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Li J, Ng WY, Qiao LC, Yuan F, Lan X, Zhu LB, Yang BL, Wang ZQ. Prevalence and risk factors of depression among patients with perianal fistulizing Crohn's disease. World J Psychiatry 2024; 14:715-725. [PMID: 38808090 PMCID: PMC11129156 DOI: 10.5498/wjp.v14.i5.715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Psychological distress, especially depression, associated with perianal fistulizing Crohn's disease (PFCD) is widespread and refractory. However, there is a surprising paucity of studies to date that have sought to identify the prevalence and risk factors of depression associated with PFCD. AIM To estimate the prevalence of depressive symptoms and investigate the depression-related risk factors in patients with PFCD. METHODS The study was conducted in the form of survey and clinical data collection via questionnaire and specialized medical staff. Depressive symptoms, life quality, and fatigue severity of patients with PFCD were assessed by Patient Health Questionnaire-9, Inflammatory Bowel Disease Patient Quality of Life Questionnaire (IBDQ), and Inflammatory Bowel Disease (IBD) Fatigue Patient Self-assessment Scale. The basic demographic information, overall disease features, perianal clinical information, and laboratory inflammation indicators were also gathered. Multivariate regression analysis was ultimately used to ascertain the risk factors of depression associated with PFCD. RESULTS A total of 123 patients with PFCD were involved, and 56.91% were suffering from depression. According to multivariate logistic regression analysis, Perianal Disease Activity Index (PDAI) score [odds ratio (OR) = 0.69, 95% confidence interval (CI): 0.50 to 0.95], IBDQ score (OR = 0.93, 95%CI: 0.88 to 0.97), modified Van Assche index (OR = 1.24, 95%CI: 1.01 to 1.53), and IBD Fatigue score (OR = 1.72, 95%CI: 1.23 to 2.42) were independent risk factors of depression-related prevalence among patients with PFCD (P < 0.05). Multiple linear regression analysis revealed that the increasing perianal modified Van Assche index (β value = 0.166, 95%CI: 0.02 to 0.31) and decreasing IBDQ score (β value = -0.116, 95%CI: -0.14 to -0.09) were independently associated with the severity of depression (P < 0.05). CONCLUSION Depressive symptoms in PFCD patients have significantly high prevalence. PDAI score, modified Van Assche index, quality of life, and fatigue severity were the main independent risk factors.
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Affiliation(s)
- Jing Li
- Department of Radiology, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Wing-Yi Ng
- Department of Acupuncture and Rehabilitation, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Li-Chao Qiao
- Department of Colorectal Surgery, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Fen Yuan
- Department of Radiology, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Xing Lan
- Department of Radiology, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Li-Bei Zhu
- Department of Colorectal Surgery, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Bo-Lin Yang
- Department of Colorectal Surgery, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Zhong-Qiu Wang
- Department of Radiology, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
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Swaroop S, Vuyyuru SK, Kante B, Kumar P, Mundhra SK, Arora U, Goyal A, Kandasamy D, Sharma R, Kabilan K, Kedia S, Dash NR, Ahuja V. A phase I/II clinical trial of ex-vivo expanded human bone marrow derived allogeneic mesenchymal stromal cells in adult patients with perianal fistulizing Crohn's Disease. Stem Cell Res Ther 2024; 15:140. [PMID: 38745184 PMCID: PMC11094973 DOI: 10.1186/s13287-024-03746-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 04/26/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Perianal fistulas (PF) affect one-third patients with Crohn's disease (CD) with limited therapeutic options. There is dearth of literature on safety and efficacy of bone marrow-derived mesenchymal stromal cells (BMSCs) in this population. METHODS An open-label, phase I/II, single-arm study was conducted involving local administration of human allogeneic bone marrow-derived mesenchymal stromal cells in perianal fistula of patients with Crohn's disease refractory to standard therapies. Clinical severity and biomarkers were assessed at baseline and periodically until week 104 , and MRI at week 24 and 104. Primary and secondary objectives were to assess safety and efficacy respectively. Fistula remission was complete closure of fistula openings with < 2 cm perianal collection on MRI, and fistula response was decrease in drainage by ≥ 50%. Change in perianal disease activity index, quality-of-life and Van Assche index on MRI over time was assessed using mixed-effect linear regression model. RESULTS Ten patients (male:8, mean age:27.4 ± 12.0years) were recruited. Self-resolving procedure-related adverse events occurred in three patients, with no follow-up adverse events. In intention to treat analysis at week 24, two patients (20%) achieved fistula remission and seven (70%) had fistula response. At week 52, two (20%) patients were in remission and seven (70%) maintained response. At 104 weeks, two (20%) patients maintained response and one (10%) was in remission. Statistically significant decrease in perianal disease activity index (P = 0.008), Van Assche Index (P = 0.008) and improvement in quality-of-life (P = 0.001) were observed over time. CONCLUSIONS Allogeneic BMSCs are safe and effective for the treatment of perianal fistulizing CD with significant improvement in clinical severity and radiological healing. TRIAL REGISTRATION The study was prospectively registered on Clinical trials registry - India (CTRI), CTRI/2020/01/022743 on 14 January 2020, http://ctri.nic.in .
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Affiliation(s)
| | | | - Bhaskar Kante
- Department of Medical Gastroenterology, KIMS Hospitals, Hyderabad, India
| | - Peeyush Kumar
- Department of Gastroenterology, AIIMS, New Delhi, India
| | | | - Umang Arora
- Department of Gastroenterology, AIIMS, New Delhi, India
| | - Ankur Goyal
- Department of Radiodiagnosis and Interventional Radiology, AIIMS, New Delhi, India
| | | | - Raju Sharma
- Department of Radiodiagnosis and Interventional Radiology, AIIMS, New Delhi, India
| | - Kavirajan Kabilan
- Department of Radiodiagnosis and Interventional Radiology, AIIMS, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology, AIIMS, New Delhi, India
| | | | - Vineet Ahuja
- Department of Gastroenterology, AIIMS, New Delhi, India.
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Devi J, Ballard DH, Aswani-Omprakash T, Parian AM, Deepak P. Perianal fistulizing Crohn's disease: Current perspectives on diagnosis, monitoring and management with a focus on emerging therapies. Indian J Gastroenterol 2024; 43:48-63. [PMID: 38308773 DOI: 10.1007/s12664-024-01524-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/02/2024] [Indexed: 02/05/2024]
Abstract
Crohn's disease (CD), a chronic inflammatory bowel disorder, manifests in various phenotypes, with fistulizing perianal CD (CD-PAF) being one of its most severe phenotypes. Characterized by fistula formation and abscesses, CD-PAF impacts 17% to 34% of all CD cases and with a significantly deleterious impact on patient's quality of life, while increasing the risk for anorectal cancers. The pathogenesis involves a complex interplay of genetic, immunological and environmental factors, with cytokines such as tumor necrosis factor-alpha (TNF-α) and transforming growth factor-beta (TGF-β) playing pivotal roles. Diagnostic protocols require a multi-disciplinary approach including colonoscopy, examination under anesthesia and magnetic resonance imaging. In terms of treatment, biologics alone often prove inadequate, making surgical interventions such as setons and fistula surgeries essential. Emerging therapies such as mesenchymal stem cells are under study. The South Asian context adds layers of complexity, including diagnostic ambiguities related to high tuberculosis prevalence, healthcare access limitations and cultural stigma toward perianal Crohn's disease and ostomy surgery. Effective management necessitates an integrated, multi-disciplinary approach, especially in resource-constrained settings. Despite advances, there remain significant gaps in understanding the disease's pathophysiology and a dearth of standardized outcome measures, underscoring the urgent need for comprehensive research.
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Affiliation(s)
- Jalpa Devi
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine in Saint Louis, 660 S. Euclid Avenue, Campus Box 8124, Saint Louis, MO, 63110, USA
| | - David H Ballard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St. Louis, MO, USA
| | | | - Alyssa M Parian
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
| | - Parakkal Deepak
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine in Saint Louis, 660 S. Euclid Avenue, Campus Box 8124, Saint Louis, MO, 63110, USA.
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Rimola J, Colombel JF, Bressler B, Adsul S, Siegelman J, Cole PE, Lindner D, Danese S. Magnetic Resonance Enterography Assessment of Transmural Healing with Vedolizumab in Moderate to Severe Crohn's Disease: Feasibility in the VERSIFY Phase 3 Clinical Trial. Clin Exp Gastroenterol 2024; 17:9-23. [PMID: 38298861 PMCID: PMC10829592 DOI: 10.2147/ceg.s429039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/14/2024] [Indexed: 02/02/2024] Open
Abstract
Purpose The VERSIFY phase 3 trial in patients with Crohn's disease (CD) treated with vedolizumab was the first to include a substudy that used a standardized magnetic resonance enterography (MRE) protocol to assess features of transmural inflammation (bowel edema and wall thickness) and extramural disease activity (enlarged lymph nodes). Patients and Methods Patients received intravenous vedolizumab (300 mg) at weeks 0 (baseline), 2, and 6, and then every 8 weeks for 26 or 52 weeks. Post hoc analyses included a subpopulation with a Magnetic Resonance Index of Activity score of ≥7 in at least one bowel segment at baseline and at least one postbaseline MRE assessment. Changes in transmural inflammation, including intramural bowel edema and wall thickness, were evaluated. Patient-level and segment-level analyses were performed. Results MRE images were evaluated in 27 patients with 83 evaluable bowel segments at baseline and week 26, and 13 patients with 38 evaluable segments at baseline, week 26, and week 52. At baseline, all patients had bowel wall edema and wall thickness of >3 mm in at least one bowel segment. The proportion of patients with edema decreased at weeks 26 (17/27 [63.0%]) and 52 (4/13 [30.8%]) and the proportion with bowel wall thickness of >3 mm decreased at weeks 26 (25/27 [92.6%]) and 52 (10/13 [76.9%]). Conclusion In patients with CD treated with vedolizumab for 26 and 52 weeks, the number of patients, and bowel segments, with MRE-detected transmural inflammation was reduced. These results highlight the impact of vedolizumab on components of transmural inflammation in CD and demonstrate that using MRE in CD multicenter clinical trials is feasible. Trial Registration ClinicalTrials.gov NCT02425111, April 23, 2015, http://www.clinicaltrials.gov NCT02425111; EU Clinical Trials Register EudraCT 2014-003509-13, https://www.clinicaltrialsregister.eu.
