Transabdominal ultrasonography as the primary investigation in patients with suspected Crohn's disease or recurrence: a prospective study

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.

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.

Role of Bowel Ultrasound in the Diagnosis and Follow-up of Patients with Crohn's Disease

Crohn's disease (CD) is an inflammatory chronic bowel disorder; it can involve the whole gastrointestinal tract, but its localization in the ileum or colon is most common. The reference standard for the diagnosis of CD is ileocolonoscopy with histologic assessment. The reference standard for the detection of any complications is surgery. However, imaging techniques have an important role both in the detection/localization of CD and in the follow-up of CD patients. In the last few years, the technical development of ultrasound equipment, the advent of new technologies such as elastography and mostly the increased expertise of sonographers have boosted the role of bowel ultrasound in assessment of the gastrointestinal tract. In fact, bowel ultrasound is particularly attractive thanks to its widespread availability, non-invasiveness, low cost and good reproducibility, as it can be easily repeated during follow-up. The aim of this article is to provide an extensive overview of the actual role of bowel ultrasound in the detection and follow-up of patients with CD.

Bowel Ultrasonography in the Management of Crohn's Disease. A Review with Recommendations of an International Panel of Experts

BACKGROUND

Bowel ultrasonography (US) is considered a useful technique for assessing mural inflammation and complications in Crohn's disease (CD). The aim of this review is to appraise the evidence on the accuracy of bowel US for CD. In addition, we aim to provide recommendations for its optimal use.

METHODS

Publications were identified by literature search from 1992 to 2014 and selected based on predefined criteria: 15 or more patients; bowel US for diagnosing CD, complications, postoperative recurrence, activity; adequate reference standards; prospective study design; data reported to allow calculation of sensitivity, specificity, agreement, or correlation values; articles published in English.

RESULTS

The search yielded 655 articles, of which 63 were found to be eligible and retrieved as full-text articles for analysis. Bowel US showed 79.7% sensitivity and 96.7% specificity for the diagnosis of suspected CD, and 89% sensitivity and 94.3% specificity for initial assessment in established patients with CD. Bowel US identified ileal CD with 92.7% sensitivity, 88.2% specificity, and colon CD with 81.8% sensitivity, 95.3% specificity, with lower accuracy for detecting proximal lesions. The oral contrast agent improves the sensitivity and specificity in determining CD lesions and in assessing sites and extent.

CONCLUSIONS

Bowel US is a tool for evaluation of CD lesions in terms of complications, postoperative recurrence, and monitoring response to medical therapy; it reliably detects postoperative recurrence and complications, as well as offers the possibility of monitoring disease progression.

Impact of Intestinal Ultrasound on Classification and Management of Crohn's Disease Patients with Inconclusive Colonoscopy

Background and Aims. We aim to evaluate the benefit of ultrasound in the assessment of Crohn's disease and to demonstrate its potential contribution to disease management. Methods. We conduct a retrospective review of adult patients with Crohn's disease examined with sonography and colonoscopy within 30 days. Study patients were identified in whom colonoscopy did not access a pathological segment, detected and evaluated by ultrasonography. Changes in management were predominantly attributed to ultrasound in those cases where the diseased segment was not assessed on endoscopy. Results. From 115 patients with temporally related ileocolonoscopy and ultrasound, 41 had disease fully assessed on ultrasound only, with complications in 26/41. Twenty-nine of 41 had mild or no endoscopic inflammation with moderate or severe disease on ultrasound at the same segment or at a segment proximal to the reach of the endoscope. Changes in management were significantly attributed to ultrasound in 22 of these 29 patients. Conclusion. The benefit of cross-sectional imaging is invaluable for the comprehensive assessment of bowel not shown on ileocolonoscopy. Ultrasound may make a significant contribution to correct classification of disease extent and severity of Crohn's disease. Prospective studies are needed to further understand the contribution of US in patient management.

Failure of gastroenterologists to apply intestinal ultrasound in inflammatory bowel disease in the Asia-Pacific: a need for action

Intestinal ultrasound (IUS) is a cheap, noninvasive, risk-free procedure that is significantly underutilized in the diagnosis and management of patients with inflammatory bowel disease (IBD) in the Asia-Pacific region. More cost-effective methods of monitoring disease activity are required in light of the increasing global burden of IBD (especially in Asia), the advent of personalized medicine, and the rising cost of healthcare. IUS is a prime example of a technique that meets these needs. Its common clinical applications include assessing the activity and complications of IBD. In continental Europe, countries such as Germany and Italy use this imaging tool as the standard of care and have integrated it into management protocols. There are formal training programs in these countries to train gastroenterologists in IUS, and it is used in an outpatient setting during patient consultations. Barriers to its use in the Asia-Pacific region include lack of experience and research data, and there are few established centers with active training programs. These concerns can be addressed by investing more in IUS service provision and by increasing allocation of resources toward local research and training. Increased uptake of IUS will ultimately benefit patients with IBD.

Diagnostic imaging in Crohn's disease: what is the new gold standard?

Historically Barium and isotope studies been used for imaging of inflammatory bowel disease (IBD) but carry risk of radiation exposure. Use of Barium is declining resulting in fewer radiologists that have the necessary expertise. Isotopes studies lack anatomical definition but 18F - fludeoxyglucose (FDG) positron emission tomography (PET) shows promise in accurate assessment of disease compared to endoscopy. Computerised tomography (CT) is particularly useful in assessment of complications of Crohn's disease (CD) but radiation exposure is high. CT enterography (CTE) has improved visualisation of small bowel mucosal disease and allows assessment of disease activity. Ultrasound is increasingly used for preliminary assessment of patients with potential IBD. Although widely available and economically attractive, the expertise required is not widespread. Finally magnetic resonance imaging (MRI) is proving to be the most accurate tool for assessment of disease extent and distribution. MRI of the pelvis has superseded other techniques in assessment of peri-anal fistulation.

Ultrasound as a diagnostic tool in detecting active Crohn's disease: a meta-analysis of prospective studies

OBJECTIVES

To evaluate the diagnostic accuracy of ultrasound in assessing active Crohn's disease (CD) in adults.

