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Minordi LM, Larosa L, Barbaro B, Angelino A, Broglia D, Cipri C, Scaldaferri F, Manfredi R, Natale L. How the Radiologist Must Reason for a Correct Diagnosis in Patients With Small Bowel Mural Thickening Studied by CT or MRI: A Pictorial Review. Curr Probl Diagn Radiol 2023; 52:393-411. [PMID: 37137738 DOI: 10.1067/j.cpradiol.2023.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/06/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023]
Abstract
Conditions that lead to small bowel mural thickening fall into a broad spectrum of diseases, including inflammatory, infectious, vascular or neoplastic. Computed tomography (CT) and Magnetic Resonance Imaging (MRI), especially CT-enterography and MR-enterography, permit evaluation of both entire small bowel and extraluminal structures. In CT/MR-enterography, the main prerequisite for the correct evaluation of small bowel is to obtain optimal intestinal distension. In fact, most errors are related to poor intestinal distension of the bowel which can lead to interpret as pathological a small bowel segment that is not very distended (false positive), or not to recognize presence of pathology in a collapsed segment (false negative). Once the examination has been performed, the images are analyzed in order to identify the presence of small bowel pathology. Pathology of the small bowel can manifest as endoluminal alteration and/or intestinal wall thickening. Once bowel wall thickening has been identified, the radiologist's first objective is trying to define benign or malignant nature of the alteration, using also patient's history and clinical features. Once the suspicion of benign or malignant pathology has been raised, the radiologist must try to formulate a diagnosis of nature. In this pictorial review we describe how the radiologist must reason for a correct diagnosis by answering a pattern of sequential questions in a patient with suspected small bowel disease studied by CT or MRI.
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Affiliation(s)
- Laura Maria Minordi
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiodiagnostica addominale, Roma, Italy.
| | - Luigi Larosa
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiodiagnostica addominale, Roma, Italy
| | - Brunella Barbaro
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiodiagnostica addominale, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | | | | | - Carla Cipri
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Franco Scaldaferri
- Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Area Medicina Interna, Gastroenterologia e Oncologia Medica, UOC di Medicina Interna e Gastroenterologia, CEMAD (Centro Malattie Apparato Digerente), Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Riccardo Manfredi
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiodiagnostica addominale, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Luigi Natale
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiodiagnostica addominale, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
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Nelms DW, Kann BR. Imaging Modalities for Evaluation of Intestinal Obstruction. Clin Colon Rectal Surg 2021; 34:205-218. [PMID: 34305469 DOI: 10.1055/s-0041-1729737] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
It is essential for the colon and rectal surgeon to understand the evaluation and management of patients with both small and large bowel obstructions. Computed tomography is usually the most appropriate and accurate diagnostic imaging modality for most suspected bowel obstructions. Additional commonly used imaging modalities include plain radiographs and contrast imaging/fluoroscopy, while less commonly utilized imaging modalities include ultrasonography and magnetic resonance imaging. Regardless of the imaging modality used, interpretation of imaging should involve a systematic, methodological approach to ensure diagnostic accuracy.
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Affiliation(s)
- David W Nelms
- Department of Colon and Rectal Surgery, Ochsner Medical Center, New Orleans, Louisiana
| | - Brian R Kann
- Department of Colon and Rectal Surgery, Ochsner Medical Center, New Orleans, Louisiana
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Minordi LM, Larosa L, Papa A, Cimino G, Bevere A, Brizi MG, Manfredi R. A review of Magnetic Resonance Enterography classification and quantitative evaluation of active disease in patients with Crohn's disease. Clin Imaging 2020; 69:50-62. [PMID: 32653818 DOI: 10.1016/j.clinimag.2020.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/04/2020] [Accepted: 06/01/2020] [Indexed: 12/21/2022]
Abstract
Crohn's disease (CD) is a chronic inflammation of the gastro-intestinal system in which episodes of clinical worsening alternate with episodes of clinical regression. Monitoring of disease is mandatory to evaluate the efficacy of therapy and it is usually performed using a combination of clinical symptoms, laboratory tests, endoscopy and radiological exams, such as MR enterography or CT enterography. MR enterography should be preferred to CT enterography because of the absence of ionizing radiation, a very high soft tissue contrast, and a lower incidence of adverse events. In 2003, Maglinte introduced a radiological classification to identify patients in different stages of disease (active inflammatory, fibrostenotic and fistulising/perforating subtypes), based on following parameters: oedema, ulcers, stenosis, mural thickening, stratified contrast enhancement, engorged vasa recta, fistulae/abscess and mesenteric inflammation. In general, medical therapy is efficient in reducing inflammation while fibrotic disease and fistulising subtypes usually require surgery. Moreover, in patients with active CD it is important to quantify disease activity in order to adequately plan therapy and to monitor drug effects, by using some MR enterography indexes such as MaRIA score, Clermont index, and others. In this review we describe how to apply Maglinte's classification in MR enterography exams and how to quantify active disease.