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Affiliation(s)
- Jordi Rimola
- IBD Unit, Radiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jean-Frédéric Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian Bressler
- Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Shashi Adsul
- Takeda Pharmaceuticals International, Zurich, Switzerland
| | | | | | - Dirk Lindner
- Takeda Pharmaceuticals International, Zurich, Switzerland
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
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Singh A, Kakkar C, Garg S, Arora K, Midha V, Mahajan R, Virk SS, Jain NP, Singh D, Sood K, Tripathi A, Gupta D, Kaushal IG, Galhotra RD, Saggar K, Sood A. Clinical and magnetic resonance imaging spectrum of complex perianal fistulizing Crohn's disease: A cohort study from northern India. Indian J Gastroenterol 2023; 42:668-676. [PMID: 37548863 DOI: 10.1007/s12664-023-01399-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 05/15/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Fistulizing perianal Crohn's disease (CD) is a debilitating condition associated with significant morbidity and reduction in the quality of life. Magnetic resonance imaging (MRI) of the pelvis is the preferred imaging modality for the comprehensive assessment of the perianal fistula. There is a paucity of data from India on the MRI spectrum of complex perianal fistula in CD. METHODS A single-centre cross-sectional analysis of patients with fistulizing perianal CD, who underwent pelvic MRI between January 2020 and December 2021, was performed. The clinical (age, sex, disease duration, disease location and behavior, disease activity [Perianal Disease Activity Index, PDAI] and treatment received) and radiological (number and location of fistulae, extensions, number and location of internal and external openings, fistula activity, presence or absence of perianal abscess and associated proctitis) characteristics of complex perianal fistula (defined according to the American Gastroenterological Association classification) were recorded. RESULTS Of total 175 patients with CD who attended the gastroenterology clinic during the study period, 27 (15.42%) (mean age 42±15.5 years, 62.96% females and median disease duration four years) had complex perianal fistula and were included in the analysis. The mean PDAI was 5.48±2.53. The median Van Assche Index was 17 (interquartile range [IQR] 13-19). A majority (96.29%) of the fistulae were trans-sphincteric and four (14.81%) fistulae extended into the supralevator space. All fistulae were active on MRI. Concomitant perianal abscess and proctitis were seen in 59.26% (n=16) and 62.96% (n=17) of patients, respectively. Combination therapy with biologics and antibiotics/immune-suppressants were the most commonly prescribed medical therapy. Six (22.22%) patients underwent combined medical and surgical (non-cutting seton, fistulectomy, fecal diversion) treatment. CONCLUSION The cumulative risk of the development of fistulizing perianal CD in a northern Indian cohort was similar to the western populations. Complex perianal fistulae were predominantly trans-sphincteric and commoner in females. MRI evaluation is pivotal for the delineation of fistula anatomy, assessment of disease extent and activity and the evaluation of concomitant perianal abscess and other complications.
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Affiliation(s)
- Arshdeep Singh
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | - Chandan Kakkar
- Department of Radiology and Radiodiagnosis, Dayanand Medical College, Ludhiana, 141 001, India
| | - Shreya Garg
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, 141 001, India
| | - Kirti Arora
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, 141 001, India
| | - Vandana Midha
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, 141 001, India
| | - Ramit Mahajan
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | - Satpal Singh Virk
- Department of Gastroenterology Surgery, Dayanand Medical College, Ludhiana, 141 001, India
| | - Narender Pal Jain
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, 141 001, India
| | - Dharmatma Singh
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | - Kriti Sood
- Department of Pediatrics, Government Medical College and Rajindra Hospital, Patiala, 147 001, India
| | - Ashish Tripathi
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, 141 001, India
| | - Dhruv Gupta
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, 141 001, India
| | - Ishita Gupta Kaushal
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, 141 001, India
| | - Ritu Dhawan Galhotra
- Department of Radiology and Radiodiagnosis, Dayanand Medical College, Ludhiana, 141 001, India
| | - Kavita Saggar
- Department of Radiology and Radiodiagnosis, Dayanand Medical College, Ludhiana, 141 001, India
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, 141 001, India.
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Nakase H, Esaki M, Hirai F, Kobayashi T, Matsuoka K, Matsuura M, Naganuma M, Saruta M, Tsuchiya K, Uchino M, Watanabe K, Hisamatsu T. Treatment escalation and de-escalation decisions in Crohn's disease: Delphi consensus recommendations from Japan, 2021. J Gastroenterol 2023; 58:313-345. [PMID: 36773075 PMCID: PMC10050046 DOI: 10.1007/s00535-023-01958-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/08/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND We aimed to develop criteria for treatment intensification in patients with (1) luminal Crohn's disease (CD), (2) CD with perianal disease and/or fistula, (3) CD with small bowel stenosis, (4) in the postoperative setting, and (5) for discontinuing or reducing the dose of treatment in patients with CD. METHODS PubMed and Embase were searched for studies published since 1998 which may be relevant to the five defined topics. Results were assessed for relevant studies, with preference given to data from randomized, controlled studies. For each question, a core panel of 12 gastroenterologists defined the treatment target and developed statements, based on the literature, current guidelines, and relevant additional studies. The evidence supporting each statement was graded using the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). A modified Delphi process was used to refine statements and gain agreement from 54 Japanese specialists at in-person and online meetings conducted between October 2020 and April 2021. RESULTS Seventeen statements were developed for treatment intensification in luminal CD (targeting endoscopic remission), six statements for treatment intensification in perianal/fistulizing CD (targeting healing of perianal lesions and complete closure of the fistula), six statements for treatment intensification in CD with small bowel stenosis (targeting resolution of obstructive symptoms), seven statements for treatment intensification after surgery (targeting endoscopic remission), and five statements for discontinuing or reducing the dose of treatment in patients with CD. CONCLUSIONS These statements provide guidance on how and when to intensify or de-intensify treatment for a broad spectrum of patients with CD.
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Affiliation(s)
- Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-Ku, Sapporo, Hokkaido 060-8543 Japan
| | - Motohiro Esaki
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo, Japan
| | - Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Chiba Japan
| | - Minoru Matsuura
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
| | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kiichiro Tsuchiya
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Motoi Uchino
- Division of Inflammatory Bowel Disease, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Kenji Watanabe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611 Japan
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Yoon S, Park SH, Kim JS. Radiologic images of complications of Crohn's disease. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2023. [DOI: 10.18528/ijgii220003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Sungjin Yoon
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - So Hyun Park
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jun Seong Kim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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8
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Jung JH, Ryu YJ, Kim JY, Yang HR. Transperineal ultrasonography for treatment response evaluation in children with perianal Crohn’s cisease. Ultrasonography 2022; 41:770-781. [PMID: 36059211 PMCID: PMC9532198 DOI: 10.14366/usg.22057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/03/2022] [Indexed: 11/03/2022] Open
Affiliation(s)
- Jae Hyeop Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Jin Ryu
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
- Correspondence to: Young Jin Ryu, MD, Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel. +82-31-787-2893 Fax. +82-31-787-4070 E-mail:
| | - Ji Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Hye Ran Yang
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Iqbal N, Sackitey C, Gupta A, Tolan D, Plumb A, Godfrey E, Grierson C, Williams A, Brown S, Maxwell-Armstrong C, Anderson I, Selinger C, Lobo A, Hart A, Tozer P, Lung P. The development of a minimum dataset for MRI reporting of anorectal fistula: a multi-disciplinary, expert consensus process. Eur Radiol 2022; 32:8306-8316. [PMID: 35732929 DOI: 10.1007/s00330-022-08931-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/08/2022] [Accepted: 05/30/2022] [Indexed: 11/27/2022]
Abstract
There are a range of sphincter-preserving procedures available to treat anorectal fistula, some of which can be precluded, or rendered more optimal by specific features of fistula anatomy. Magnetic resonance imaging (MRI) is the gold standard modality for assessing anorectal fistula. To maximise clinical utility, the MRI report should accurately describe these clinically relevant features. We aimed to develop a minimum dataset for reporting MRI of anorectal fistula, in order to improve the assessment and management of these patients. A longlist of 70 potential items for the minimum dataset was generated through systematic review of the literature. This longlist was presented to radiologists, surgeons and gastroenterologists in an online survey to understand the features that shape current clinical practice. The longlist and survey results were then presented to an expert consensus panel to generate the final minimum dataset through discussion and anonymous voting. The final minimum dataset details the general characteristics, features of the internal and external openings, path of the fistula through the sphincters and any associated extensions and collections that should be described in all MRI reports for anal fistula. Additional surgical and perianal Crohn's disease subsets were developed to indicate the features that aid decision-making for these patients, in addition to a minimum dataset for the clinical request. This study represents a multi-disciplinary approach to developing a minimum dataset for MRI reporting of anal fistula, highlighting the most important features to report that can assist in clinical decision-making. KEY POINTS: • This paper recommends the minimum features that should be included in all MRI reports for the assessment of anal fistula, including Parks classification, number of tracts, features of the internal and external opening, path of the tract through the sphincters, the presence and features of extensions and collections. • Additional features that aid decision-making for surgery or in the presence of Crohn's disease have been identified. • The items that should be included when requesting an MRI are specified.
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Affiliation(s)
- Nusrat Iqbal
- Robin Phillips' Fistula Research Unit, St Mark's Hospital, London, UK
| | - Charlene Sackitey
- Robin Phillips' Fistula Research Unit, St Mark's Hospital, London, UK
| | | | | | | | | | | | - Andrew Williams
- Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Steven Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | | | - Alan Lobo
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ailsa Hart
- Robin Phillips' Fistula Research Unit, St Mark's Hospital, London, UK
| | - Phil Tozer
- Robin Phillips' Fistula Research Unit, St Mark's Hospital, London, UK
| | - Phillip Lung
- Robin Phillips' Fistula Research Unit, St Mark's Hospital, London, UK.