METHODS

We systematically searched PubMed, EMBASE, Web of Science and the Cochrane Library for prospective studies in which ultrasound was performed to evaluate active CD in adults from January 1993 to April 2013. Pooled sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR-) and diagnostic odds ratios (DORs) in a per-patient-based analysis were estimated. Additionally, the area under the receiver-operating characteristic (ROC) curve was calculated to measure the diagnostic accuracy of ultrasound in patients with known or suspected CD.

RESULTS

Fifteen studies involving 1,558 patients were included in this meta-analysis. Overall, the pooled sensitivity (0.88) and LR- (0.14) were not heterogeneous, whereas the pooled specificity (0.97, I(2) = 72.9 %) and LR + (15.10, I(2) = 71.8 %) were. The DOR of ultrasound for assessing active CD was 121.70, with significant heterogeneity (I(2) = 63.3 %). A symmetrical summary ROC curve was plotted showing that the area under the curve was 0.94, indicating good diagnostic accuracy. Meta-regression and subgroup analysis showed that the disease location may be a major cause of heterogeneity.

CONCLUSIONS

This meta-analysis suggests that ultrasound has high diagnostic accuracy in detecting active CD in adults, especially for small bowel CD.

KEY POINTS

• Ultrasound can detect active Crohn's disease (CD). • A meta-analysis of ultrasound for detecting active CD was carried out. • This revealed that ultrasound has high diagnostic accuracy for detecting CD.

Transabdominal ultrasound for bowel evaluation

This article considers the case for a strategic place for ultrasound (US) bowel evaluation focusing on three common clinical contexts. These include imaging for suspected acute appendicitis and acute diverticulitis, as well as the role of US in a multimodality approach for the diagnosis and management of inflammatory bowel disease and associated complications.

Imaging of pediatric patients with inflammatory bowel disease

OBJECTIVE

The goal of this review is to examine the current imaging literature and develop basic imaging guidelines for evaluation of children with inflammatory bowel disease (IBD). The three following typical clinical scenarios in the imaging evaluation of IBD are considered: patient with an initial diagnosis of suspected IBD, the goals being to determine disease extent and severity and to differentiate Crohn disease from ulcerative colitis; patient with known IBD presenting with new acute symptoms (fever, peritonitis, leukocytosis) requiring urgent evaluation; and patient with known IBD presenting with nonacute symptomatic recurrence (abdominal pain, diarrhea), the goals being to assess the efficacy of the current treatment and to evaluate the possible need for additional medical or surgical intervention.

CONCLUSION

Imaging of pediatric patients with IBD must balance considerations of diagnostic accuracy against concerns about patient exposure to ionizing radiation and tolerance of the imaging technique. The imaging modality chosen depends on the clinical presentation and expected pathologic finding.

Graded compression and power Doppler ultrasonography versus endoscopy to assess paediatric Crohn disease activity pre- and posttreatment

OBJECTIVE

The aim of this study was to assess whether power Doppler ultrasound (PDU) can serve as a reliable replacement for endoscopy in follow-up assessment of disease activity in children with Crohn disease.

METHODS

Nineteen children (13 boys), median age 14.8 (5.4-15.8) years, with macroscopically diagnosed Crohn disease were included in the study. Clinical parameters, histological evaluation, and graded PDU assessments were undertaken in all patients at diagnosis and following their initial treatment. Discriminant analysis was used to build predictive models from the PDU data for the histological evaluation.

RESULTS

The median Pediatric Crohn's Disease Activity Index (PCDAI) was 31.5 (15.5-42.0) at diagnosis. All clinical and ultrasonographic parameters and the histological evaluation showed an improvement between pre- versus posttreatment results; 1-way analysis of variance showed a significant difference because of treatment (P < 0.005) for all variables apart from the superior mesenteric artery flow (SMA); paired sample t tests indicated that these differences were statistically significant (P < 0.001), with the exception of SMA (P = 0.178). There was a statistically significant correlation (P < 0.001) between the platelet count and the bowel wall stratification (STRAT). Significant correlation was also observed between the histology findings and the mean mucosal, transmural, and segmental flow (MFL) and STRAT and between platelets and both MFL and small bowel thickening (SBT) (P < 0.01 in all cases). There was a statistically significant correlation (P < 0.05) between C-reactive protein and MFL and between histology and SBT, MFL, and STRAT. Discriminant analysis using discriminating factors SBT, STRAT, and MFL could assign 84.6% of cases to the correct classification of "no/mild inflammation" or "medium/severe inflammation."

CONCLUSIONS

Results obtained using power Doppler ultrasonography and endoscopy showed statistically significant correlations. Power Doppler sonography, in the hands of an experienced examiner, can be used for follow-up assessment of disease activity in children with Crohn disease.

Ultrasound of the small bowel in Crohn's disease

Several radiological and endoscopic techniques are now available for the study of inflammatory bowel diseases. In everyday practice, the choice of the technique to be used depends upon its availability and a careful evaluation of diagnostic accuracy, clinical usefulness, safety, and cost. The recent development of innovative and noninvasive imaging techniques has led to a new and exciting area in the exploration of the gastrointestinal tract, especially in Crohn's disease patients by using ultrasound with oral or intravenous contrast.

Noninvasive imaging of the small bowel in Crohn's disease: the final frontier

The substantial morbidity and mortality associated with Crohn's disease underlines the importance of accurate assessment at presentation, during follow-up, when investigating complications, and when evaluating the response to therapeutic interventions. Accurate methods are required to quantify the severity and extent of disease.

New concepts in intestinal imaging for inflammatory bowel diseases

In the last decade, multiple imaging technologies have been developed that improve visualization of the mucosal, mural, and perienteric inflammation associated with inflammatory bowel diseases. Whereas these technologies have traditionally been used to detect and stage suspected enteric inflammation, we review new, emerging roles in detecting clinically occult inflammation (in asymptomatic patients) and inflammatory complications, predicting response prior to therapy, assessing response after therapy, and enteric healing. We compare the relative performance of these technologies in detecting inflammation, focusing on their advantages and disadvantages and how they might complement each other. We also discuss their potential benefits for patients and clinical trials, reviewing technologic developments and areas of research that could provide important insights into the pathophysiology of inflammatory bowel diseases-related enteric inflammation.