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Affiliation(s)
- Laura Maria Minordi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC di Radiologia Diagnostica e Interventistica Generale, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Largo Francesco Vito, 1, 00168 Roma, Italy.
| | - Luigi Larosa
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC di Radiologia Diagnostica e Interventistica Generale, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Largo Francesco Vito, 1, 00168 Roma, Italy
| | - Alfredo Papa
- Università Cattolica del Sacro Cuore, Istituto di Radiologia, Largo Francesco Vito, 1, 00168 Roma, Italy; Fondazione Policlinico Universitario A. Gemelli IRCCS, Gastroenterologia, Largo Francesco Vito, 1, 00168 Roma, Italy
| | - Giovanni Cimino
- Università Cattolica del Sacro Cuore, Istituto di Radiologia, Largo Francesco Vito, 1, 00168 Roma, Italy
| | - Antonio Bevere
- Università Cattolica del Sacro Cuore, Istituto di Radiologia, Largo Francesco Vito, 1, 00168 Roma, Italy
| | - Maria Gabriella Brizi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC di Radiologia Diagnostica e Interventistica Generale, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Largo Francesco Vito, 1, 00168 Roma, Italy; Università Cattolica del Sacro Cuore, Istituto di Radiologia, Largo Francesco Vito, 1, 00168 Roma, Italy
| | - Riccardo Manfredi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC di Radiologia Diagnostica e Interventistica Generale, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Largo Francesco Vito, 1, 00168 Roma, Italy; Università Cattolica del Sacro Cuore, Istituto di Radiologia, Largo Francesco Vito, 1, 00168 Roma, Italy
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Does MR enterography offer added value after a recent CT in the evaluation of abdominal pain in Crohn's disease patients? Clin Imaging 2019; 54:78-83. [DOI: 10.1016/j.clinimag.2018.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 11/20/2018] [Accepted: 12/08/2018] [Indexed: 01/19/2023]
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Zhu NY, Zhao XS, Miao F. Magnetic resonance imaging and Crohn’s disease endoscopic index of severity: Correlations and concordance. World J Gastroenterol 2018; 24:2279-2290. [PMID: 29881237 PMCID: PMC5989242 DOI: 10.3748/wjg.v24.i21.2279] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/28/2018] [Accepted: 04/26/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To examine the correlation between magnetic resonance imaging (MRI) and endoscopic index of severity (CDEIS) in patients with Crohn’s disease (CD).
METHODS This was a retrospective study of 104 patients with CD that were treated at the Ruijin Hospital between March 2015 and May 2016. Among them, 61 patients with active CD were evaluated before/after treatment. MRI and endoscopy were performed within 7 d. CDEIS was evaluated. MRI parameters included MaRIA scores, total relative contrast enhancement (tRCE), arterial RCE (aRCE), portal RCE (pRCE), delay phase RCE (dRCE), and apparent diffusion coefficient. The correlation and concordance between multiple MRI findings and CDEIS changes before and after CD treatment were examined.
RESULTS Among the 104 patients, 61 patients were classified as active CD and 43 patients as inactive CD. Gender, age, disease duration, and disease location were not significantly different between the two groups (all P > 0.05). CRP levels were higher in the active group than in the inactive group (25.12 ± 4.12 vs 5.14 ± 0.98 mg/L, P < 0.001). Before treatment, the correlations between CDEIS and MaRIAs in all patients were r = 0.772 for tRCE, r = 0.754 for aRCE, r = 0.738 for pRCE, and r = 0.712 for dRCE (all MaRIAs, P < 0.001), followed by MRI single indexes. Among the active CD patients, 44 cases were remitted to inactive CD after treatment. The correlations between CDEIS and MaRIAs were r = 0.712 for aRCE, r = 0.705 for tRCE, r = 0.685 for pRCE, and r = 0.634 for dRCE (all MaRIAs, P < 0.001).
CONCLUSION Arterial MaRIA should be an indicator for CD follow-up and dynamic assessment. CD treatment assessment was not completely concordant between CDEIS and MRI.
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Affiliation(s)
- Nai-Yi Zhu
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xue-Song Zhao
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Fei Miao
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Magnetic resonance enterography with oral mannitol solution: Diagnostic efficacy and image quality in Crohn disease. Diagn Interv Imaging 2017; 98:893-899. [DOI: 10.1016/j.diii.2017.06.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 05/06/2017] [Accepted: 06/01/2017] [Indexed: 12/18/2022]
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Masselli G, Mastroiacovo I, De Marco E, Francione G, Casciani E, Polettini E, Gualdi G. Current tecniques and new perpectives research of magnetic resonance enterography in pediatric Crohn's disease. World J Radiol 2016; 8:668-82. [PMID: 27551337 PMCID: PMC4965351 DOI: 10.4329/wjr.v8.i7.668] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 03/24/2016] [Accepted: 04/07/2016] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease affects more than 500000 individuals in the United States, and about 25% of cases are diagnosed during the pediatric period. Imaging of the bowel has undergone dramatic changes in the past two decades. The endoscopy with biopsy is generally considered the diagnostic reference standard, this combination can evaluates only the mucosa, not inflammation or fibrosis in the mucosa. Actually, the only modalities that can visualize submucosal tissues throughout the small bowel are the computed tomography (CT) enterography (CTE) with the magnetic resonance enterography (MRE). CT generally is highly utilized, but there is growing concern over ionizing radiation and cancer risk; it is a very important aspect to keep in consideration in pediatric patients. In contrast to CTE, MRE does not subject patients to ionizing radiation and can be used to detect detailed morphologic information and functional data of bowel disease, to monitor the effects of medical therapy more accurately, to detect residual active disease even in patients showing apparent clinical resolution and to guide treatment more accurately.