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10
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Sirmai L, Pelletier AL, Gault N, Zallot C, Bouguen G, Bouchard D, Roland Nicaise P, Peyneau M, Sironneau S, Bittencourt MDC, Petitcollin A, Fernandez P, Roblin X, Siproudhis L, Abramowitz L. Relationship between clinical remission of perianal fistulas in Crohn’s disease and serum adalimumab concentrations: A multi-center cross-sectional study. World J Gastroenterol 2022; 28:961-972. [PMID: 35317057 PMCID: PMC8908286 DOI: 10.3748/wjg.v28.i9.961] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/25/2021] [Accepted: 01/29/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Crohn’s disease (CD) is complicated by perianal fistulas in approximately 20% of patients. Achieving permanent fistula closure remains a challenge for physicians. An association between serum anti-tumor necrosis factor-α concentrations and clinical outcomes in patients with CD has been demonstrated; however, little information is available on serum adalimumab (ADA) concentrations and remission of perianal fistulas in such patients.
AIM To study the relationship between serum ADA concentrations and clinical remission of CD-associated perianal fistulas.
METHODS This cross-sectional study of patients with CD-associated perianal fistulas treated with ADA was performed at four French hospitals between December 2013 and March 2018. At the time of each serum ADA concentration measurement, we collected information about the patients and their fistulas. The primary study endpoint was clinical remission of fistulas defined as the absence of drainage (in accordance with Present’s criteria), with a PDAI ≤ 4, absence of a seton and assessment of the overall evaluation as favorable by the proctologist at the relevant center. We also assessed fistula healing [defined as being in clinical and radiological (magnetic resonance imaging, MRI) remission] and adverse events.
RESULTS The study cohort comprised 34 patients who underwent 56 evaluations (patients had between one and four evaluations). Fifteen patients had clinical remissions (44%), four of whom had healed fistulas on MRI. Serum ADA concentrations were significantly higher at evaluations in which clinical remission was identified than at evaluations in which it was not [14 (10-16) vs 10 (2-15) μg/mL, P = 0.01]. Serum ADA concentrations were comparable at the times of evaluation of patients with and without healed fistulas [11 (7-14) vs 10 (4-16) μg/mL, P = 0.69]. The adverse event rate did not differ between different serum ADA concentrations.
CONCLUSION We found a significant association between high serum ADA concentrations and clinical remission of CD-associated perianal fistulas.
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Affiliation(s)
- Laura Sirmai
- Division of Hepato-Gastroenterology and Digestive Oncology, Bichat Claude Bernard University Hospital, Paris 75018, France
- Division of Hepato-Gastroenterology, Hospital Croix Saint Simon, Paris 75020, France
| | - Anne-Laure Pelletier
- Division of Hepato-Gastroenterology and Digestive Oncology, Bichat Claude Bernard University Hospital, Paris 75018, France
| | - Nathalie Gault
- Division of Epidemiology, Biostatistics and Clinical Research, University Hospital Center Bichat, Paris 75018, France
- National Institute of Health and Medical Research CIC-EC1425, University Hospital Center Bichat, Paris 75018, France
| | - Camille Zallot
- Division of Gastroenterology, Nancy Regional and University Hospital Center, Nancy 54035, France
| | - Guillaume Bouguen
- Imphy CIC 1414 Group and Division of Gastroenterology and Hepatology, University Hospital of Rennes, Pontchaillou, Rennes 35033, France
| | | | | | - Marine Peyneau
- Division of Immunology, University Hospital Center Bichat, Paris 75018, France
- Inflammation, Microbiome and Immunosurveillance, Faculty of Pharmacy, Université Paris-Saclay, Châtenay-Malabry 92290, France
| | | | - Marcelo De Carvalho Bittencourt
- Division of Immunology, Nancy Regional and University Hospital Center, Nancy 54000, France
- University of Lorraine, CNRS UMR 7365, IMoPA, Nancy 54000, France
| | - Antoine Petitcollin
- Department of Clinical and Biological Pharmacology and Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, Rennes 35700, France
| | - Pedro Fernandez
- Division of Radiology, University Hospital Center Bichat, Paris 75018, France
- Orangerie Center, Le Perreux-sur-Marne 94170, France
| | - Xavier Roblin
- Division of Gastroenterology, CHU Saint Etienne, Saint-Priest-en-Jarez 42270, France
| | - Laurent Siproudhis
- Imphy CIC 1414 Group and Division of Gastroenterology and Hepatology, University Hospital of Rennes, Pontchaillou, Rennes 35033, France
| | - Laurent Abramowitz
- Division of Gastroenterology and Hepatology and Proctology, University Hospital Center Bichat, Paris 75018, France
- Ramsay GDS Clinique Blomet, Paris 75018, France
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11
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Abramowitz L, Brochard C, Pigot F, Roumeguere P, Pillant H, Vinson Bonnet B, Faucheron JL, Senéjoux A, Bonnaud G, Meurette G, Fayette JM, Train C, Staumont G, Siproudhis L, Bouchard D. Surgical closure, mainly with glue injection and anti-tumour necrosis factor α, in fistulizing perianal Crohn's disease: A multicentre randomized controlled trial. Colorectal Dis 2022; 24:210-219. [PMID: 34623746 DOI: 10.1111/codi.15947] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 12/14/2022]
Abstract
AIM In patients with fistulizing perianal Crohn's disease (CD), the need for a secondary surgical step is not defined. The aim was to assess the efficacy of surgical closure compared to a single seton removal in patients with drained fistulizing perianal CD treated with adalimumab. METHODS This was a multicentre, randomized controlled trial, comparing seton removal + surgical closure (closure group) to seton removal alone (control group) with a stratification according to the American Gastroenterological Association classification. The primary end-point was fistula closure at month 12 defined by the association of the following criteria: no seton, absence of a visible external opening, absence of discharge from the tract after finger compression, absence of an internal opening, absence of perianal pain/abscess and absence of fistula-related abnormalities. RESULTS Among the 64 included patients (262 expected) (48 complex fistula, 75%), 33 were randomized to the closure group and 31 to the control group. In the closure group, 26 patients (78.8%) had glue. At month 12, overall fistula closure was achieved in 35 of the evaluable 58 patients (60%): 18/32 (56%) in the surgery group and 17/26 (65%) in the control group (P = 0.479). In the closure group, fistula closure was observed in 13/25 (52%) and 5/7 (71%) patients with complex and simple fistula respectively (P = 0.426), compared with 12/18 (67%) and 5/8 (63%), respectively in the control group (P = 1.000). CONCLUSIONS Seton removal alone seems to be no more effective than a secondary surgical step (in particular glue injection) in patients having fistulizing perianal CD controlled by an initial drainage combined with adalimumab. The results should be interpreted with caution.
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Affiliation(s)
- Laurent Abramowitz
- Service d'Hépato-gastroentérologie et Proctologie, Hôpital Bichat-Claude Bernard, Paris, France.,Ramsay Général de Santé, Clinique Blomet, Paris, France
| | - Charlène Brochard
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France.,CIC 1414, INPHY, Université de Rennes 1, Rennes, France
| | - François Pigot
- Service de Proctologie, Hôpital Bagatelle, Maison de Santé Protestante Bagatelle, Talence, France
| | | | - Hélène Pillant
- Service de Proctologie, Groupe Hospitalier Paris Saint Joseph, Institut Léopold-Bellan, Paris, France
| | - Béatrice Vinson Bonnet
- Service de Chirurgie Viscérale et Digestive, CHI, Poissy-St-Germain-en-Laye, Paris, France
| | - Jean Luc Faucheron
- Unité de Chirurgie Colo-rectale, Service de Chirurgie Digestive et de l'Urgence, Hôpital Michallon, CHUGA, Grenoble, France
| | | | | | - Guillaume Meurette
- Clinique de Chirurgie Digestive et Endocrinienne (CCDE), Institut des Maladies de l'Appareil Digestif (IMAD), University Hospital of Nantes, Nantes, France
| | | | | | | | - Laurent Siproudhis
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France.,CIC 1414, INPHY, Université de Rennes 1, Rennes, France
| | - Dominique Bouchard
- Service de Proctologie, Hôpital Bagatelle, Maison de Santé Protestante Bagatelle, Talence, France
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12
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Garg P, Yagnik VD, Dawka S, Kaur B, Menon GR. A Novel MRI and Clinical-Based Scoring System to Assess Post-Surgery Healing and to Predict Long-Term Healing in Cryptoglandular Anal Fistulas. Clin Exp Gastroenterol 2022; 15:27-40. [PMID: 35210804 PMCID: PMC8860728 DOI: 10.2147/ceg.s343254] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background Anal fistulas cause great uncertainty and anxiety in patients and surgeons alike. This is largely because of the inability to accurately confirm postoperative fistula healing, especially long-term healing. There is no scoring system available that can objectively assess cryptoglandular anal fistulas for postoperative healing and can also accurately predict long-term healing. Methods Several parameters that could indicate anal fistula healing were assessed. Out of these, six parameters (four MRI-based and two clinical) were finalized, and a weighted score was given to each parameter. A novel scoring system (NSS) was developed. A minimum possible score (zero) indicated complete healing whereas the maximum weighted score (n = 20) indicated confirmed non-healing. Scoring was done with postoperative MRI (at least 3 months post-surgery), then compared with the actual healing status, and subsequently correlated with the final long-term clinical outcome. Results The NSS was validated in 183 operated cryptoglandular fistula-in-ano patients over a 3-year period in whom 283 MRIs (preoperative plus postoperative) were performed. The postoperative follow-up was 12–48 months (median-30 months). The NSS was found to have a very high positive predictive value (98.2%) and moderately high negative predictive value (83.7%) for long-term fistula healing. Additionally, its sensitivity and specificity in predicting healing were 93.9% and 94.7%, respectively. Conclusion Thus, this new scoring system is highly accurate and would be a useful tool for surgeons and radiologists managing anal fistulas. By objectivizing the assessment of postoperative healing, it can both ease and streamline management. Moreover, reliable prediction of recurrence-free long-term healing will greatly allay the apprehensions associated with this dreaded disease.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Indus Super Specialty Hospital, Mohali, Punjab, India
- Department of Colorectal Surgery, Garg Fistula Research Institute Surgery, Panchkula, Haryana, India
- Correspondence: Pankaj Garg, Department of Colorectal Surgery, Indus Super Specialty Hospital, Mohali, Punjab, 140507, India, Fax +91 9501011000, Email
| | - Vipul D Yagnik
- Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Centre, Patan, Gujarat, India
| | - Sushil Dawka
- Department of Surgery, SSR Medical College, Belle Rive, Mauritius
| | - Baljit Kaur
- Department of Radiology, SSRD MRI Imaging Centre, Chandigarh, Haryana, India
| | - Geetha R Menon
- National Institute of Medical Statistics, Indian Council of Medical Research, New Delhi, India
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13
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Alyami A, Hoad CL, Tench C, Bannur U, Clarke C, Latief K, Argyriou K, Lobo A, Lung P, Baldwin-Cleland R, Sahnan K, Hart A, Limdi JK, Mclaughlin J, Atkinson D, Parker GJM, O’Connor JPB, Little RA, Gowland PA, Moran GW. Quantitative Magnetic Resonance Imaging in Perianal Crohn's Disease at 1.5 and 3.0 T: A Feasibility Study. Diagnostics (Basel) 2021; 11:2135. [PMID: 34829482 PMCID: PMC8624877 DOI: 10.3390/diagnostics11112135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/08/2021] [Accepted: 11/12/2021] [Indexed: 01/06/2023] Open
Abstract
Perianal Crohn's Disease (pCD) is a common manifestation of Crohn's Disease. Absence of reliable disease measures makes disease monitoring unreliable. Qualitative MRI has been increasingly used for diagnosing and monitoring pCD and has shown potential for assessing response to treatment. Quantitative MRI sequences, such as diffusion-weighted imaging (DWI), dynamic contrast enhancement (DCE) and magnetisation transfer (MT), along with T2 relaxometry, offer opportunities to improve diagnostic capability. Quantitative MRI sequences (DWI, DCE, MT and T2) were used in a cohort of 25 pCD patients before and 12 weeks after biological therapy at two different field strengths (1.5 and 3 T). Disease activity was measured with the Perianal Crohn's Disease Activity index (PDAI) and serum C-reactive protein (CRP). Diseased tissue areas on MRI were defined by a radiologist. A baseline model to predict outcome at 12 weeks was developed. No differences were seen in the quantitative MR measured in the diseased tissue regions from baseline to 12 weeks; however, PDAI and CRP decreased. Baseline PDAI, CRP, T2 relaxometry and surgical history were found to have a moderate ability to predict response after 12 weeks of biological treatment. Validation in larger cohorts with MRI and clinical measures are needed in order to further develop the model.
