonoscopy and magnetic resonance imaging cause significant stress in the pediatric population. The most important parameters of inflammation that can be assessed using IUS are bowel wall thickness and hyperemia of the bowel wall. Research has shown that IUS has the potential to be a valuable additional point-of-care tool to guide treatment choice and to monitor and predict treatment response, although evidence of its accuracy and value in clinical practice is still limited. This review gives an update and overview of the current evidence on the use and accuracy of IUS in children with inflammatory bowel disease.

The Use of Transabdominal Ultrasound in Inflammatory Bowel Disease

Transabdominal ultrasound (TAUS) is useful in all aspects of lesion screening, monitoring activity, or treating/diagnosing any related complications of inflammatory bowel disease. Its ability to screen or diagnose complications is almost the same as that of other methods, such as CT or MRI. Moreover, its noninvasiveness makes it a first-line examination method. A TAUS image depicting ulcerative colitis will show large intestinal wall thickening that is continuous from the rectum, which is mainly due to mucosal layer thickening, while for Crohn’s disease, a TAUS image is characterized by a diversity in the areas affected, distribution, and layer structure. Indicators of activity monitoring include wall thickness, wall structure, and vascular tests that use Doppler ultrasound or contrast agents. While all of these have been reported to be useful, at this time, no single parameter has been established as superior to others; therefore, a comprehensive evaluation of these parameters is justified. In addition, evaluating the elasticity of lesions using elastography is particularly useful for distinguishing between fibrous and inflammatory stenoses. However, the lack of objectivity is the biggest drawback of using ultrasound. Standardizing and popularizing the ultrasound process will be necessary, including scanning methods, equipment settings, and image analysis.

Intestinal Ultrasound in Inflammatory Bowel Disease: A Valuable and Increasingly Important Tool

Background

Intestinal ultrasound is emerging as a non-invasive tool for monitoring disease activity in inflammatory bowel disease patients due to its low cost, excellent safety profile, and availability. Herein, we comprehensively review the role of intestinal ultrasound in the management of these patients.

Summary

Intestinal ultrasound has a good accuracy in the diagnosis of Crohn's disease, as well as in the assessment of disease activity, extent, and evaluating disease-related complications, namely strictures, fistulae, and abscesses. Even though not fully validated, several scores have been developed to assess disease activity using ultrasound. Importantly, intestinal ultrasound can also be used to assess response to treatment. Changes in ultrasonographic parameters are observed as early as 4 weeks after treatment initiation and persist during short- and long-term follow-up. Additionally, Crohn's disease patients with no ultrasound improvement seem to be at a higher risk of therapy intensification, need for steroids, hospitalisation, or even surgery. Similarly to Crohn's disease, intestinal ultrasound has a good performance in the diagnosis, activity, and disease extent assessment in ulcerative colitis patients. In fact, in patients with severe acute colitis, higher bowel wall thickness at admission is associated with the need for salvage therapy and the absence of a significant decrease in this parameter may predict the need for colectomy. Short-term data also evidence the role of intestinal ultrasound in evaluating therapy response, with ultrasound changes observed after 2 weeks of treatment and significant improvement after 12 weeks of follow-up in ulcerative colitis.

Key Messages

Intestinal ultrasound is a valuable tool to assess disease activity and complications, and to monitor response to therapy. Even though longer prospective data are warranted, intestinal ultrasound may lead to a change in the paradigm of inflammatory bowel disease management as it can be used in a point-of-care setting, enabling earlier intervention if needed.

Insights into the role of gastrointestinal ultrasound in ulcerative colitis

Endoscopic evaluation with histological sampling is the gold standard for the diagnosis and follow-up of patients with inflammatory bowel disease (IBD), but in the past few years, gastrointestinal ultrasound (GIUS) has been gaining ground. Due to the transmural nature of inflammation in Crohn's disease, GIUS has been mainly applied in this context. However, GIUS is now being reported to be accurate also for ulcerative colitis (UC). This review summarizes current knowledge on the use of GIUS in UC, with a focus on clinical practice. The review covers topics such as GIUS parameters, especially bowel wall thickness; the use of GIUS in assessing disease extent and in monitoring disease activity; GIUS indexes and scores; and the combination of GIUS with transperineal ultrasound for a better assessment of the rectum. With the always growing body of evidence supporting the accuracy of GIUS in UC, this diagnostic imaging modality can be expected to play a bigger role in disease flare evaluation, early treatment monitoring, and acute severe disease management.

Intestinal Ultrasound to Assess Disease Activity in Ulcerative Colitis: Development of a novel UC-Ultrasound Index

INTRODUCTION

Intestinal ultrasound [IUS] is useful to assess inflammation in ulcerative colitis [UC] patients. We aimed to develop an ultrasonographic activity index using endoscopy as the reference standard.

METHODS

Patients were included consecutively. IUS was performed within 3 weeks from endoscopy. IUS parameters and endoscopy were compared for each colonic segment [except the rectum]. The best parameters were used to construct a UC-IUS index, which was correlated with endoscopic disease activity using the Spearman's rank test.