Inflammatory bowel disease: a systematic review on the value of diagnostic testing in primary care

AIM

The clinical presentation of inflammatory bowel disease in primary care represents a diagnostic challenge as its symptoms are heterogeneous and common. To assist the primary care physician, we have summarized the available evidence on diagnostic tests in patients with abdominal symptoms.

METHOD

We searched PubMed and Embase and screened references. Studies were selected if the design was a primary diagnostic study. Patients were adults attending with nonacute abdominal symptoms. Tests included clinical assessment, blood or faecal tests or abdominal ultrasonography. Quality assessment using a modified version of the QUADAS tool and data extraction was performed by two reviewers independently. Diagnostic two-by-two tables and pooled estimates of sensitivity and specificity are given. We refrained from pooling when there was considerable clinical or statistical heterogeneity.

RESULTS

A total of 24 studies were included. While the diagnostic performance of the individual symptoms was highly variable (range sensitivity 0.0-0.96, specificity 0.09-1.0), the performance of symptom-based classification systems was both more consistent and better (sensitivity 0.65-1.0, specificity 0.17-0.82). Among faecal and blood tests, calprotectin was studied most frequently and showed the best results (sensitivity 0.61-1.0, specificity 0.71-1.0). Statistical pooling for ultrasonography resulted in a sensitivity of 0.73 (0.65-0.80) and a specificity of 0.95 (0.91-0.97).

CONCLUSION

Although calprotectin and ultrasonography showed consistent and promising findings, none of the studies was performed in primary care. To assist primary care physicians in diagnostic decision making, we urgently need high quality studies performed in primary care.

Imaging techniques in inflammatory bowel disease: recent trends, questions and answers

Imaging techniques have undergone substantial progress in recent years and contribute significantly in the diagnosis of inflammatory bowel diseases in conjunction with patient history, clinical and laboratory examination. Modern cross-sectional imaging modalities such as computed tomography and magnetic resonance imaging allow an evaluation not only of the complete bowel wall of the small intestine, but also of extraluminal structures. They constitute a major diagnostic component in the initial workup, in stricturing or fistulizing disease and in suspected abscess. Transabdominal ultrasonography has been re-appreciated in these settings as an easy- and ready-to-use tool yielding real-time information. Positron emission tomography was found useful to add functional diagnosis of inflammation. Colonoscopy techniques still represent the gold standard for evaluation of inflammatory activity and for cancer surveillance. Here, chromoendoscopy has proven efficacy for enhanced detection of flat intraepithelial neoplasias in ulcerative colitis and has been incorporated into recent surveillance guidelines. Narrow band imaging may provide virtual chromoendoscopy in the future, but confirmatory studies are still on the way. Confocal endomicroscopy allows in vivo microscopy at high resolution and with excellent accuracy in first trials to predict histology of inflammatory and neoplastic lesions. The current data from endoscopic studies should result in an integrated approach to both identify and characterize a suspicious lesion during ongoing endoscopy for reliable, accurate diagnosis and targeted, immediate therapy.

Use of small bowel imaging for the diagnosis and staging of Crohn's disease--a survey of current UK practice

OBJECTIVES

This study used a postal survey to assess the current use of small bowel imaging investigations for Crohn's disease within National Health Service (NHS) radiological practice and to gauge gastroenterological referral patterns.

METHODS

Similar questionnaires were posted to departments of radiology (n = 240) and gastroenterology (n = 254) identified, by the databases of the Royal College of Radiologists and British Society of Gastroenterologists. Questionnaires enquired about the use of small bowel imaging in the assessment of Crohn's disease. In particular, questionnaires described clinical scenarios including first diagnosis, disease staging and assessment of suspected extraluminal complications, obstruction and disease flare. The data were stratified according to patient age.

RESULTS

63 (27%) departments of radiology (20 in teaching hospitals and 43 in district general hospitals (DGHs)) and 73 (29%) departments of gastroenterology replied. These departments were in 119 institutions. Of the 63 departments of radiology, 55 (90%) routinely performed barium follow-though (BaFT), 50 (80%) CT, 29 (46%) small bowel ultrasound (SbUS) and 24 (38%) small bowel MRI. BaFT was the most commonly used investigation across all age groups and indications. SbUS was used mostly for patients younger than 40 years of age with low index of clinical suspicion for Crohn's disease (in 44% of radiology departments (28/63)). MRI was most frequently used in patients under 20 years of age for staging new disease (in 27% of radiology departments (17/63)) or in whom obstruction was suspected (in 29% of radiology departments (18/63)). CT was preferred for suspected extraluminal complications or obstruction (in 73% (46/63) and 46% (29/63) of radiology departments, respectively). Gastroenterological referrals largely concurred with the imaging modalities chosen by radiologists, although gastroenterologists were less likely to request SbUS and MRI.

CONCLUSION

BaFT remains the mainstay investigation for luminal small bowel Crohn's disease, with CT dominating for suspected extraluminal complications. There has been only moderate dissemination of the use of MRI and SbUS.

Impact of high-resolution transabdominal ultrasound in the diagnosis of complications of Crohn's disease

OBJECTIVE

Crohn's disease is associated with intestinal complications such as strictures, fistulas and abscesses. As the management of the patients is influenced by the presence or absence of complication, sensitive diagnostic modalities to detect these complications are needed. The aim of this prospective study was to evaluate the diagnostic accuracy of high-resolution transabdominal ultrasound in the diagnosis of complications of Crohn's disease.

MATERIAL AND METHODS

From April 2003 to July 2009, 58 patients (31 women, 27 men; mean age 36.3 years, range 13-86 years) with known Crohn's disease were included in the study and investigated with high-resolution transabdominal ultrasound. The diagnosis of Crohn's disease was based on clinical, endoscopic, histological, radiological and operative findings. Patients with other forms of enteritis (e.g. infectious) were excluded from the study. Twenty of the 58 patients were investigated on a second occasion with other symptoms than at the first admission. The time duration between the two ultrasound investigations was at least 3 months. Consequently, a total of 78 ultrasound investigations were done in 58 patients. With respect to their clinical symptoms, all patients were further investigated within 2 weeks after ultrasound with magnetic resonance imaging, and/or computed tomography, and/or enteroclysis, and/or endoscopy with biopsy. Together with clinical data (Crohn's disease activity index) and surgical findings these investigations were used as reference procedure.