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Affiliation(s)
- Ali Alyami
- Department of Diagnostic Radiography Technology, College of Applied Medical Sciences, Jazan University, Jazan 45142, Saudi Arabia;
- Translational Medical Sciences Academic Unit, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham NG7 2UH, UK;
- National Institute of Health Research Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK; (C.L.H.); (C.T.); (P.A.G.)
| | - Caroline L. Hoad
- National Institute of Health Research Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK; (C.L.H.); (C.T.); (P.A.G.)
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham NG7 2QX, UK
| | - Christopher Tench
- National Institute of Health Research Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK; (C.L.H.); (C.T.); (P.A.G.)
- Division of Clinical Neurosciences, Clinical Neurology, University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK
| | - Uday Bannur
- Department of Radiology, Queens Medical Centre Campus, Nottingham University Hospitals, Nottingham NG7 2UH, UK; (U.B.); (C.C.); (K.L.)
| | - Christopher Clarke
- Department of Radiology, Queens Medical Centre Campus, Nottingham University Hospitals, Nottingham NG7 2UH, UK; (U.B.); (C.C.); (K.L.)
| | - Khalid Latief
- Department of Radiology, Queens Medical Centre Campus, Nottingham University Hospitals, Nottingham NG7 2UH, UK; (U.B.); (C.C.); (K.L.)
| | - Konstantinos Argyriou
- Translational Medical Sciences Academic Unit, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham NG7 2UH, UK;
| | - Alan Lobo
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK;
| | - Philip Lung
- Department of Radiology, St Mark’s Hospital and Academic Institute, London North West Healthcare NHS Trust, London HA1 3UJ, UK; (P.L.); (R.B.-C.)
| | - Rachel Baldwin-Cleland
- Department of Radiology, St Mark’s Hospital and Academic Institute, London North West Healthcare NHS Trust, London HA1 3UJ, UK; (P.L.); (R.B.-C.)
| | - Kapil Sahnan
- Fistula Research Unit, St Mark’s Hospital and Academic Institute, London North West Healthcare NHS Trust, London HA1 3UJ, UK; (K.S.); (A.H.)
| | - Ailsa Hart
- Fistula Research Unit, St Mark’s Hospital and Academic Institute, London North West Healthcare NHS Trust, London HA1 3UJ, UK; (K.S.); (A.H.)
| | - Jimmy K. Limdi
- Department of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Greater Manchester, Crumpsall M8 5RB, UK;
| | - John Mclaughlin
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford M6 8HD, UK;
| | - David Atkinson
- Centre for Medical Imaging, University College London, London W1W 7TS, UK;
| | - Geoffrey J. M. Parker
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London WC1V 6LJ, UK;
- Bioxydyn Limited, Manchester M15 6SZ, UK
| | - James P. B. O’Connor
- Quantitative Biomedical Imaging Laboratory, Division of Cancer Science, University of Manchester, Manchester M13 9PL, UK (R.A.L.)
| | - Ross A. Little
- Quantitative Biomedical Imaging Laboratory, Division of Cancer Science, University of Manchester, Manchester M13 9PL, UK (R.A.L.)
| | - Penny A. Gowland
- National Institute of Health Research Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK; (C.L.H.); (C.T.); (P.A.G.)
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham NG7 2QX, UK
| | - Gordon W. Moran
- Translational Medical Sciences Academic Unit, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham NG7 2UH, UK;
- National Institute of Health Research Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK; (C.L.H.); (C.T.); (P.A.G.)
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14
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Perianal Imaging in Crohn Disease: Current Status With a Focus on MRI, From the AJR Special Series on Imaging of Inflammation. AJR Am J Roentgenol 2021; 218:781-792. [PMID: 34549607 DOI: 10.2214/ajr.21.26615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Fistulizing perianal disease is a frequent, chronic, and often debilitating manifestation of Crohn disease (CD) in adults and children, which in the past was relatively refractory to treatment. The advent of biologic agents such as anti-tumor necrosis factor-α and cellular therapies, used in conjunction with a range of surgical interventions, has greatly improved disease outcomes, although complete remission can still be elusive. This review considers current perianal imaging options, specifically pelvic MRI and endoanal and transperineal ultrasound, and their roles in diagnosis, management, and assessment of treatment response. Pelvic MRI is the first line technique for imaging of perianal CD given the complexity of fistulas encountered in CD. MRI technical acquisition parameters for adults and children and an approach to MRI interpretation and reporting are provided. Anatomic classification systems for fistulising perianal disease are presented. We also explore the history, current landscape, and future developments of MRI features of perianal disease as imaging biomarkers to quantify activity and severity, and consider CD MRI-based inflammatory activity scores. We discuss the reliability and validation of a number of indices (including PEMPAC, MAGNIFI-CD, mVAI, and Van Assche Index), their potential to quantify treatment response, and possible prognostic capabilities.
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15
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Buscail E, Le Cosquer G, Gross F, Lebrin M, Bugarel L, Deraison C, Vergnolle N, Bournet B, Gilletta C, Buscail L. Adipose-Derived Stem Cells in the Treatment of Perianal Fistulas in Crohn's Disease: Rationale, Clinical Results and Perspectives. Int J Mol Sci 2021; 22:ijms22189967. [PMID: 34576129 PMCID: PMC8470328 DOI: 10.3390/ijms22189967] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/07/2021] [Accepted: 09/12/2021] [Indexed: 12/16/2022] Open
Abstract
Between 20 to 25% of Crohn’s disease (CD) patients suffer from perianal fistulas, a marker of disease severity. Seton drainage combined with anti-TNFα can result in closure of the fistula in 70 to 75% of patients. For the remaining 25% of patients there is room for in situ injection of autologous or allogenic mesenchymal stem cells such as adipose-derived stem/stromal cells (ADSCs). ADSCs exert their effects on tissues and effector cells through paracrine phenomena, including the secretome and extracellular vesicles. They display anti-inflammatory, anti-apoptotic, pro-angiogenic, proliferative, and immunomodulatory properties, and a homing within the damaged tissue. They also have immuno-evasive properties allowing a clinical allogeneic approach. Numerous clinical trials have been conducted that demonstrate a complete cure rate of anoperineal fistulas in CD ranging from 46 to 90% of cases after in situ injection of autologous or allogenic ADSCs. A pivotal phase III-controlled trial using allogenic ADSCs (Alofisel®) demonstrated that prolonged clinical and radiological remission can be obtained in nearly 60% of cases with a good safety profile. Future studies should be conducted for a better knowledge of the local effect of ADSCs as well as for a standardization in terms of the number of injections and associated procedures.
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Affiliation(s)
- Etienne Buscail
- Department of Surgery, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France;
- IRSD, University of Toulouse, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Guillaume Le Cosquer
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (B.B.); (C.G.)
| | - Fabian Gross
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France; (F.G.); (M.L.); (L.B.)
| | - Marine Lebrin
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France; (F.G.); (M.L.); (L.B.)
| | - Laetitia Bugarel
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France; (F.G.); (M.L.); (L.B.)
| | - Céline Deraison
- IRSD, University of Toulouse, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Nathalie Vergnolle
- IRSD, University of Toulouse, INSERM 1022, INRAe, ENVT, UPS, 31300 Toulouse, France; (C.D.); (N.V.)
| | - Barbara Bournet
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (B.B.); (C.G.)
| | - Cyrielle Gilletta
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (B.B.); (C.G.)
| | - Louis Buscail
- Department of Gastroenterology and Pancreatology, CHU Toulouse-Rangueil and Toulouse University, UPS, 31059 Toulouse, France; (G.L.C.); (B.B.); (C.G.)