RESULTS

In 60 patients, 207 colonic segments were evaluated endoscopically. Bowel wall thickness [BWT] > 2.1 mm was optimal to discriminate between Mayo 0 and Mayo 1-3 (sensitivity 82.6%; specificity 93.0%; area under the curve [AUC] 0.910), a cut-off of 3.2 mm was optimal to discriminate between Mayo 0-1 and Mayo 2-3 [sensitivity 89.1%; specificity 92.3%; AUC 0.946] and BWT > 3.9 mm was optimal for detection of Mayo 3 [sensitivity 80.6%; specificity 84.1%; AUC 0.909]. The presence of colour Doppler signal [CDS] predicted active disease, stretches of CDS were associated with Mayo 2-3, lack of haustrations predicted active disease and fat wrapping was associated with severe disease. Inter- and intra-rater intraclass correlation for BWT was substantial. Inter-rater agreement for CDS was substantial and ranged from slight to substantial for haustrations. Intra-rater agreement for CDS was substantial and ranged from moderate to almost perfect for haustrations. The index showed strong correlation with endoscopic disease activity [Mayo: ρ 0.830; p < 0.001, UCEIS: ρ 0.759; p < 0.001].

CONCLUSION

We developed an UC-IUS index which showed strong correlation with endoscopic disease activity using internal validation. It is currently being validated in prospective studies.

Non-invasive Ultrasonographic Score for Assessment of the Severity of Inflammatory Bowel Disease

Intestinal ultrasound and shear wave elastography have gained increasing interest because of their promising results in the assessment of inflammatory bowel disease. The aim of this study was to find an ultrasonographic score to replace invasive endoscopic procedures for the management of these patients. The score includes ultrasound parameters that correlate well with clinical severity scales and inflammatory markers: bowel wall thickness, the Limberg score, disease extension and acoustic radiation force impulse measurements. The score proved to be well correlated with the Harvey Bradshaw Index, the Mayo score, C-reactive protein and fecal calprotectin. For Crohn's disease, a cutoff value of 8 points could identify active disease with 81.81% sensitivity and 83% specificity, while for ulcerative colitis, a cutoff value of 7 points could discriminate between remission and relapse with 86.85% sensitivity and 94% specificity. In conclusion, our ultrasonographic score can differentiate relapse from remission in inflammatory bowel disease.

Systematic Review: Gastrointestinal Ultrasound Scoring Indices for Inflammatory Bowel Disease

BACKGROUND AND AIMS

Serial measurements of luminal disease activity may facilitate inflammatory bowel disease management. Gastrointestinal ultrasound is an easily performed, non-invasive alternative to other assessment modes. However, its widespread use is limited by concerns regarding validity, reliability, and responsiveness. We systematically identified ultrasound scoring indices used to evaluate inflammatory bowel disease activity and examine their operating characteristics.

METHODS

Electronic databases were searched from inception to June 14, 2019 using pre-defined terms. Studies that reported on gastrointestinal ultrasound index operating properties in an inflammatory bowel disease population were eligible for inclusion. Study characteristics, index components, and operating property data [ie, validity, reliability, responsiveness, sensitivity, specificity, accuracy, positive predictive value, and negative predictive value] were extracted. The QUADAS-2 tool was used to examine study-level risk of bias.

RESULTS

Of the 2610 studies identified, 26 studies reporting on 21 ultrasound indices were included. The most common index components included bowel wall thickness, colour Doppler imaging, and bowel wall stratification. The correlation between ultrasound indices and references standards ranged r = 0.62-0.95 and k = 0.40-0.96. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive values ranged 39-100%, 63-100%, 73-100%, 57-100%, and 40-100%, respectively. Reliability and responsiveness data were limited. Most [92%, 24/26] studies received at least one unclear or high risk of bias rating.

CONCLUSIONS

Several gastrointestinal ultrasound indices for use in inflammatory bowel disease have been developed. Future research should focus on fully validating existing or novel gastrointestinal ultrasound scoring instruments for assessment of Crohn's disease and ulcerative colitis.

Color Doppler Ultrasound Assessment of Clinical Activity in Inflammatory Bowel Disease

BACKGROUND

Ulcerative colitis (UC) and Crohn's disease (CD) are two varieties of inflammatory bowel disease (IBD). Clinicians need a monitoring technique in the IBD. The disease activity can be assessed with endoscopy, activity indexes, and imaging techniques. Color Doppler US (CDUS) is also a non-invasive, radiation, and contrast material free examination which shows the intramural blood flow.

OBJECTIVE

To evaluate the usefulness of B-mode, CDUS, and a newly developed software Color Quantification (CQ) to determine the activity of the IBD.

METHODS

The disease activity was assessed by clinical activity indexes. Caecum, terminal ileum, ascending colon, transverse colon, and descending colon were evaluated by B-mode, CDUS, and the CQ. Bowel wall thickness (BWT), loss of bowel stratification, loss of haustration, and the presence of enlarged lymph nodes, mesenteric masses, abscesses, fistula, visual vascular signal patterns of the bowel as "hypo and hyper-flow" and the CQ values were investigated. BWT was compared with laboratory results and clinical activities. Vascular signal patterns and the CQ values were compared with BWT and clinical activity. The diagnostic performances of the CQ were investigated.