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The Role of MR Enterography in Assessing Crohn's Disease Activity and Treatment Response. Gastroenterol Res Pract 2015; 2016:8168695. [PMID: 26819611 PMCID: PMC4706951 DOI: 10.1155/2016/8168695] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/23/2015] [Accepted: 08/27/2015] [Indexed: 12/17/2022] Open
Abstract
MR enterography (MRE) has become the primary imaging modality in the assessment of Crohn's disease (CD) in both children and adults at many institutions in the United States and worldwide, primarily due to its noninvasiveness, superior soft tissue contrast, and lack of ionizing radiation. MRE technique includes distention of the small bowel with oral contrast media with the acquisition of T2-weighted, balanced steady-state free precession, and multiphase T1-weighted fat suppressed gadolinium contrast-enhanced sequences. With the introduction of molecule-targeted biologic agents into the clinical setting for CD and their potential to reverse the inflammatory process, MRE is increasingly utilized to evaluate disease activity and response to therapy as an imaging complement to clinical indices or optical endoscopy. New and emerging MRE techniques, such as diffusion-weighted imaging (DWI), magnetization transfer, ultrasmall superparamagnetic iron oxide- (USPIO-) enhanced MRI, and PET-MR, offer the potential for an expanded role of MRI in detecting occult disease activity, evaluating early treatment response/resistance, and differentiating inflammatory from fibrotic strictures. Familiarity with MR enterography is essential for radiologists and gastroenterologists as the technique evolves and is further incorporated into the clinical management of CD.
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MRI for Crohn's Disease: Present and Future. BIOMED RESEARCH INTERNATIONAL 2015; 2015:786802. [PMID: 26413543 PMCID: PMC4564596 DOI: 10.1155/2015/786802] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 10/09/2014] [Accepted: 12/11/2014] [Indexed: 12/18/2022]
Abstract
Crohn's disease (CD) is a chronic inflammatory condition with relapsing-remitting behavior, often causing strictures or penetrating bowel damage. Its lifelong clinical course necessitates frequent assessment of disease activity and complications. Computed tomography (CT) enterography has been used as primary imaging modality; however, the concern for radiation hazard limits its use especially in younger population. Magnetic resonance (MR) imaging has advantages of avoiding radiation exposure, lower incidence of adverse events, ability to obtain dynamic information, and good soft-tissue resolution. MR enterography (MRE) with oral contrast agent has been used as primary MR imaging modality of CD with high sensitivity, specificity, and interobserver agreement. The extent of inflammation as well as transmural ulcers and fibrostenotic diseases can be detected with MRE. Novel MR techniques such as diffusion-weighted MRI (DWI), motility study, PET-MRI, and molecular imaging are currently investigated for further improvement of diagnosis and management of CD. MR spectroscopy is a remarkable molecular imaging tool to analyze metabolic profile of CD with human samples such as plasma, urine, or feces, as well as colonic mucosa itself.
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Malgras B, Pautrat K, Dray X, Pasquier P, Valleur P, Pocard M, Soyer P. Multidisciplinary management of gastrointestinal fibrotic stenosis in Crohn's disease. Dig Dis Sci 2015; 60:1152-68. [PMID: 25381203 DOI: 10.1007/s10620-014-3421-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 10/30/2014] [Indexed: 12/21/2022]
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease that can involve virtually any part of the gastrointestinal tract. CD complications are the main indications for surgery. A large proportion of these interventions are due to stricturing disease. Although immunosuppressive treatments have been used more frequently during the last 25 years, there is no significant decrease in the need for surgery in patients with CD. Unfortunately, surgery is not curative, as the disease ultimately reoccurs in a substantial subset of patients. To best identify the patients who will require a specific treatment and to plane the most appropriate therapeutic approach, it is important to precisely define the type, the size, and the location of CD stenosis. Diagnostic approaches aim to distinguish fibrotic from inflammatory strictures. Medical therapy is required for inflammatory stenosis. Mechanical treatments are required when fibrotic CD strictures are symptomatic. The choice between endoscopic balloon dilation, stricturoplasty, and laparoscopic or open surgery is based on the presence of perforating complications, the remaining length of small bowel, and the number and length of strictures. The non-hierarchical decision-making process for the treatment of fibrotic CD therefore requires multidisciplinary clinical rounds with radiologists, gastroenterologists, interventional endoscopists, and surgeons.
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Affiliation(s)
- Brice Malgras
- Department of Surgery, Laiboisiere Hospital, Paris 7 University and AP-HP, 2 rue Ambroise Paré, 75475, Paris Cedex 10, France,
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