- Centre for Clinical Investigation in Biotherapy, CHU Toulouse-Rangueil and INSERM U1436, 31059 Toulouse, France; (F.G.); (M.L.); (L.B.)
- Correspondence: ; Tel.: +33-561323055
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16
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Garg P, Kaur B, Yagnik VD, Dawka S, Menon GR. Guidelines on postoperative magnetic resonance imaging in patients operated for cryptoglandular anal fistula: Experience from 2404 scans. World J Gastroenterol 2021; 27:5460-5473. [PMID: 34588745 PMCID: PMC8433608 DOI: 10.3748/wjg.v27.i33.5460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/12/2021] [Accepted: 08/05/2021] [Indexed: 02/06/2023] Open
Abstract
Magnetic resonance imaging (MRI) is considered the gold standard for the evaluation of anal fistulas. There is sufficient literature available outlining the interpretation of fistula MRI before performing surgery. However, the interpretation of MRI becomes quite challenging in the postoperative period after the surgery of fistula has been undertaken. Incidentally, there are scarce data and no set guidelines regarding analysis of fistula MRI in the postoperative period. In this article, we discuss the challenges faced while interpreting the postoperative MRI, the timing of the postoperative MRI, the utility of MRI in the postoperative period for the management of anal fistulas, the importance of the active involvement and experience of the treating clinician in interpreting MRI scans, and the latest advancements in the field.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula 134113, Haryana, India
- Department of Colorectal Surgery, Indus International Hospital, Mohali 140201, Punjab, India
| | - Baljit Kaur
- Department of Radiology, SSRD Magnetic Resonance Imaging Institute, Chandigarh 160011, Chandigarh, India
| | - Vipul D Yagnik
- Department of Surgical Gastroenterology, Nishtha Surgical Hospital and Research Center, Patan 384265, Gujarat, India
| | - Sushil Dawka
- Department of Surgery, SSR Medical College, Belle Rive, Mauritius
| | - Geetha R Menon
- Department of Statistics, Indian Council of Medical Research, New Delhi 110029, New Delhi, India
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17
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Gu B, De Gregorio M, Pipicella JL, Vande Casteele N, Andrews JM, Begun J, Connell W, D'Souza B, Gholamrezaei A, Hart A, Liew D, Radford-Smith G, Rimola J, Sutherland T, Toong C, Woods R, Wu Y, Xuan W, Williams AJ, Ng W, Ding NS, Connor S. Prospective randomised controlled trial of adults with perianal fistulising Crohn's disease and optimised therapeutic infliximab levels: PROACTIVE trial study protocol. BMJ Open 2021; 11:e043921. [PMID: 34210720 PMCID: PMC8252869 DOI: 10.1136/bmjopen-2020-043921] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Perianal fistulising Crohn's disease (pfCD) can be somewhat treatment refractory. Higher infliximab trough levels (TLIs) may improve fistula healing rates; however, it remains unclear whether escalating infliximab therapy to meet higher TLI targets using proactive, or routine, therapeutic drug monitoring (TDM) improves outcomes. This randomised controlled trial aimed to assess whether infliximab therapy targeting higher TLIs guided by proactive TDM improves outcomes compared with standard therapy. METHODS AND ANALYSIS Patients with active pfCD will be randomised 1:1 to either the proactive TDM arm or standard dosing arm and followed up for 54 weeks. Patients in the proactive TDM arm will have infliximab dosing optimised to target higher TLIs. The targets will be TLI ≥ 25 µg/mL at week 2, ≥ 20 µg/mL at week 6 and ≥ 10 µg/mL during maintenance therapy. The primary objective will be fistula healing at week 32. Secondary objectives will include fistula healing, fistula closure, radiological fistula healing, patient-reported outcomes and economic costs up to 54 weeks. Patients in the standard dosing arm will receive conventional infliximab dosing not guided by TLIs (5 mg/kg at weeks 0, 2 and 6, and 5 mg/kg 8 weekly thereafter). Patients aged 18-80 years with pfCD with single or multiple externally draining complex perianal fistulas who are relatively naïve to infliximab treatment will be included. Patients with diverting ileostomies or colostomies and pregnant or breast feeding will be excluded. Fifty-eight patients per arm will be required to detect a 25% difference in the primary outcome measure, with 138 patients needed to account for an estimated 6.1% primary non-response rate and 10% dropout rate. ETHICS AND DISSEMINATION Results will be presented in peer-reviewed journals and international conferences. Ethics approval has been granted by the South Western Sydney Local Health District Human Research Ethics Committee in Australia. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12621000023853); Pre-results.
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Affiliation(s)
- Bonita Gu
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Michael De Gregorio
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Joseph Louis Pipicella
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
- Biostatistics Unit, The Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Niels Vande Casteele
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Jane M Andrews
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jakob Begun
- Immunity, Infection, and Inflammation Program, Mater Research Institute, Brisbane, Queensland, Australia
- Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - William Connell
- Department of Gastroenterology and Hepatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Basil D'Souza
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Ali Gholamrezaei
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
- Biostatistics Unit, The Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Ailsa Hart
- Inflammatory Bowel Diseases Unit, St Mark's Hospital, Harrow, UK
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Graham Radford-Smith
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jordi Rimola
- Inflammatory Bowel Disease Unit, Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Tom Sutherland
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Medical Imaging Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Catherine Toong
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Immunology, NSW Health Pathology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Rodney Woods
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Yang Wu
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Wei Xuan
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Biostatistics Unit, The Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Astrid-Jane Williams
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Watson Ng
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Nik Sheng Ding
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Susan Connor
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
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Cho YJ, Kwon H, Kwon YJ, Kim KM, Oh SH, Kim DY. Efficacy and safety of autologous adipose tissue-derived stem cell therapy for children with refractory Crohn's complex fistula: a Phase IV clinical study. Ann Surg Treat Res 2021; 101:58-64. [PMID: 34235117 PMCID: PMC8255577 DOI: 10.4174/astr.2021.101.1.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 03/10/2021] [Accepted: 03/30/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose Autologous adipose tissue-derived stem cells (ASCs) have been proposed for patients with refractory Crohn disease, but research is lacking in pediatric patients. This Phase IV study evaluated the efficacy and safety of ASCs in children with refractory Crohn's fistulae. Methods Patients with a refractory Crohn's fistula who did not have conventional therapy for more than 3 months or with a recurrent complex Crohn's fistula were included. All patients were at least 14 years old. Patients with infection, poor condition, or active Crohn disease with a disease activity index of 450 and above were excluded. Five patients were treated with ASCs from 2014 to 2015 in Asan Medical Center. ASC administration was adjusted according to fistula size (1 mL per cm2). We evaluated the efficacy and safety 8 weeks after injection and followed patients for 6 months. Results Fistulae were healed in 4 patients by 8 weeks after ASC injection. Of these 4 patients, 1 had complete fistula closure and sustainability after 6 months. The other 3 with healing effects had less than 50% fistula closure by 6 months. None of these 4 patients have persistent fistulae. One patient had no healing effect, and seton ligation was performed 8 months after ASC injection. There were no adverse effects related to ASC administration. Conclusion ASC therapy is a simple and well-tolerated therapeutic option for children with refractory Crohn's complex fistulae. Complete closure was well-sustained. However, more data from a larger number of patients are needed.
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Affiliation(s)
- Yu Jeong Cho
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyunhee Kwon
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Jae Kwon
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Yeon Kim
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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Heterogeneity in outcome selection, definition and measurement in studies assessing the treatment of cryptoglandular anal fistula: findings from a systematic review. Tech Coloproctol 2021; 25:761-830. [PMID: 33963945 PMCID: PMC8187216 DOI: 10.1007/s10151-021-02452-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/15/2021] [Indexed: 12/12/2022]
Abstract
Background Treatment for cryptoglandular anal fistula (AF) is challenging and a lack of uniform outcomes in the literature prevents direct comparison of treatments. This can be addressed by developing a core outcome set, a standardised set of outcomes reported in all interventional studies for a specific condition. The aim of this systematic review is to assess the range of outcomes, their definitions, and the measurement instruments currently utilised in interventional studies for adult patients with AF. This will inform the development of an AF core outcome set. Methods Medline, Embase and The Cochrane Library were searched to identify all patient- and clinician-reported outcomes in studies assessing medical, surgical or combination treatment of adult patients with AF published from January 2008 to May 2020. The resulting outcomes were categorized according to the Core Outcome Measurement in Effectiveness Trials (COMET) taxonomy to better understand their distribution. Results In total, 155 studies were included, 552 outcomes were extracted, with a median of three outcomes (interquartile range 2–5) per study. Only 25% of studies demonstrated high-quality outcome reporting. The outcomes were merged into 52 unique outcomes and structured into four core areas and 14 domains, with the majority in the domain of physiological or clinical (gastrointestinal) outcomes. The most commonly reported outcomes were healing (77%), incontinence (63%), and recurrence (40%), with no single outcome assessed across all studies. There was a wide variation in outcome definitions and measurement instruments used. Conclusions There is substantial heterogeneity in outcomes, definitions, and measurement instruments reported in interventional studies for cryptoglandular anal fistula. This emphasises the need for standardised outcome reporting and measurement.