RESULTS

Fifty-two patients with IBD were evaluated. Patients with increased BWT at the transverse colon had an increased frequency of "hyper-flow" pattern. Clinically active patients had an increased incidence of "hyper-flow" pattern at the terminal ileum, ascending colon, and whole segments. They had increased CQ values at the terminal ileum, ascending colon, and descending colon, and whole segments. A cut-off value for the CQ (24.7%) was obtained at the terminal ileum. In the diagnostic performances of CQ, we observed utilities significantly at the ascending colon, descending colon, terminal ileum, and whole segments. There was a positive correlation between the CQ values and BWT at the caecum, ascending colon, transverse colon, and descending colon.

CONCLUSION

Increased visual vascular signal scores and CQ values might be useful for monitoring the disease activity in patients with IBD.

Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the use of abdominal ultrasound in inflammatory bowel disease

Ultrasound has an excellent diagnostic performance when Crohn's disease is suspected, when performing an activity assessment, or determining the extension and location of Crohn's disease, very similar to other examinations such as MRI or CT. It has a good correlation with endoscopic lesions and allows the detection of complications such as strictures, fistulas or abscesses. It complements colonoscopy in the diagnosis and, given its tolerance, cost and immediacy, it can be considered as a good tool for disease monitoring. In ulcerative colitis, its role is less relevant, being limited to assessing the extent and activity when it is not possible with other diagnostic techniques or if there are doubts with these. Despite its advantages, its use in inflammatory bowel disease (IBD) is not widespread in Spain. For this reason, this document reviews the advantages and disadvantages of the technique to promote knowledge about it and implementation of it in IBD Units.

Ulcerative Colitis: Making the Diagnosis

Ulcerative colitis is an inflammatory condition of the colon. The diagnosis of ulcerative colitis is based on clinical presentation, endoscopic evaluation, and histologic parameters in the absence of demonstrable alternate etiology. The differential diagnosis remains broad, and infection in particular must be considered and excluded. Although laboratory and radiographic findings can aid in the diagnosis of ulcerative colitis, endoscopy remains the gold standard for diagnosis. A correct diagnosis and disease staging are imperative because these factors affect treatment options and prognosis.

Usefulness of intestinal ultrasound in inflammatory bowel disease

Imaging techniques play a fundamental role in the initial diagnosis and follow-up of inflammatory bowel disease. Intestinal ultrasound has high sensitivity and specificity in patients with suspected Crohn's disease and in the detection of inflammatory activity. This technique enables the early diagnosis of intra-abdominal complications such as stenosis, fistulas, and abscesses. It has also proven useful in monitoring the response to treatment and in detecting postsurgical recurrence. Technical improvements in ultrasound scanners, technological advances such as ultrasound contrast agents and elastography, and above all increased experience have increased the role of ultrasound in the evaluation of the gastrointestinal tract. The features that make ultrasound especially attractive include its wide availability, its noninvasiveness and lack of ionizing radiation, its low cost, and its good reproducibility, which is important because it is easy to repeat the study and the study is well tolerated during follow-up. This review summarizes the role of intestinal ultrasound in the detection and follow-up of inflammatory bowel disease.

Intestinal ultrasound for monitoring therapeutic response in patients with ulcerative colitis: results from the TRUST&UC study

OBJECTIVE

Prospective evaluation of intestinal ultrasound (IUS) for disease monitoring of patients with ulcerative colitis (UC) in routine medical practice.

DESIGN

TRansabdominal Ultrasonography of the bowel in Subjects with IBD To monitor disease activity with UC (TRUST&UC) was a prospective, observational study at 42 German inflammatory bowel disease-specialised centres representing different care levels. Patients with a diagnosis of a proctosigmoiditis, left-sided colitis or pancolitis currently in clinical relapse (defined as Short Clinical Colitis Activity Index ≥5) were enrolled consecutively. Disease activity and vascularisation within the affected bowel wall areas were assessed by duplex/Colour Doppler ultrasonography.

RESULTS

At baseline, 88.5% (n=224) of the patients had an increased bowel wall thickness (BWT) in the descending or sigmoid colon. Even within the first 2 weeks of the study, the percentage of patients with an increased BWT in the sigmoid or descending colon decreased significantly (sigmoid colon 89.3%-38.6%; descending colon 83.0%-42.9%; p<0.001 each) and remained low at week 6 and 12 (sigmoid colon 35.4% and 32.0%; descending colon 43.4% and 37.6%; p<0.001 each). Normalisation of BWT and clinical response after 12 weeks of treatment showed a high correlation (90.5% of patients with normalised BWT had symptomatic response vs 9.5% without symptomatic response; p<0.001).

CONCLUSIONS

IUS may be preferred in general practice in a point-of-care setting for monitoring the disease course and for assessing short-term treatment response. Our findings give rise to the assumption that monitoring BWT alone has the potential to predict the therapeutic response, which has to be verified in future studies.