RESULTS

The sensitivity, specificity, positive predictive and negative predictive values of ultrasound were as follows: 0.86, 0.90, 0.83 and 0.92 for stenoses; 0.78, 0.95, 0.86, and 0.91 for fistulas; 0.90, 0.99, 0.90 and 0.99 for abscesses, respectively.

CONCLUSIONS

High-resolution transabdominal ultrasound done by experienced examiners has an excellent diagnostic accuracy in the diagnosis of complications in patients with Crohn's disease. Thus, it can be recommended as one of the primary investigative procedures for evaluation of Crohn's disease.

Ultrasound and inflammatory bowel disease

Transabdominal bowel sonography is a fast, efficient, and cheap way of examining the intestines. It is also virtually hazard-free and well accepted by patients. During the last 20 years, it has been established as a procedure for detecting bowel disease early in the diagnostic workup. Although rather unspecific, the method is sensitive for detection of bowel disease and can be applied to find the extent and location of inflammatory bowel disease. In patients with known ulcerative colitis and Crohn disease, it can also be used for follow-up because it is easily repeatable and radiation-free. Because it can be applied to find both intraluminal and peri-intestinal pathological features, it is a particularly valuable tool for the detection of complications of Crohn disease as stenosis, fistulas, and abscesses. Neither B-mode nor Doppler techniques have been proven obviously useful in categorizing disease activity, but new techniques using intravenous contrast might come closer to solving this question. Finally, recent longitudinal studies using transabdominal bowel sonography show that it can also give important prognostic information and be used for monitoring the effect of therapy.

ACR Appropriateness Criteria on Crohn's disease

In the past decade, new therapeutic agents have been developed that permit gastroenterologists to treat virtually all forms of Crohn's disease. The success of these treatments depends on an accurate diagnosis of the nature and extent of disease. Fortunately, radiologists now possess a powerful arsenal of imaging techniques to guide the choice of therapy. This article discusses the usefulness of both traditional and newer imaging techniques in the management of Crohn's disease and its various clinical presentations.

Transabdominal sonography in assessment of the bowel in adults

OBJECTIVE

We describe the key sonographic features and technical aspects of assessment of bowel disorders in adults.

CONCLUSION

Initial imaging with transabdominal sonography in the radiologic evaluation of bowel disease in adults often is reserved for patients with equivocal historical, physical, and laboratory findings related to the gastrointestinal tract. Because of technologic advances and accumulated experience in interpretation of the images, sonography yields substantial information about gastrointestinal disorders.

Reproducibility of bowel ultrasonography in the evaluation of Crohn's disease

BACKGROUND

Bowel ultrasonography is increasingly used in the detection and follow-up of patients with Crohn's disease, but a limitation to its further diffusion is the lack of standardisation of ultrasonography parameters.

AIMS

This study aimed to standardise the most common bowel ultrasonography parameters in order to develop an unequivocal imaging interpretation and to assess bowel ultrasonography reproducibility.

PATIENTS

Twenty patients with Crohn's disease were examined.

METHODS

Six ultrasonographers (mean bowel ultrasonography experience=16 years) performed the study. They chose and discussed a common assessment methodology concerning eight ultrasonography parameters: bowel wall thickness, bowel wall pattern, bowel wall blood flow, enlarged mesenteric lymph nodes, mesenteric hypertrophy, abdominal free fluid, and stenosis or fistulae at four preliminary meetings. The day of the study operators were randomised to two rooms where they independently and in turn performed ultrasonography scans. Interobserver agreement was scored by kappa statistics.

RESULTS

Excellent k values were observed for bowel wall thickness (0.72-1). k Values were poor for bowel wall pattern (-0.22-0.85) and good for bowel wall blood flow (0.53-0.89). The presence of lymph nodes was reproducible (0.56-0.90) except in one case (0.25). Concordance on free fluid was excellent (0.85-1), whereas that on mesenteric hypertrophy was generally poor (0.14-0.69). Agreement was excellent for stenosis (0.81-1) whereas that for fistula was fair in room abscesses (0.31-0.48) and very good in room B (0.87-1).

CONCLUSION

Bowel ultrasonography signs used in Crohn's disease can be standardised as most of them showed a fair to good reproducibility. In particular, bowel wall thickness, the most relevant parameter for Crohn's disease detection, showed an excellent reproducibility.

Inflammatory bowel disease diagnosed with US, MR, scintigraphy, and CT: meta-analysis of prospective studies

PURPOSE

To compare, by performing a meta-analysis, the accuracies of ultrasonography (US), magnetic resonance (MR) imaging, scintigraphy, computed tomography (CT), and positron emission tomography (PET) in the diagnosis of inflammatory bowel disease (IBD).

MATERIALS AND METHODS

MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched for studies on the accuracy of US, MR imaging, scintigraphy, CT, and PET, as compared with a predefined reference standard, in the diagnosis of IBD. Sensitivity and specificity estimates were calculated on per-patient and per-bowel-segment bases by using a bivariate random-effects model.

RESULTS

Thirty-three studies, from a search that yielded 1406 articles, were included in the final analysis. Mean sensitivity estimates for the diagnosis of IBD on a per-patient basis were high and not significantly different among the imaging modalities (89.7%, 93.0%, 87.8%, and 84.3% for US, MR imaging, scintigraphy, and CT, respectively). Mean per-patient specificity estimates were 95.6% for US, 92.8% for MR imaging, 84.5% for scintigraphy, and 95.1% for CT; the only significant difference in values was that between scintigraphy and US (P = .009). Mean per-bowel-segment sensitivity estimates were lower: 73.5% for US, 70.4% for MR imaging, 77.3% for scintigraphy, and 67.4% for CT. Mean per-bowel-segment specificity estimates were 92.9% for US, 94.0% for MR imaging, 90.3% for scintigraphy, and 90.2% for CT. CT proved to be significantly less sensitive and specific compared with scintigraphy (P = .006) and MR imaging (P = .037)

CONCLUSION

No significant differences in diagnostic accuracy among the imaging techniques were observed. Because patients with IBD often need frequent reevaluation of disease status, use of a diagnostic modality that does not involve the use of ionizing radiation is preferable.