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20
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Effectiveness of Infliximab on Deep Radiological Remission in Chinese Patients with Perianal Fistulizing Crohn's Disease. Dig Dis Sci 2021; 66:1658-1668. [PMID: 32524415 DOI: 10.1007/s10620-020-06398-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 06/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Information concerning deep radiological healing of perianal fistulas in Chinese patients with CD is limited. The present study aimed to establish the effectiveness of infliximab on CD-related perianal fistulas using magnetic resonance imaging (MRI) and identify predictors of deep radiological remission of fistulas. METHODS We retrospectively reviewed patients with CD with draining perianal fistulas treated with infliximab and included only those who underwent clinical assessment and MRI before and after infliximab therapy. RESULTS Among 178 patients who underwent repeated MRI and clinical assessment, 65.2% had complex fistulas. Post-infliximab therapy, 55.1% of patients with perianal fistulizing CD showed clinical remission and 26.4% presented a clinical response; 38.2% had deep radiological remission, and 34.3% had a partial response based on the Ng score; the Van Assche scores decreased obviously compared with baseline. Prolonged infliximab infusion (18 times) presented higher radiological remission rates in patients with CD with complex fistulas. Concomitant treatment with azathioprine increased the fistula healing rate compared with infliximab alone (50% vs. 36.9%, P < 0.001). Younger age at diagnosis of CD, proctitis and requiring perianal surgery were identified as predictors of poor deep radiological remission of fistulas. Eight of ten patients who stopped infliximab and switched to an alternative agent retained a status of fistula healing in the first year of follow-up. CONCLUSIONS Infliximab induced deep radiological remission of perianal fistulas in Chinese patients with CD. Routine MRI should be used to monitor fistula healing. Patients with younger age at diagnosis of CD, proctitis, and/or requiring perianal surgery should receive combined therapy and careful monitoring.
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21
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Lee T, Kamm MA, Bell S, Lust M, Brown S, Niewiadomski O, Basnayake C, Wright E, D'Souza B, Woods R, Wei SC, Connell W, Thompson A, Yong E, Ding NS. Long-term outcomes of perianal fistulizing Crohn's disease in the biologic era. JGH OPEN 2020; 5:235-241. [PMID: 33553661 PMCID: PMC7857282 DOI: 10.1002/jgh3.12475] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/21/2020] [Accepted: 11/30/2020] [Indexed: 11/08/2022]
Abstract
Background and Aim While the advent of biologic therapy has led to improved outcomes in perianal fistulizing Crohn's disease (pfCD), loss of response is common. Previous studies suggest that patients who achieve radiological healing (with healing of underlying tracts on magnetic resonance imaging [MRI]) have a longer duration of response. The aim of this study was to characterize MRI outcomes of pfCD at a specialist inflammatory bowel disease (IBD) unit and compare the long-term clinical outcomes between patients achieving MRI and clinical healing. Methods A retrospective analysis of perianal fistulizing Crohn's patients treated at one specialist IBD unit was performed. Records were reviewed for patient demographics, disease history, clinical assessments, investigation results, and disease flares. Clinical remission was defined as closure of all baseline fistula openings. Radiological healing was defined as the absence of any T2-hyperintense sinuses, tracts, or collections. The primary end-point was rate of MRI healing. The secondary outcome was defined as flare-free period (time between clinical or radiological healing and patients' first signs/symptoms requiring therapy escalation). Results A total of 93 patients were included, with a median follow-up of 4.8 years (interquartile range, 2.4-6 years). Of 44 patients, 22 (50%) achieved clinical remission, while 15 of 93 (16%) achieved radiological healing. Of 22 patients, 10 (45%) with clinical remission had a subsequent disease flare (median time of 7 months) compared with 3 of 15 (20%) patients with MRI healing (median time of 3.6 years). Radiological healing was associated with a significantly longer flare-free period (P = 0.01). Conclusion Radiological healing occurs less commonly but represents a deeper form of healing, associated with improved long-term clinical outcomes.
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Affiliation(s)
- Tanya Lee
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Michael A Kamm
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Sally Bell
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Mark Lust
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Steve Brown
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Ola Niewiadomski
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Chamara Basnayake
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Emily Wright
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Basil D'Souza
- Department of Colorectal Surgery St Vincent's Hospital Melbourne Victoria Australia
| | - Rodney Woods
- Department of Colorectal Surgery St Vincent's Hospital Melbourne Victoria Australia
| | - Shu Chen Wei
- Department of Internal Medicine National Taiwan University Hospital and College of Medicine Taipei Taiwan
| | - William Connell
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Alexander Thompson
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
| | - Eric Yong
- Department of Radiology St Vincent's Hospital Melbourne Victoria Australia
| | - Nik Sheng Ding
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia.,Department of Medicine University of Melbourne Melbourne Victoria Australia
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22
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Wang WG, Lu WZ, Yang CM, Yu KQ, He HB. Modified Van Assche magnetic resonance imaging-based score for assessing the clinical status of anal fistulas. Medicine (Baltimore) 2020; 99:e20075. [PMID: 32384475 PMCID: PMC7440082 DOI: 10.1097/md.0000000000020075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The modified Van Assche magnetic resonance imaging (MRI)-based score is a feasible system to assess the clinical status of anal fistulas in Crohn disease. In this study, we evaluated this score's association with clinical status in patients with anal fistulas (AFs).We included all patients with AF who underwent contrast-enhanced pelvic MRI and surgery between January 2011 and December 2016. The score was evaluated retrospectively preoperatively and 1, 3, and 6 months postoperatively. Univariate and multivariate analyses of the risk factors for AF recurrence were also performed.We retrospectively analyzed data for 104 patients. Twelve (11.5%) patients developed AF recurrence. We classified patients' preoperative clinical status into three grades: 52 (50.0%) grade A, 31 (29.8%) grade B, and 21 (20.2%) grade C. The preoperative MRI-based score was significantly correlated with patients' preoperative clinical status grade (Pearson correlation: 0.547; P < .001). The 3 preoperative clinical status grades showed significant (F = 23.303, P < .001) tendencies for associations with lower respective MRI-based scores. The incidence of AF recurrence decreased with the MRI-based score to 1-month postoperatively, then gradually increased (F = 60.863, P = .000). Long duration of disease, prior interventions, and high MRI-based score were independent risk factors for AF recurrence.The MRI-based score objectively assessed the clinical status and disease activity of patients with AFs, with a high score being associated with severe clinical status and long recovery time.
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Affiliation(s)
- Wei-Guo Wang
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University
| | - Wen-Zhu Lu
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University
| | - Chun-Mei Yang
- Department of Integrated Traditional Chinese and Western Medicine, Cheng Du Shang Jin Nan Fu Hospital, Chengdu, Sichuan Province, China
| | - Ke-Qiang Yu
- Department of Integrated Traditional Chinese and Western Medicine, Cheng Du Shang Jin Nan Fu Hospital, Chengdu, Sichuan Province, China
| | - Hong-Bo He
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University
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23
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Louis E. Tailoring Biologic or Immunomodulator Treatment Withdrawal in Inflammatory Bowel Disease. Front Med (Lausanne) 2020; 6:302. [PMID: 31970158 PMCID: PMC6960136 DOI: 10.3389/fmed.2019.00302] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/02/2019] [Indexed: 01/16/2023] Open
Abstract
There is currently no cure for inflammatory bowel disease. Most recent treatments and treatment strategies allow for healing intestinal lesions and maintaining steroid-free remission in a subset of patients. These patients and their doctors often ask themselves whether the treatment could be withdrawn. Several studies in both Crohn's disease and ulcerative colitis have demonstrated a risk of relapse, which varies between 20 and 50% at 1 year and between 50 and 80% beyond 5 years. These numbers clearly highlight that stopping therapy should not be a systematically proposed strategy in those remitting patients. Nevertheless, they also indicate that a minority of patients may not relapse over mid-term and that those who have relapsed may have benefited from a drug-free period before being treated again for a new cycle of treatment. In this context, it would be good to optimally select patients who can be candidates for a successful treatment withdrawal. The criteria impacting this decision are as follows: the risk of relapse (linked to factors like mucosal healing and biomarkers), the consequence of a potential relapse, the tolerance and potential side effects of therapy, patients' priorities and preferences, and the costs. Integration of these parameters allows for the proposal of a decisional algorithm that may help the patients and doctors to make an appropriate decision for their individual case.
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Affiliation(s)
- Edouard Louis
- Department of Gastroenterology, University and CHU Liège, Liège, Belgium
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24
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Lee T, Yong E, Ding NS. Radiological outcomes in perianal fistulizing Crohn's disease: A systematic review and meta-analysis. JGH OPEN 2019; 4:340-344. [PMID: 32514434 PMCID: PMC7273731 DOI: 10.1002/jgh3.12295] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 12/01/2019] [Indexed: 12/17/2022]
Abstract
Perianal fistulas are a common and debilitating manifestation of Crohn's disease. Since the advent of biological agents, patient outcomes appear to have improved. While rates of clinical response and remission are well characterized in literature, magnetic resonance imaging (MRI) outcomes remain less so. This is despite previous studies demonstrating the persistence of fistula tracts on MRI, in spite of clinical healing, suggesting radiological markers of improvement may be more accurate. The aims of this study were to systematically review the literature for all studies reporting on MRI outcomes following biological therapy and to compare rates of radiological healing to clinical remission. A search was performed according to the Preferred Reporting Items For Systematic Reviews and Meta‐Analysis (PRISMA) guidelines. Nine articles were included, with a total sample size of 259 patients. Of these 259 patients, 47% achieved clinical remission following induction therapy and 42% following a median of 52 weeks' maintenance therapy. Out of the 259 patients, 7% achieved radiological healing in the short term and 25% in the long term. The odds ratio of MRI versus clinical healing was 0.10 (95% confidence interval [CI], 0.02–0.39) and 0.43 (95% CI, 0.26–0.71), respectively, at those corresponding time points. MRI healing of perianal fistulizing Crohn's, while arguably a more accurate assessment of treatment response, is significantly less common than clinical remission. Heterogeneity exists in the definition of radiological and clinical response, leading to variation in reported rates. Further studies, directly comparing the long‐term outcomes of patients achieving clinical remission and MRI healing are required, to better inform the role of MRI follow up in clinical practice.