Bowel Ultrasound Scan Predicts Corticosteroid Failure in Children With Acute Severe Colitis

BACKGROUND AND OBJECTIVE

Acute severe colitis (ASC) is a potentially life-threatening event. Optimal timing for second-line treatment in children is mainly based on the clinical score Pediatric Ulcerative Colitis Activity Index. The aim of our study was to evaluate the potential role of bowel ultrasound scan (BUS) in predicting the need of second-line therapy in ASC.

METHODS

Patients younger than 18 years admitted to a single tertiary referral center with ASC were included. We retrospectively reviewed medical records collecting clinical and BUS data. Colonic wall thickness (CWT), loss of colonic wall stratification (CWS), presence of hyperechoic lymph nodes, and colonic wall flow evaluated at power Doppler were assessed at BUS performed within the third day of hospitalization.

RESULTS

Sixty-nine ASC episodes from 52 different patients were identified. CWT showed significantly higher values in patients who required second-line therapy (5.14 vs 3.69 mm; P < 0.001). Loss of CWS was present in 17 of 36 (47.2%) of steroid-resistant ASC versus only 1 of 33 of those responding to intravenous corticosteroids (P < 0.001, sensitivity = 47%, specificity = 97%). Using a receiver operating characteristic curve, a cut-off of 3.4 mm was individuated for CWT to predict steroid treatment failure, showing a sensitivity of 92% and a specificity of 52%. The multivariable binary logistic regression analysis identified thickened colonic wall (CWT >3.4 mm) and loss of CWS as independent predictors of steroid resistance.

CONCLUSIONS

BUS is a noninvasive, easily accessible, and cost-effective resource that may identify at an early stage first-line therapy failure in pediatric ASC.

Systematic Review: Clinical Utility of Gastrointestinal Ultrasound in the Diagnosis, Assessment and Management of Patients With Ulcerative Colitis

BACKGROUND AND AIMS

Gastrointestinal ultrasound is useful in the assessment of patients with Crohn's disease, but its application in ulcerative colitis [UC] is less well established. Here we systematically review the role of gastrointestinal ultrasound in patients with UC.

METHODS

Searches of the PUBMED and EMBASE databases were performed with the following search strategy: [ultrasound OR sonography] AND [intestinal OR bowel] AND [ulcerative colitis OR inflammatory bowel disease]. The final search was performed in August 2019.

RESULTS

Of 6769 studies identified in the search with a further two studies found from other sources, 50 studies met the inclusion criteria. Increased bowel wall thickness and detection of increased blood flow by colour Doppler were the most often applied criteria for defining disease activity and distribution. When compared with other reference investigations, gastrointestinal ultrasound accurately determined disease extent, severity and response to medical therapy. While further information can be obtained from haemodynamic measurements of the abdominal vessels and contrast-enhanced ultrasound, their clinical value was uncertain. Likewise, hydrocolonic sonography has few advantages over standard gastrointestinal ultrasound examination. Of several scoring systems proposed, there is disparity between the measures and a general lack of validation. There has been limited application of gastrointestinal ultrasound in acute severe ulcerative colitis with toxic megacolon, and, while performing well in children, normal limits differ from those in adults.

CONCLUSION

Current evidence indicates that gastrointestinal ultrasound has utility in the non-invasive assessment of patients with UC. Continued advances in technology with better image resolution, validation of scoring systems and application at the point of care by gastroenterologists are likely to contribute to increased use of gastrointestinal ultrasound in routine clinical practice.

Can a transition clinic bridge the gap between paediatric and adult inflammatory bowel disease care models?

Transition care in inflammatory bowel disease is increasingly recognized as challenging given the inherent differences between paediatric and adult health care models, disease characteristics and treatment strategies. Transition is a dynamic process involving adolescents and young adults that are moving from a paediatric to an adult health care setting, and it should be flexible, continually updated and tailored to each patient. The implementation of a transition clinic is essential given the increasing incidence of the paediatric population with inflammatory bowel disease and the lifelong impact of this disease. The key question is when and how to structure transition according to the adolescent's clinical, psycho-social, educational needs and expectations to ensure continuity of care. In the attempt to improve the management of transition in inflammatory bowel disease and address the wide gap between adult and child care, we provide an update of the transition clinic and we propose a "treat to target" approach in transition to facilitate an effective and successful transition programme. In the changing landscape of the treatment of inflammatory bowel disease, further studies are necessary to determine the role of the transition clinic in determining the choice and strategy of therapy and its monitoring and the adoption of newer strategies such as biomarkers guided treating to target.

Nongynecologic Causes of Pelvic Pain: Ultrasound First

Ultrasonography (US) is often the first-line imaging study used to evaluate women who present with acute or chronic pelvic pain. Detection of nongynecologic causes of pelvic pain is critical, because delay in diagnosis can cause significant morbidity and mortality. Evaluation of these entities requires a variety of transducers to achieve optimal imaging depth and changes in patient positioning. Specific imaging techniques (such as graded compression) may be required if bowel pathology is suspected. Contrast-enhanced ultrasonography is increasingly used to improve detection of certain entities. The US appearance of common gastrointestinal and urinary tract-related causes of pelvic pain is reviewed.