Bowel ultrasound in Crohn's disease

Most published studies have found bowel ultrasound to be a useful tool in the management of Crohn's disease. Indeed, it has been successfully used as the imaging technique of choice in screening patients with clinically suspected Crohn's disease. In these patients, bowel ultrasound, which is well accepted by patients, non-invasive and of low cost, may be the first diagnostic tool employed for young patients and can be used in the preliminary diagnostic work-up prior to further invasive tests. The most important application of bowel ultrasound is, however, in the follow-up of patients already diagnosed with Crohn's disease, in whom it may be useful to assess the site and extent of the lesions and to ensure the early detection of intra-abdominal complications, particularly abscesses and strictures. In this regard, improving the ultrasound assessment of intramural blood flow by means of colour power-Doppler ultrasonography and intravenous contrast agents may help to differentiate fibrotic and inflammatory strictures, and to discriminate inflammatory masses from intra-abdominal abscesses. Despite several attempts to correlate ultrasound findings with clinical and biochemical activity, there are as yet no convincing data on the usefulness of ultrasound in assessing the activity of Crohn's disease. In contrast, preliminary results are in agreement regarding the usefulness of ultrasound in the assessment of postoperative recurrence and in monitoring the outcome of the disease following surgery. In fact, the persistence of a thickened bowel wall or increased high bowel wall thickening at ultrasound following surgery has been identified as an index of early surgical recurrence. How these data may be usefully employed in the management of individuals with Crohn's disease needs to be investigated in further studies.

Role of US in detection of Crohn disease: meta-analysis

PURPOSE

To evaluate the accuracy of ultrasonography (US) in the detection of Crohn disease in adults by systematically reviewing both cohort studies (those including patients whose clinical characteristics were consistent with those caused by an inflammatory bowel disease) and case-control studies (those in which patients with Crohn disease were compared with patients with other bowel diseases or healthy control subjects).

MATERIALS AND METHODS

The MEDLINE, EMBASE, and Cochrane Library databases were used to retrieve all the cross-sectional studies that assessed the diagnostic accuracy of US against that of one of several predefined reference standards (ie, radiologic, endoscopic, or histologic findings). The studies that fulfilled the inclusion criteria were identified, and their methodological quality was evaluated. Of the 2860 primary studies identified, two case-control and five cohort series fulfilled the inclusion criteria. Statistical analysis was performed by using the summary receiver operating characteristic (SROC) model.

RESULTS

The ranges of US sensitivity and specificity for the diagnosis of Crohn disease reported for the included series were 75%-94% and 67%-100%, respectively; the heterogeneity of these values prevented the calculation of a cumulative value. The SROC curve revealed a clear cutoff effect that depended on the chosen bowel wall thickness threshold. Sensitivity and specificity of 88% and 93%, respectively, were achieved when a bowel wall thickness threshold greater than 3 mm was used, and sensitivity and specificity of 75% and 97%, respectively, were achieved when a threshold greater than 4 mm was used.

CONCLUSION

US examination seems appropriate for confirming or excluding Crohn disease as a diagnosis in a clinical context characterized by a pretest probability of Crohn disease that ranges from 12% to about 60%. In particular, for Crohn disease limited to the ileum, US may represent a valid alternative to the small-bowel series, while for colonic involvement US may be useful in ruling out the diagnosis.

Small intestine contrast ultrasonography: an alternative to radiology in the assessment of small bowel disease

BACKGROUND

Radiology and transabdominal ultrasonography (TUS) are used in the evaluation of the small bowel; however, the former technique is limited by radiation exposure, and the latter by its inability to visualize the entire small bowel.

AIM

To evaluate the diagnostic accuracy of small intestine contrast ultrasonography (SICUS) to assess the presence, number, site, and extension of small bowel lesions.

SUBJECTS AND METHODS

TUS, SICUS, and small bowel follow-through (SBFT) were performed in 148 consecutive patients (78 women; age range, 12 to 89 yr), 91 with undiagnosed conditions, and 57 with previously diagnosed Crohn's disease (CD).

RESULTS

In the undiagnosed patients, the sensitivity and specificity of TUS and SICUS were 57% and 100%, and 94.3% and 98%, respectively. In the CD patients, the sensitivity of TUS and SICUS was 87.3% and 98%, respectively. In comparison with SBFT, the extension of lesions was correctly assessed with SICUS and greatly underestimated with TUS. The concordance index between SBFT and SICUS for the number and site of lesions was 1 and 1 (P < 0.001), respectively, in undiagnosed patients, and 0.81 and 0.83 (P < 0.001), respectively, in CD patients. Between SBFT and TUS, the concordance index was 0.28 and 0.27 (not significant), respectively, in undiagnosed patients, and 0.28 and 0.31 (not significant), respectively, in CD patients.

CONCLUSIONS

The diagnostic accuracy of SICUS is comparable to that of a radiologic examination, and is superior to that of TUS in detecting the presence, number, extension, and sites of small bowel lesions. These findings support the use of noninvasive SICUS for an initial investigation when small bowel disease is suspected and in the follow-up of CD patients.

Crohn's disease: a comparative prospective study of transabdominal ultrasonography, small intestine contrast ultrasonography, and small bowel enema

BACKGROUND

Small intestine contrast ultrasonography (SICUS), when performed after distention of the small bowel lumen with an iso-osmolar polyethylene glycol electrolyte-balanced solution, shows high sensitivity (100%) and specificity (97%) in detecting small bowel abnormalities in patients who have not received a diagnosis but in whom there is a suspicion of intestinal diseases. The diagnostic yield of SICUS remains to be established in detecting small bowel lesions in patients with proven Crohn's disease (CD) in comparison with transabdominal ultrasonography (TUS), and in relationship to the experience of the operator, using small bowel enema (SBE) as the "gold standard."