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Affiliation(s)
- Tanya Lee
- St Vincent's Clinical School University of Melbourne Melbourne Victoria Australia
| | - Eric Yong
- Department of Radiology St Vincent's Hospital Melbourne Victoria Australia
| | - Nik S Ding
- Department of Gastroenterology St Vincent's Hospital Melbourne Victoria Australia
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25
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Algazzar HY, Eldib DB, Bahram MA, Zaher NA. Preoperative MRI of perianal fistula evaluation and its impact on surgical outcome. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2019. [DOI: 10.1186/s43055-019-0085-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Perianal fistula (PAF) is an abnormal tract communicating an external cutaneous opening in the perianal region to the anal canal. PAF is one of the common anorectal disorders in surgical practice with high prevalence. The current study aimed to determine the ability of preoperative MRI for preoperative evaluation of perianal fistula.
Results
This is a retrospective evaluation of 65 patients with perianal fistula. MRI fistula imaging-related data were revised, and fistula severity was scored using criteria of both local extension of fistulas and active inflammation for a total maximum score of 22. Preoperative MRI could predict the severity of perianal disease with sensitivity, specificity, and accuracy rates of 75%, 92%, and 84.6%, respectively. Surgical findings concerning PAF severity correlated significantly with MRI findings. Diffusion-weighted magnetic resonance imaging (DW-MRI) provided high sensitivity and accuracy with 100% specificity for fistula visualization and highest sensitivity, specificity, and accuracy for detection of cavities > 3 mm in diameter. DW-MRI provided the highest specificity rate on ROC curve analysis among the three MRI pulse sequences (DW-MRI, short tau inversion recovery (STIR), and T1 post-contrast).
Conclusion
MRI is valuable and accurate for preoperative investigation for PAF evaluation and abscess localization. MRI allowed accurate detection of internal fistula opening and its relation to sphincters. DW-MRI is a valuable sequence with highest diagnostic yield, and its addition to STIR WI improves sensitivity and specificity for determination of fistula activity and extension.
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26
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Kedia S, Sharma R, Makharia G, Ahuja V, Desai D, Kandasamy D, Eapen A, Ganesan K, Ghoshal UC, Kalra N, Karthikeyan R, Madhusudhan KS, Philip M, Puri A, Puri S, Sinha SK, Banerjee R, Bhatia S, Bhat N, Dadhich S, Dhali GK, Goswami BD, Issar SK, Jayanthi V, Misra SP, Nijhawan S, Puri P, Sarkar A, Singh SP, Srivastava A, Abraham P, Ramakrishna BS. Indian guidelines on imaging of the small intestine in Crohn's disease: A joint Indian Society of Gastroenterology and Indian Radiology and Imaging Association consensus statement. Indian J Radiol Imaging 2019; 29:111-132. [PMID: 31367083 PMCID: PMC6639863 DOI: 10.4103/ijri.ijri_153_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients suspected to have or having Crohn's disease. The 29 consensus statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.
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Affiliation(s)
- Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Radiadiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Devendra Desai
- Division of Gastroenterology, P D Hinduja Hospital, Mumbai, Maharashtra, India
| | | | - Anu Eapen
- Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India
| | - Karthik Ganesan
- Department of Radiodiagnosis, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
| | - Naveen Kalra
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - R Karthikeyan
- Department of Radiodiagnosis, SRM Institute of Medical Sciences and Research, Chennai, India
| | | | - Mathew Philip
- Department of Gastroenterology, PVS Memorial Hospital, Kochi, Kerala, India
| | - Amarender Puri
- Department of Gastroenterology, GB Pant Institute of Medical Education and Research, New Delhi, India
| | - Sunil Puri
- Department of Radiodiagnosis, GB Pant Institute of Medical Education and Research, New Delhi, India
| | - Saroj K Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rupa Banerjee
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Shobna Bhatia
- Department of Gastroenterology, KEM Hospital, Mumbai, India
| | - Naresh Bhat
- Department of Gastroenterology, Aster CMI Hospital, Bengaluru, Karnataka, India
| | - Sunil Dadhich
- Department of Gastroenterology, SN Medical College, Jodhpur, Rajasthan, India
| | - G K Dhali
- Department of Gastroenterology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, West Bengal, India
| | - B D Goswami
- Department of Gastroenterology, Guwahati Medical College, Guwahati, Assam, India
| | - S K Issar
- Department of Gastroenterology, Jawaharlal Nehru Hospital and Research Centre, Bhilai, Chhattishgarh, India
| | - V Jayanthi
- Department of Gastroenterology, Gleneagles Global Hospitals, Chennai, India
| | - S P Misra
- Department of Gastroenterology, MLN Medical College, Allahabad, UP, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, Gleneagles Global Hospitals, Chennai, India
| | - Pankaj Puri
- Department of Gastroenterology, Military Hospital, Jodhpur, Rajasthan, India
| | - Avik Sarkar
- Department of Radiodiagnosis, School of Digestive and Liver Diseases, Institute of Post Graduate Medical, Education and Research, Kolkata, West Bengal, India
| | - S P Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Odisha, India
| | - Anshu Srivastava
- Department of Paediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
| | - Philip Abraham
- Division of Gastroenterology, P D Hinduja Hospital, Mumbai, Maharashtra, India
| | - B S Ramakrishna
- Department of Gastroenterology, SRM Institute of Medical Sciences and Research, Chennai, India
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Abstract
During the past 30 years, classifications and scoring systems have been developed in order to evaluate and objectify the degree and activity of anorectal fistulas. Only a few of these disease-specific instruments have been adopted into daily clinical routine. Generally, clinicians tend to use global medical judgement rather than numeric activity indices, which often seem complex and time consuming. Activity scores in Crohn disease, however, appeared to be very useful in clinical trials regarding evaluation of therapy response. Thus, activity indices must be simple and reproducible. The years 1976 and 1995, in which the Parks Classification and Perianal Disease Activity Index (PDAI) were established, can be considered milestone years for classifying patients with anorectal fistulizing disease. These instruments should be recognized at present as the gold standard for evaluating the complexity as well as the severity of anorectal fistulas and perianal Crohn disease.
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28
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Ho E, Rickard MJFX, Suen M, Keshava A, Kwik C, Ong YY, Yang J. Perianal sepsis: surgical perspective and practical MRI reporting for radiologists. Abdom Radiol (NY) 2019; 44:1744-1755. [PMID: 30770939 DOI: 10.1007/s00261-019-01920-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This article describes the development of a structured MRI reporting template and diagrammatic worksheet for perianal sepsis through collaboration between radiologists and colorectal surgeons at our institution, and the rationale behind each component of the worksheet. Benefits of this reporting worksheet include optimizing communication of key imaging findings that have a real impact on patient management, less time spent on reporting the study, and easier comparison between studies. We illustrate the utility of the report template with case studies. We summarize the current surgical approaches to perianal sepsis to help radiologists focus on reporting the findings relevant to surgical planning.
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29
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Thipphavong S, Costa AF, Ali HA, Wang DC, Brar MS, Jhaveri KS. Structured reporting of MRI for perianal fistula. Abdom Radiol (NY) 2019; 44:1295-1305. [PMID: 30474723 DOI: 10.1007/s00261-018-1839-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The purpose of this article is to review MRI technique, relevant anatomy, and MRI classification systems for the assessment of perianal fistulising disease. We present a stepwise approach to the assessment of perianal fistulas on MRI utilizing a systematic reporting format. CONCLUSION MRI is invaluable for the assessment of perianal fistulas. A systematic report can help communicate the anatomy of complex fistulising disease to assist with optimal management.
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Affiliation(s)
- Seng Thipphavong
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, and Women's College Hospital, University of Toronto, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.
| | - Andreu F Costa
- Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Bldg, 3rd Fl, 1276 S Park St, Halifax, NS, B3H 2Y9, Canada
| | - Hamideh Ale Ali
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, and Women's College Hospital, University of Toronto, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - David Chenhan Wang
- Department of Medical Imaging, University of Toronto, 4th Floor, 263 McCaul Street, Toronto, ON, M5T 1W7, Canada
| | - Mantaj S Brar
- Division of General Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Suite 451, Toronto, ON, M5G 1X5, Canada
| | - Kartik S Jhaveri
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, and Women's College Hospital, University of Toronto, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
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Treatment of Crohn's anal fistulas guided by magnetic resonance imaging. GASTROENTEROLOGY REVIEW 2019; 14:55-61. [PMID: 30944678 PMCID: PMC6444106 DOI: 10.5114/pg.2019.83426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 10/07/2018] [Indexed: 02/06/2023]
Abstract
Introduction Clinical evaluation of the Crohn’s anal fistulas (CF) closure is inadequate to some extent due to earlier closure of cutaneous openings compared to fistulous tracts. There is a need for a more accurate method of assessment. Aim To compare clinical signs of CF with radiological findings, before and after treatment, to follow complete closure. Material and methods It was a retrospective study of 23 patients suffering from CF admitted to a single specialist centre, who were treated with a combination of surgical and biological therapy. Fistula healing was evaluated with fistula drainage assessment classification (FDA), perianal disease activity index (PDAI), and van Assche magnetic resonance imaging score (MRI) before and 3 months after surgery and induction of the biological treatment. Results Clinical response occurred in 13 (57%) patients 3 months after induction treatment. Complete clinical response was achieved in 8 (35%) patients, whereas partial response occurred in 5 (22%) patients. Persistence of a fistula tract was visualised on MRI in 4 (50%) patients with clinical closure. Conclusions The healing process of CF should be monitored by MRI due to the discrepancy between premature closure of external openings and fistulous tracts. Prolonged biological therapy until complete healing of anal fistulas confirmed on MRI might improve the results of treatment.