Impact of intestinal ultrasound on the management of patients with inflammatory bowel disease: how to apply scientific evidence to clinical practice

Technological improvements and growing sonographers' expertise boost the role of intestinal ultrasound (IUS) in assessing patients with inflammatory bowel diseases (IBD). Non-invasiveness, low cost and good reproducibility make IUS attractive. Leveraging on the Authors' long-term field experience, this review focuses on the IUS role in IBD patients' clinical management. For detecting IBD, particularly Crohn's disease, the IUS parameters - above all the evidence of a thickened bowel wall (BWT) - show very good diagnostic accuracy similar to that of MRI or CT scan. The standard IUS parameters are not accurate enough to detect inflammatory activity, but intravenous contrast-enhanced US (CEUS) is highly accurate in ruling active inflammation out. However, its routinely use remains limited in clinical practice and its parameters need standardization. IUS is accurate in detecting IBD main complications: in particular, fistulae and abscesses. As to stenosis the recent introduction of IUS-based elastographic techniques allows to differentiate prevalently inflammatory from highly fibrotic strictures. IUS proves valid also for monitoring IBD patients. In particular, the evidence of transmural healing, defined as BWT normalization, has got an important prognostic meaning, as associated with better long-term clinical outcomes. Post-surgery CD recurrence can be suggested by early IUS assessment.

Bowel ultrasound measurements in healthy children - systematic review and meta-analysis

BACKGROUND

Ultrasound (US) is a noninvasive method of assessing the bowel that can be used to screen for bowel pathology, such as Inflammatory Bowel Disease, in children. Knowledge about US findings of the bowel in healthy children is important for interpreting US results in cases where disease is suspected.

OBJECTIVE

To assess the bowel wall thickness in different bowel segments in healthy children and to assess differences in bowel wall thickness among pediatric age categories.

MATERIALS AND METHODS

We conducted a systematic search in the PubMed, Embase, Cochrane, and CINAHL databases for studies describing bowel wall thickness measured by transabdominal US in healthy children. We excluded studies using contrast agent. We calculated the pooled mean and standard deviation scores and assessed differences among age categories (0-4 years, 5-9 years, 10-14 years, 15-18 years), first with analysis of variance (ANOVA) and further with subsequent Student's t-tests for independent samples, corrected for multiple testing.

RESULTS

We identified 191 studies and included 7 of these studies in the systematic review. Reported bowel wall thickness values ranged from 0.8 mm to 1.9 mm in the small bowel and from 1.0 mm to 1.9 mm in the colon. The mean colonic bowel wall thickness is larger in children ages 15-19 years compared to 0-4 years (range in difference: 0.3-0.5 mm [corrected P<0.02]).

CONCLUSION

The reported upper limit of bowel wall thickness in healthy children is 1.9 mm in the small bowel and the colon, and mean thickness increases slightly with age in jejunum and colon. These values can be used as guidance when screening for bowel-related pathology in children.

Imaging Inflammation and Infection in the Gastrointestinal Tract

A variety of seemingly non-specific symptoms manifest within the gastrointestinal (GI) tract, particularly in the colon, in response to inflammation, infection, or a combination thereof. Differentiation between symptom sources can often be achieved using various radiologic studies. Although it is not possible to provide a comprehensive survey of imaging gastrointestinal GI tract infections in a single article, the purpose of this review is to survey several topics on imaging of GI tract inflammation and infections. The review discusses such modalities as computed tomography, positron emission tomography, ultrasound, endoscopy, and magnetic resonance imaging while looking at up-an-coming technologies that could improve diagnoses and patient comfort. The discussion is accomplished through examining a combination of organ-based and organism-based approaches, with accompanying selected case examples. Specific focus is placed on the bacterial infections caused by Shigella spp., Escherichia coli, Clostridium difficile, Salmonella, and inflammatory conditions of diverticulitis and irritable bowel disease. These infectious and inflammatory diseases and their detection via molecular imaging will be compared including the appropriate differential diagnostic considerations.

Diagnostic Accuracy of Transabdominal Ultrasound in Detecting Intestinal Inflammation in Paediatric IBD Patients-a Systematic Review

BACKGROUND AND AIMS

Currently used non-invasive tools for monitoring children with inflammatory bowel disease [IBD], such as faecal calprotectin, do not accurately reflect the degree of intestinal inflammation and do not provide information on disease location. Ultrasound [US] might be of added value. This systematic review aimed to assess the diagnostic test accuracy of transabdominal US in detecting intestinal inflammation in children with IBD in both diagnostic and follow-up settings.

METHODS

We systematically searched PubMed, Embase [Ovid], Cochrane Library, and CINAHL [EBSCO] databases for studies assessing diagnostic accuracy of transabdominal US for detection of intestinal inflammation in patients diagnosed or suspected of IBD, aged 0-18 years, with ileo-colonoscopy and/or magnetic resonance enterography [MRE] as reference standards. Studies using US contrast were excluded. Risk of bias was assessed with QUADAS-2.