AIM

The aim of this study was to evaluate the diagnostic value of SICUS, when performed by a sonologist with 1 year of experience, and TUS, when performed by a sonologist with 10 years of experience, compared to SBE in the assessment of the site, extension, and stenosis of small intestinal lesions in CD patients.

PATIENTS AND METHODS

A total of 28 consecutive patients (men, 16; women, 12; age range, 21 to 60 yr) with a diagnosis of CD underwent TUS and SICUS, which were performed by 2 sonologists who were unaware of the radiologic findings, on the same day. SICUS was performed after the ingestion of 375 mL of a polyethylene glycol contrast solution. A standard SBE was performed on a different day by an expert radiologist who was unaware of the sonographic findings.

RESULTS

Sensitivities in the detection of small bowel lesions were 96% for TUS and 100% for SICUS. Compared with SBE, SICUS detected the presence of 4 lesions in the jejunum that had been missed by TUS. The mean (+/-SD) extent of the ileal disease was 22 +/- 12.5 cm when measured during SBE, 14.5 +/- 8.6 cm when measured during TUS, and 19.5 +/- 12.5 cm when measured during SICUS [P = 0.05 (SICUS versus SBE)]. The correlation of the extension of the lesions between SICUS and SBE (r = 0.88) was better than that between TUS and SBE (r = 0.64). The sensitivities of TUS and SICUS in the detection of at least 1 stricture were 76% and 94%, respectively. Sensitivity and specificity in assessing prestenotic dilatation were 50% and 100%, respectively, at TUS, and 100% and 90%, respectively, at SICUS.

CONCLUSION

In inexperienced hands, SICUS is a more accurate technique for assessing CD lesions, and the accuracy is better than that of TUS performed by an expert sonologist. The use of SICUS, instead of SBE, could be indicated for the follow-up of patients with CD.

Bowel wall thickness at abdominal ultrasound and the one-year-risk of surgery in patients with Crohn's disease

OBJECTIVES

Abdominal ultrasound can assess the extent and localization of Crohn's disease, and an increased bowel wall thickness is the most common finding. Our aim was to correlate bowel wall thickness at ultrasound, with the risk of short-term surgical outcome in patients with Crohn's disease.

MATERIALS AND METHODS

From 1997 to 2000 we performed ultrasound in 174 consecutive patients with Crohn's disease. Surgical operations were recorded over a 1-yr follow-up. Logistic regression analysis was performed to identify clinical and ultrasound risk factors for surgery.

RESULTS

Fifty-two patients underwent surgery within 1 yr. Indication for surgery was strictures in most of the cases. Median bowel wall thickness was higher in patients with surgery (8 mm) than those without surgery (6 mm) (p < 0.0001). A receiver operating characteristic (ROC) curve was constructed taking into account bowel wall thickness for selecting patients with a high risk of surgery. The optimized cut-off for equally important sensitivity and specificity was calculated at 7.008 mm. The binary regression analysis showed that CDAI > 150, absence of previous surgery, stricturing-penetrating pattern, the presence of intestinal complications, and intestinal wall thickness >7 mm were associated with an increased risk of surgery. Patients with intestinal wall thickness >7 mm at ultrasound had the highest risk (OR: 19.521, 95% CI: 5.362-71.065).

CONCLUSIONS

Data suggest that bowel wall thickness >7 mm at ultrasound is a risk factor for intestinal resection over a short period of time. Routine use of abdominal ultrasound during evaluation of patients with Crohn's disease may identify a subgroup that is at high risk for surgery. (Am J Gastroenterol 2004;99:1-7)

Modern imaging of Crohn's disease using bowel ultrasound

Technological advancement of ultrasound (US) equipments and understanding of bowel appearances with high resolution US during the last decade has led to consideration of this imaging procedure as an important tool for inflammatory bowel diseases assessment. In particular, Crohn's disease (CD) for its pathologic characteristics (that is, inflammatory infiltration of the entire bowel wall with possible extension to the surrounding mesentery) is the disease entity which has mainly taken advantage from this non-invasive, radiation-free technique. Beside correctly defining anatomic location and extension of CD lesions within the bowel in the majority of cases, US also shows perigut abnormalities and may demonstrate complications such as fistulas and abscesses. With the help of Power Doppler function, some additional information may be obtained about the local activity of the disease which is particularly useful in the presence of strictures. New US technologies (such as those using intravenous bolus contrast agents or oral nonabsorbable anechoic solutions) may further improve diagnostic capability of US in this context, thus probably revolutioning the diagnostic approach to this disease in the near future, particularly during follow-up in CD of the small bowel.

Activity of Crohn disease: value of Color-Power-Doppler and contrast-enhanced ultrasonography

Diagnosis and follow-up of Crohn disease (CD) often require invasive instrumental examinations, with a high risk of iatrogenic damage. Ultrasound (US) examination of bowel walls could be the first choice in managing patients with CD. We evaluated the role of tissue color power Doppler (CPD) and B-mode US with intravenous injection of contrast medium in the detection of disease activity. In our series, 52 patients with CD underwent US examination. Each study was completed with tissue CPD and US with intravenous injection of contrast medium (Sono Vue) to evaluate intestinal wall vascularization as an index of disease activity. We then compared our results with those from clinical and laboratory tests and follow-up. Data from US examination with intravenous injection of Sono Vue partly agreed with clinical and laboratory tests and CPD in disease activity evaluation but were most useful in the follow-up. Bowel US examination associated with CPD and in particular US contrast medium injection can be used to detect CD activity and modulate therapy and follow-up.