RESULTS

The search yielded 276 records of which 14 were included. No meta-analysis was performed, because of heterogeneity in study design and methodological quality. Only four studies gave a clear description of their definition for an abnormal US result. The sensitivity and specificity of US ranged from 39-93% and 90-100% for diagnosing de novo IBD, and 48-93% and 83-93% for detecting active disease during follow-up, respectively.

CONCLUSIONS

The diagnostic accuracy of US in detecting intestinal inflammation as seen on MRE and/or ileo-colonoscopy in paediatric IBD patients remains inconclusive, and there is currently no consensus on defining an US result as abnormal. Prospective studies with adequate sample size and methodology are needed before US can be used in the diagnostics and monitoring of paediatric IBD.

The Role of the Radiologist in Determining Disease Severity in Inflammatory Bowel Diseases

Crohn's disease and ulcerative colitis are chronic inflammatory diseases that lead to progressive bowel damage including the development of stricturing and penetrating complications. Increasingly, cross-sectional imaging with computed tomography or magnetic resonance scans have emerged as leading tools to: (1) assess disease activity; (2) monitor response to therapy or disease recurrence; and (3) identify disease-related complications. Several validated radiological scoring systems have been developed to quantify cross-sectional and longitudinal inflammatory burden in these diseases and to monitor response to treatment. Bowel ultrasound is also a simple and inexpensive tool but is operator dependent in its performance.

The Simple Pediatric Activity Ultrasound Score (SPAUSS) for the Accurate Detection of Pediatric Inflammatory Bowel Disease

OBJECTIVE

The aim of the study was to identify the most significant ultrasound (US) parameters that predict inflammatory activity and develop a simple US activity score.

METHODS

Patients were identified through retrospective evaluation of an established database of children with inflammatory bowel disease (IBD). Patients with endoscopy and US within 60 days were included (N = 75). US parameters evaluated included: bowel wall thickness (BWT), mesenteric inflammatory fat, lymphadenopathy, and hyperemia. The weighted kappa statistic was calculated to assess agreement between sonographic and endoscopically identified disease location. Using a proportional odds model and ordinal logistic regression, statistically significant (P < 0.05) parameters were used to generate a score. Variables were weighted to classify individuals into severity classes. Receiver operating characteristic curves were plotted to demonstrate the score's discriminative and predictive capacity.

RESULTS

There was substantial agreement between US and endoscopy for all disease locations (weighted kappa = 0.85) and substantial agreement for ileocolonic disease (weighted kappa = 0.96). Two sonographic parameters were identified as contributing significantly to disease activity: BWT and mesenteric inflammatory fat (P < 0.05). A predictive score was developed incorporating BWT, hyperemia and inflammatory fat, and receiver operating characteristic curve curves demonstrated good predictive capacity to distinguish between the absence of disease (normal) and active disease with an area under the curve of 82.1%.

CONCLUSIONS

The most important sonographic parameters for predicting disease activity were BWT and mesenteric inflammatory fat. When combined with hyperemia into a simple score, there was accurate detection of inflammatory activity in children with inflammatory bowel disease. This score may facilitate noninvasive, bedside detection of inflammation, and standardize the use of US in children.

Validation of US evaluation of ulcerative colitis activity

This study was aimed at validating the inter-rater grading agreement for assessing disease activity in patients with established ulcerative colitis (UC) using transabdominal ultrasonography (US) versus colonoscopy (CS). Fifty-seven patients underwent US and CS at four facilities. UC disease activity was assessed using the original US grading system and CS Matts classification. Initially, the US and CS grades were assessed at each examining facility, and still images and movie clips were re-assessed at the central facility. Grading agreement between the examining and central facilities was evaluated. Grading agreement for US and CS were 0.75 and 0.72 in all segments and 0.82 and 0.70 in the maximum grade of each patient, respectively (all p < 0.001). US grading agreement was "almost perfect" for the maximum grade and "moderate" to "substantial" for other assessments. The inter-rater US grading agreement was good and not inferior to that of CS for evaluating UC disease activity.

Noninvasive testing in the management of children with suspected inflammatory bowel disease

Objective: To assess the accuracy of noninvasive parameters, fecal calprotectin (FC), increased bowel wall thickening (BWT) at intestinal ultrasound (IUS) and blood inflammatory indexes (BII), alone or in combination, as diagnostic tools for inflammatory bowel disease (IBD) in pediatric patients. Methods: Retrospective data were collected on consecutive children (age 2-18 years) referred to our pediatric gastroenterology clinic, for recurrent abdominal pain and/or altered bowel habit from 2007 to 2013. Subjects who had diagnostic workup: laboratory tests (FC, BII, white blood cell (WBC), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)) and IUS as initial assessment were eligible. Subjects with known gastrointestinal (GI) diseases, or signs or symptoms highly suggestive for organic diseases necessitating prompt endoscopy (e.g., perianal disease or rectal bleeding), or who had recently performed endoscopy were excluded. The accuracy of noninvasive tests for detecting IBD was assessed using endoscopic and/or radiological investigations, performed in subsequent clinical follow up, as reference gold standard. Results: Seventy-seven patients (mean age 11.3, 44 males) were included, 23 (29.9%) with a final diagnosis of IBD. As single tests, FC gave the highest sensitivity (96%) but lower specificity (72%) and IUS highest specificity (96%) with lower sensitivity (70%). The combination of FC + IUS showed excellent accuracy for detecting children with IBD with positive predictive value: 100%; negative predictive value: 88.5%. The probability of IBD in children with normal FC, BII and IUS was 0.09%. Conclusions: FC and increased BWT at IUS are accurate to guide reassurance or proceeding with further invasive procedures for detecting IBD in children with mild GI symptoms.

CT Enterography score: a potential predictor for severity assessment of active ulcerative colitis

BACKGROUND

Evaluate the possibility of CT enterography (CTE) score system as a predictor in assessing active ulcerative colitis (UC) severity.

METHODS

Forty-six patients with active UC with CTE and colonoscopy were enrolled. Based on modified Mayo score, patients were divided into three groups: mild (n = 10), moderate (n = 17) and severe (n = 19). A cumulative CTE score was calculated in each patient and its correlation with modified Mayo score was analyzed. The optimal cutoff values of CTE score were determined by receiver operating characteristic (ROC) curves analysis.

RESULTS

Significant between-group differences were observed in CTE spectrums of mucosal bubbles, mural stratification, loss of haustration, enlarged mesenteric lymph nodes and engorged mesenteric vessels (P < 0.05). The cumulative CTE scores were significant difference between three groups (CTE score:4.9 ± 2.3, 7.6 ± 2.6, and 10.9 ± 2.0, respectively, P < 0.01). The cumulative CTE score showed a positive correlation with modified Mayo score (r = 0.835, P < 0.05). The optimal cut-off value for CTE score predicting moderate and severe UC was 9.5 (area under the curve [AUC]:0.847, sensitivity:78.9%, specificity:82.4%).

CONCLUSION

Disease severity assessment by CTE score demonstrates strong positive correlation with severity established modified Mayo score. CTE score system maybe a potential predictor for active UC severity assessment.

Management of Paediatric Ulcerative Colitis, Part 2: Acute Severe Colitis-An Evidence-based Consensus Guideline From the European Crohn's and Colitis Organization and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition

BACKGROUND AND AIM

Acute severe colitis (ASC) is one of the few emergencies in pediatric gastroenterology. Tight monitoring and timely medical and surgical interventions may improve outcomes and minimize morbidity and mortality. We aimed to standardize daily treatment of ASC in children through detailed recommendations and practice points which are based on a systematic review of the literature and consensus of experts.

METHODS

These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Fifteen predefined questions were addressed by working subgroups. An iterative consensus process, including 2 face-to-face meetings, was followed by voting of the national representatives of ECCO and all members of the Paediatric Inflammatory Bowel Disease (IBD) Porto group of ESPGHAN (43 voting experts).

RESULTS

A total of 24 recommendations and 43 practice points were endorsed with a consensus rate of at least 91% regarding diagnosis, monitoring, and management of ASC in children. A summary flowchart is presented based on daily scoring of the Paediatric Ulcerative Colitis Activity Index. Several topics have been altered since the previous 2011 guidelines and from those published in adults.

DISCUSSION

These guidelines standardize the management of ASC in children in an attempt to optimize outcomes of this intensive clinical scenario.

Ultrasound for Assessing Disease Activity in IBD Patients: A Systematic Review of Activity Scores

BACKGROUND AND AIMS

Ultrasound [US] indices for assessing disease activity in IBD patients have never been critically reviewed. We aimed to systematically review the quality and reliability of available ultrasound [US] indices compared with reference standards for grading disease activity in IBD patients.

METHODS

Pubmed, Embase and Medline were searched for relevant literature published within the period 1990 to June 2017. Relevant publications were identified through full text review after initial screening by two investigators. Data on methodology and index characteristics were collected. Study quality was assessed using a modified version of the Quadas-2 tool for risk of bias assessment.

RESULTS

Of 20 studies with an US index, 11 studies met the inclusion criteria. Out of these 11 studies, 7 and 4 studied Crohn's disease [CD] and ulcerative colitis [UC0 activity indices, respectively. Parameters that were used in these indices included bowel wall thickness [BWT], Doppler signal [DS], wall layer stratification [WLS], compressibility, peristalsis, haustrations, fatty wrapping, contrast enhancement [CE], and strain pattern. Study quality was graded high in 5 studies, moderate in 3 studies and low in 3 studies. Ileocolonoscopy was used as the reference standard in 9 studies. In 1 study a combined index of ileocolonoscopy and barium contrast radiography and in 1 study histology was used as the reference standard. Only 5 studies used an established endoscopic index for comparison with US.

CONCLUSIONS

Several US indices for assessing disease activity in IBD are available; however, the methodology for development was suboptimal in most studies. For the development of future indices, stringent methodological design is required.