Detection of ileocecal Crohn's disease using ultrasound as the primary imaging modality

At our hospital ultrasound (US) is used as an initial screening procedure in all patients with abdominal symptoms. The purpose of this study was to assess the effect of this policy on the detection of ileocecal Crohn's disease. We retrospectively studied all patients with a new diagnosis of ileocecal Crohn's disease from our institute over the period 1990-2001. The final diagnosis was based on clinical follow-up and pathological, surgical, US, and other radiological findings. We noted who referred the patient to the radiology department, what the initial clinical presumption was, and what the first imaging study was. US diagnoses were determined from the initial US report and US findings were registered from the images. There were a total of 47 patients (20 men, 27 women) with a mean age of 30 years and a median age of 27 years (range 14-75 years). In all patients the initial imaging study was an abdominal US. Using US, a confident diagnosis of ileocecal Crohn's disease was made in 35 of the 47 patients, Crohn's disease was suggested among the differential diagnosis in 10, and an incorrect diagnosis was made in 2 patients. In 28 of 47 patients, the referring physician did not consider Crohn's disease when requesting the initial US examination. In eight patients with appendicitis-like symptoms, the US findings strongly influenced the decision to refrain from operation at that point in time. US, when used as a low-threshold diagnostic procedure, is a reliable and noninvasive means for making an early diagnosis of ileocecal Crohn's disease in patients who present with atypical symptoms. It may prevent both unnecessary therapeutic delay as well as unnecessary surgery.

Role of early ultrasound in detecting inflammatory intestinal disorders and identifying their anatomical location within the bowel

BACKGROUND

Although bowel ultrasound is a widely accepted diagnostic tool in bowel diseases, its value as the primary imaging procedure in patients with symptoms/signs suggestive of inflammatory bowel disorders is still unclear.

AIM

To investigate the accuracy of bowel ultrasound compared with barium X-ray studies, computed tomography, endoscopy and bowel surgery in the initial assessment of inflammatory bowel disorders.

METHODS

Four hundred and eighty-seven patients hospitalized consecutively for symptoms or signs suggestive of a bowel disorder between December 1999 and March 2002 were initially enrolled in the study. All patients underwent bowel ultrasound as the first imaging procedure within 36 h of admission; radiographic evaluations, endoscopy and/or surgery were then performed as appropriate and the results of these investigations were used as the gold standard.

RESULTS

Three hundred and thirty-six patients had pathological findings of the bowel detectable at ultrasound as the final diagnosis. The main organic disorders found were Crohn's disease (56%), ulcerative/indeterminate colitis (30%), bowel tumours (5%), appendicitis/diverticulitis (2%) and other inflammatory conditions (8%). The overall sensitivity and specificity of bowel ultrasound were 85% and 95%, respectively, whereas the positive and negative predictive values were 98% and 75%, respectively. Comparisons of ultrasound with X-ray or endoscopic results by disease localization showed that the diagnostic performance of ultrasound was higher for inflammatory conditions of the ileum and sigmoid/descending colon (sensitivity of 92% and 87%, respectively), whereas abnormalities localized in the rectum, duodenum and proximal jejunum were often missed by ultrasound.

CONCLUSIONS

In expert hands, bowel ultrasound is highly predictive of inflammatory disease localized in the ileum or colon, and may well be used as the primary imaging method when Crohn's disease or ulcerative colitis is suspected on a clinical basis.

Small intestine contrast ultrasonography (SICUS) in the diagnosis of small intestine lesions

After the ingestion of iso-osmolar polyethylene glycol solution, the small bowel can be visualized on ultrasonography. The aim of this study was to assess sensitivity and specificity of SICUS in diagnosis of small bowel lesions. A total of 53 consecutive patients with suspected intestinal pathology underwent a diagnostic workup, including a small bowel follow-through and SICUS performed by independent operators. The sonologist was unaware of the clinical data. Diagnostic sensitivity and specificity were assessed using radiologic findings. Diagnostic sensitivity of SICUS was 100%, with a specificity of 97%. The concordance index was 0.956 (p < 0.003, kappa statistics) and the conformity between SICUS and radiology was 1. The diagnostic accuracy of SICUS to detect small bowel lesions is comparable to that of small bowel follow-through. Results of this study support the use of noninvasive, widely available, inexpensive, and nondemanding SICUS as an initial investigation in patients with suspected small bowel disease.

Transabdominal ultrasonography of the small bowel after oral administration of a non-absorbable anechoic solution: comparison with barium enteroclysis

AIM

The aim of this study was to determine if oral administration of a non-absorbable anechoic solution conveys any benefit during abdominal ultrasound (US), with special reference to its accuracy.

MATERIALS AND METHODS

Fifty-three adult out-patients scheduled for small bowel barium enema (SBE) were included. The day before SBE all patients underwent abdominal US before and after oral administration of an isotonic non-absorbable electrolyte solution containing polyethylene glycol (PEG-ELS). Sensitivity and specificity were evaluated using SBE as a gold standard.

RESULTS

After ingestion of PEG-ELS satisfactory distension of the intestinal lumen was obtained (11-25 mm) with sequential visualization of jejunoileal loops in 30.9 +/- 17.3 min. In 15 out of 53 cases both US and SBE showed bowel changes characteristic of Crohn's disease. In three out of 53 cases both US and SBE showed neoplasms. In one out of 53 cases US was negative, SBE positive for local nodularity and ulcerations typical of Crohn's disease. In one out of 53 cases US was negative, SBE positive for macronodularity consistent with coeliac disease. In five out of 53 cases US was negative, while SBE was positive for mininodularity expressive of lymphoid hyperplasia. In 28 out of 53 cases both examinations were negative.

CONCLUSION

PEG-ELS administration allows a thorough US investigation of the small bowel, with fair sensitivity (72%) and excellent specificity (100%). False negative findings are mainly due to lymphoid hyperplasia, a feature of uncertain significance in adults.

Inflammatory bowel disease in children and young adults: correlation of sonographic and clinical parameters during treatment

OBJECTIVE

The objective of this study was to evaluate the sonographic findings of inflammatory bowel disease activity in children undergoing treatment.

SUBJECTS AND METHODS

Eighty-eight sonograms were obtained of 23 bowel segments in 17 children and young adults (age range, 10-21 years; mean, 16 years) with new or recurrent inflammatory bowel disease. Sixteen segments were involved with Crohn's disease and seven with ulcerative colitis. Serial sonography (range, two to eight examinations; mean, four per segment) was performed while patients underwent treatment. Bowel wall thickness measurements and color and power Doppler sonography grading were recorded and compared with clinical data.