Item Generation and Reduction Toward Developing a Patient-reported Outcome for Pediatric Ulcerative Colitis (TUMMY-UC)

BACKGROUND

The Pediatric Ulcerative Colitis Activity Index (PUCAI) is a noninvasive clinician-based index, which reflects disease severity in pediatric ulcerative colitis (UC) when no endoscopy is performed. Here, we aimed to explore signs and symptoms important to children with UC and their caregivers as the first stage of developing a patient-reported outcome (PRO) measure for pediatric UC (ie, the TUMMY-UC index) to supplement endoscopic assessment.

METHODS

Concept elicitation qualitative interviews were performed with children who have UC and their caregivers in 6 centers. Items were rank-ordered by the interviewees according to the frequency of endorsement and importance, graded on a 1 to 5 scale.

RESULTS

A total of 46 children (ages 12.5 ± 3.3 years, range 7-18, 48% boys, 83% with pancolitis, 24% with moderate-severe disease) and 33 caregivers were interviewed (ie, 79 interviews). The following items were identified by the children, in decreasing order of weights: abdominal pain (importance × frequency weight 3.9), rectal bleeding (3.6), stool frequency (3.0), stool consistency (3.0), general well-being/fatigue (2.9), urgency (1.9), and nocturnal stools (1.6). Two other items were scored lower: lack of appetite (1.1) and weight loss (0.6). Children 13 to 18 years comprehended adult vocabulary, children 8 to 12 years comprehended simple vocabulary, and younger children had poor understanding in completing the questions.

CONCLUSIONS

In this first stage of the TUMMY-UC development, items were generated and ranked by input from patients. These items are now being explored for optimal vocabulary and response options. The TUMMY-UC will supplement the PUCAI in clinical trial outcome assessment.

Abdominal ultrasonography of the pediatric gastrointestinal tract

Ultrasound is an invaluable imaging modality in the evaluation of pediatric gastrointestinal pathology; it can provide real-time evaluation of the bowel without the need for sedation or intravenous contrast. Recent improvements in ultrasound technique can be utilized to improve detection of bowel pathology in children: Higher resolution probes, color Doppler, harmonic and panoramic imaging are excellent tools in this setting. Graded compression and cine clips provide dynamic information and oral and intravenous contrast agents aid in detection of bowel wall pathology. Ultrasound of the bowel in children is typically a targeted exam; common indications include evaluation for appendicitis, pyloric stenosis and intussusception. Bowel abnormalities that are detected prenatally can be evaluated after birth with ultrasound. Likewise, acquired conditions such as bowel hematoma, bowel infections and hernias can be detected with ultrasound. Rare bowel neoplasms, vascular disorders and foreign bodies may first be detected with sonography, as well. At some centers, comprehensive exams of the gastrointestinal tract are performed on children with inflammatory bowel disease and celiac disease to evaluate for disease activity or to confirm the diagnosis. The goal of this article is to review up-to-date imaging techniques, normal sonographic anatomy, and characteristic sonographic features of common and uncommon disorders affecting the gastrointestinal tract in children.

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

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

Bowel Ultrasonography in Inflammatory Bowel Disease

BACKGROUND

The diagnosis of inflammatory bowel disease (IBD) is based on a combination of endoscopic, clinical and biochemical investigations as well as cross-sectional imaging. The applications of cross-sectional imaging in IBD are manifold. Ultrasonography has emerged as an important imaging modality in the diagnosis of Crohn's disease (CD) as well as for monitoring disease progression and in the therapeutic response to CD and ulcerative colitis (UC). Key Messages: Ultrasonography is non-invasive, radiation free, cheap, easy to use and well tolerated and accepted by patients. Bowel ultrasonography can be used for the primary diagnosis of CD as it has a similar sensitivity and specificity like that of MRI and CT, particularly in the case of CD. Ultrasonography can also be used to monitor treatment response to therapy and to detect disease recurrence of CD as well as UC. In CD, ultrasonography can also be used to detect complications such as strictures as well as extramural complications, including abscesses and fistulas. Contrast-enhanced ultrasonography is a useful tool that might be helpful to detect certain indications in CD, in particular the differentiation between abscesses and inflammation.

CONCLUSION

A variety of advantages of bowel ultrasonography over other imaging modalities suggest the more frequent use of this method to manage IBD patients in daily practice. Bowel ultrasonography should be a standard tool in IBD centers.

Use of Imaging Techniques in Inflammatory Bowel Diseases That Minimize Radiation Exposure

The use of imaging in the management of inflammatory bowel disease (IBD) has grown exponentially in the last few years. This has raised concerns about the risk of high cumulative level of radiation exposure from medical imaging in IBD patients during their lifetime, especially when the disease begins in pediatric age. Physicians caring for IBD children should be aware of the malignant potential of ionizing radiation and of the availability of alternative radiation-free techniques such as magnetic resonance imaging (MRI) and ultrasonography (US), in order to use them whenever possible. This review will focus on the value of US and MRI in pediatric IBD.