RESULTS

All 17 patients had at least one abnormal bowel segment on initial sonography. The correlation was significant (p < 0.01). Agreement was 91% on direction of change over time between bowel wall thickness and Doppler grades, with 100% correlation between color and power Doppler sonography grades. In patients with Crohn's disease, the correlation was significant (p < 0.05) between bowel wall thickness and Doppler grades with two of seven and four of seven clinical parameters, respectively. In patients with ulcerative colitis, the correlation was significant (p < 0.05) between bowel wall thickness and Doppler sonography grades with four of seven and three of seven clinical parameters, respectively. The erythrocyte sedimentation rate correlated with all sonographic measurements in both patient groups. Combining bowel wall thickness and Doppler sonography, the percentage of agreement was significant in the direction of change, with five of seven clinical parameters in both patient groups.

CONCLUSION

Gray-scale and color or power Doppler sonography can show changes in disease activity in children and young adults undergoing treatment for inflammatory bowel disease.

Contrast ultrasonography of the normal small bowel

In basal conditions, the small bowel loops cannot be properly visualized by means of real-time ultrasound (US). Aims of this study were: 1. to assess whether an isosmolar solution containing a nondigestable, nonabsorbable and nonfermentable hydrophilic macro molecule, such as polyethylene glycol (PEG), can be profitably used as a contrast agent to visualize the entire small intestine with US (small intestine contrast ultrasonography, SICUS); and 2. to define the normal US values of wall thickness and luminal diameter of the jejunum, ileum and terminal ileum. Real-time ultrasonography was performed in 10 healthy volunteers with 4-and 5-MHz linear-array transducers in basal fasting conditions and after ingestion of an isosmolar PEG solution. In basal fasting conditions, only a few segments of jejunum and/or ileum could be visualized in some of the investigated subjects. After ingestion of the contrast solution, the entire small bowel could be visualized in any single subject. A contrast sonography of the entire small bowel could be satisfactorily performed with 200 mL-820 mL of contrast solution in a time period that did not exceed 65 min. Luminal diameter at the level of the jejunum (19 +/- 2.3 mm) and proximal ileum (18 +/- 1.8 mm) was significantly greater (p < 0.01) than at the level of distal ileum (16.4 +/- 2.8 mm). Wall thickness was greater at the level of the terminal ileum (2 +/- 0.4 mm) than of the jejunum (1.6 +/- 0.5 mm) but the difference did not reach statistical significance. Details such as valvulae conniventes and multilayered structure of the wall could be recognized. In conclusion, after the ingestion of an isosmolar PEG electrolyte balanced solution, it is possible to visualize with ultrasonography the entire small intestine and to measure wall thickness and luminal diameter of the jejunum, the ileum and the terminal ileum. Such a noninvasive, inexpensive method can be used to investigate the morphological aspects of the small bowel.

Anterior abdominal wall pathologies detected by high-frequency annular array

AIM AND METHODS

In 1850 patients, high-frequency (HF: 7.5-10 MHz) annular array US examination was performed to evaluate the value of HF annular US in the detection of pathologies of the anterior abdominal wall.

RESULTS

HF annular US revealed pathological lesions (metastasis, benign tumor, lymphoma, hematoma, fistula, hernia, abscess) in 37 patients. The lesions were detected by conventional medium-frequency (3.5-3.75 MHz) US in only 8 of 37 cases (21.6%). HF annular US added information that altered clinical management in 19 cases (51.4%), predominantly in cases with tumors and fistulas.

CONCLUSION

The addition of HF annular US to a conventional US examination increases the detectability of small, but clinically important pathologies in the anterior abdominal wall.

Role of ultrasonography in the diagnosis of postsurgical recurrence of Crohn's disease

OBJECTIVE

Ultrasonography is a valid tool in the diagnosis of Crohn's disease, but its sensitivity, specificity, and overall accuracy in the diagnosis of postoperative recurrence are still not well established. The aim of this study was to evaluate the accuracy of ultrasonography compared with endoscopy in the diagnosis of postoperative recurrence of Crohn's disease.

METHODS

Forty-seven patients resected for Crohn's ileitis were studied by ultrasonography and colonoscopy to detect possible recurrence of the disease; 10 patients operated on for cancer of the right colon were used as controls. Six patients with Crohn's disease were excluded from the study because of failure to endoscopically reach the anastomosis; the remaining 41 patients had both ultrasonography and colonoscopy over a period of 14 days. Sonographic recurrence was defined as the presence of >5 mm thickness of the ileal wall.

RESULTS

Sensitivity, specificity, and overall accuracy of ultrasonography in diagnosis of postoperative recurrence were 81%, 86%, and 83% respectively. Positive predictive value was 96% and negative predictive value was 57%.

CONCLUSION

This study is the first to assess the role of ultrasonography in comparison with endoscopy in detecting Crohn's disease recurrence after surgery. Our data suggest that ultrasonography should be used first in the case of clinical suspicion of Crohn's disease recurrence, reserving ileocolonoscopy for negative or uncertain cases.

Crohn's disease: new imaging techniques

This chapter reviews the current state of imaging in Crohn's disease. Imaging plays an important role in the diagnosis and management of Crohn's disease. Imaging is complementary to the clinical assessment of the patient and other investigations including endoscopy. The choice of imaging modality depends on the clinical circumstances and local availability of resources and skills. Close co-operation between clinicians and radiologists is important. Barium radiology remains important. Magnetic resonance imaging (MRI) and ultrasound (US) should get special consideration because of the lack of ionizing radiation. MRI is particularly good at demonstrating the perianal complication of Crohn's disease. Computer tomography (CT) and US can be used for image-guided drainage of abscesses.

Computed tomography in chronic inflammatory bowel disease

In children with complicated inflammatory bowel disease, conventional ultrasound imaging may not define the extent of extraluminal disease and the involvement of other viscera. Three children with chronic inflammatory bowel disease are presented, where computed tomography was well tolerated and provided valuable information on extraluminal disease, involvement of other organs, and the state of the bowel wall and mesentery. In children in whom ultrasound examination is inconclusive or limited by gas or tenderness, computed tomography can provide important information that may determine clinical management.