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Tuncyurek O, Garces-Descovich A, Jaramillo-Cardoso A, Durán EE, Cataldo TE, Poylin VY, Gómez SF, Cabrera AM, Hegazi T, Beker K, Mortele KJ. Structured versus narrative reporting of pelvic MRI in perianal fistulizing disease: impact on clarity, completeness, and surgical planning. Abdom Radiol (NY) 2019; 44:811-820. [PMID: 30519819 DOI: 10.1007/s00261-018-1858-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate clarity, completeness, and impact on surgical planning of MRI reporting of perianal fistulizing disease using a structured disease-specific template versus narrative reporting for planning of disease treatment by colorectal surgeons. MATERIALS AND METHODS In this HIPAA-compliant, IRB-approved study with waiver of informed consent, a structured reporting template for perianal fistulizing disease MRIs was developed based on collaboration between colorectal surgeons and abdominal radiologists. The study population included 45 consecutive patients who underwent pelvic MRI for perianal fistulizing disease prior to implementation of structured reporting, and 60 consecutive patients who underwent pelvic MRI for perianal fistulizing disease after implementation of structured reporting. Objective evaluation of the reports for the presence of 12 key features was performed, as also subjective evaluation regarding the clarity and completeness of reports, and impact on surgical planning. RESULTS Significantly more key features were absent in narrative reports [mean: 6.3 ± 1.8 (range 3-11)] than in structured reports [mean: 0.3 ± 0.9 (range 1-5)] (p ≤ 0.001). The use of structured reporting also increased the percentage of completeness (72.5-88.3% for surgeon 1, and 61.2-81.3% for surgeon 2; p = 0.05 and 0.03, respectively), helpfulness in surgical planning (7.1 ± 1.5-7.6 ± 1.5 for surgeon 1, and 5.8 ± 1.4-7.1 ± 1.1 for surgeon 2; p = 0.05 and p < 0.001, respectively), and clarity (7.6 ± 1.3-8.3 ± 1.1 for surgeon 1, and 5.2 ± 1.4-7.1 ± 1.3 for surgeon 2; p = 0.006 and p < 0.001, respectively) of the reports. CONCLUSION Structured MRI reports in patients with perianal fistulizing disease miss fewer key features than narrative reports. Moreover, structured reports were described as more complete and clear, and more helpful for treatment planning.
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Ciccocioppo R, Klersy C, Leffler DA, Rogers R, Bennett D, Corazza GR. Systematic review with meta-analysis: Safety and efficacy of local injections of mesenchymal stem cells in perianal fistulas. JGH OPEN 2019; 3:249-260. [PMID: 31276044 PMCID: PMC6586577 DOI: 10.1002/jgh3.12141] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/24/2018] [Indexed: 12/15/2022]
Abstract
Perianal fistulas in Crohn's disease (CD) represent a highly debilitating and difficult‐to‐treat condition. Given emerging supportive evidence, we conducted a systematic review and meta‐analysis of all trials/observational studies to establish the safety and efficacy of local injections of mesenchymal stem cells (MSCs). The PRISMA‐P statement was applied for planning and reporting, and MEDLINE, EMBASE, Web of Science, Cochrane, CINAHL, ClinicalTrials.gov database, and ECCO 2017 proceedings were searched for published observational studies and one‐arm and randomized clinical trials (RCTs). Safety was assessed in terms of acute local/systemic events, long‐term events, and relatedness with MSC treatment. Efficacy was evaluated in terms of external and/or radiological closure of fistula tracks. After a review of 211 citations, 23 studies, including 696 participants, were evaluated. Four were RCTs with a total of 483 patients. Overall, fistula closure occurred in 80% of MSC‐treated patients. In RCTs, this rate was 64% in the MSC arm and 37% in the control arm (relative risk (RR) = 1.54). Radiological response occurred in 83% of MSC‐treated patients. Treatment‐related adverse events occurred in 1% of MSC‐treated patients, with severe treatment‐related adverse events reaching 0% over a median follow‐up of 6 months. In RCTs, treatment‐related adverse events occurred in 13% in the MSC arm and 24% in the control arm (RR = 0.65). The relapse rate was 0. These results suggest that a local MSC injection is safe and efficacious. Further clinical trials with standardized end‐points are required to ensure the timely implementation of this new therapy in the management of perianal CD.
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Affiliation(s)
- Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine AOUI Policlinico GB Rossi and University of Verona Verona Italy
| | - Catherine Klersy
- Service of Clinical Epidemiology & Biostatistics, Fondazione IRCCS Policlinico San Matteo and University of Pavia Pavia Italy
| | - Daniel A Leffler
- Department of Clinical Science Takeda Pharmaceutical Company Limited Cambridge Massachusetts USA.,Division of Gastroenterology Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Raquel Rogers
- Department of Pharmacovigilance Takeda Pharmaceutical Company Limited Cambridge Massachusetts USA
| | - Dimitri Bennett
- Department of Epidemiology Takeda Pharmaceutical Company Limited Cambridge Massachusetts USA
| | - Gino Roberto Corazza
- Department of Internal Medicine Fondazione IRCCS Policlinico San Matteo and University of Pavia Pavia Italy
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Cattapan K, Chulroek T, Kordbacheh H, Wancharoenrung D, Harisinghani M. Contrast- vs. non-contrast enhanced MR data sets for characterization of perianal fistulas. Abdom Radiol (NY) 2019; 44:446-455. [PMID: 30159595 DOI: 10.1007/s00261-018-1761-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the diagnostic efficacy between pre- and post-contrast MRI sequences in perianal fistulas using intra-operative findings as the gold standard. MATERIALS AND METHODS Retrospective analysis of 50 patients with a history of perianal fistula and MRI performed between January 2006 and January 2018 was performed. The inclusion criteria were patients who underwent MRI prior to surgery and had a detailed surgical report available. Pre- and post-contrast MR data sets were evaluated by two radiologists at two-week-intervals, assessed fistula type, internal/external opening, presence of abscess/secondary tracts, and confidence scores. The area under the curve (AUC) was used for comparison the diagnostic ability. The sensitivity and specificity were compared using the McNemar's test. RESULTS The confidence scores in detecting perianal fistulas were significantly higher in the post-contrast MR data set (p < 0.003). The post-contrast MR data set had similar ability to classify perianal fistulas as combined T2-DWI and isolated T2 data sets in 49/50 cases. For internal/external opening, the post-contrast MR, combined T2-DWI, and isolated T2 data sets had 100% concordance with intra-operative reports. For perianal abscess, there was no significant difference in sensitivity or AUC value between the isolated T2 or combined T2-DWI data sets and post-contrast MR data set (p > 0.05). All MR data sets correctly identified secondary tracts in all 50 cases. CONCLUSIONS Although contrast-enhanced MR studies can improve a radiologist's confidence, non-contrast MR studies had similar diagnostic efficacy in identifying perianal fistulas and their complications. Therefore, a non-contrast study may suffice in selected patients such as those with renal impairment.
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Affiliation(s)
- Kamonwon Cattapan
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA, 02114, USA
- Department of Radiology, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thitinan Chulroek
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA, 02114, USA
- Department of Diagnostic Radiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hamed Kordbacheh
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA, 02114, USA
| | - Dearada Wancharoenrung
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA, 02114, USA
- Department of Diagnostic Radiology, Faculty of Medicine, Vajira Hospital, Nawamindradhiraj University, Bangkok, Thailand
| | - Mukesh Harisinghani
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA, 02114, USA.
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Bouchard D, Pigot F, Staumont G, Siproudhis L, Abramowitz L, Benfredj P, Brochard C, Fathallah N, Faucheron JL, Higuero T, Panis Y, de Parades V, Vinson-Bonnet B, Laharie D. Management of anoperineal lesions in Crohn's disease: a French National Society of Coloproctology national consensus. Tech Coloproctol 2019; 22:905-917. [PMID: 30604249 DOI: 10.1007/s10151-018-1906-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 12/07/2018] [Indexed: 12/11/2022]
Abstract
The French National Society of Coloproctology established national recommendations for the treatment of anoperineal lesions associated with Crohn's disease. Treatment strategies for acute abscesses, active fistulas (active denovo and still active under treatment), fistulas in remission, and rectovaginal fistulas are suggested. Recommendations have been graded following the international recommendations, and when absent, professional agreement has been established. For each situation, practical algorithms have been drawn.
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Affiliation(s)
- D Bouchard
- Hôpital Bagatelle, 203 Route de Toulouse, 33401, Talence Cedex, France.
| | - F Pigot
- Hôpital Bagatelle, 203 Route de Toulouse, 33401, Talence Cedex, France
| | - G Staumont
- Clinique Saint Jean du Languedoc, 20 Route de Revel, 31400, Toulouse, France
| | - L Siproudhis
- Centre Hospitalier Universitaire, 35033, Rennes Cedex 9, France
| | - L Abramowitz
- Centre Hospitalier Universitaire Bichat, 75877, Paris, France
| | - P Benfredj
- Hôpital Saint Joseph, 185 Rue Raymond Losserand, 75014, Paris, France
| | - C Brochard
- Centre Hospitalier Universitaire, 35033, Rennes Cedex 9, France
| | - N Fathallah
- Hôpital Saint Joseph, 185 Rue Raymond Losserand, 75014, Paris, France
| | - J-L Faucheron
- Centre Hospitalier Universitaire Grenoble-Alpes, Avenue Maquis du Grésivaudan, 38700, La Tronche, France
| | - T Higuero
- , 11 Boulevard du Général Leclerc, 06240, Beausoleil, France
| | - Y Panis
- Hôpital Beaujon, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - V de Parades
- Hôpital Saint Joseph, 185 Rue Raymond Losserand, 75014, Paris, France
| | - B Vinson-Bonnet
- Hôpital de Poissy-Saint Germain en Laye, 10 Rue Champ Gaillard, 78300, Poissy, France
| | - D Laharie
- Centre Hospitalier Universitaire Haut Lévêque, Avenue Magellan, 33604, Pessac Cedex, France
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Bermejo F, Guerra I, Algaba A, López-Sanromán A. Pharmacological Approach to the Management of Crohn's Disease Patients with Perianal Disease. Drugs 2018; 78:1-18. [PMID: 29139091 DOI: 10.1007/s40265-017-0842-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Perianal localization of Crohn's disease involves significant morbidity, affects quality of life and results in an increased use of healthcare resources. Medical and surgical therapies contribute to its management. The objective of this review is to address the current understanding in the management of perianal Crohn's disease, with the main focus in reviewing pharmacological therapies, including stem cells. In complex fistulas, once local sepsis has been controlled by surgical drainage and/or antibiotics, anti-TNF drugs (infliximab, adalimumab) are the first-line therapy, with or without associated immunomodulators. Combining surgery and anti-TNF therapy has additional benefits for healing. However, response is inadequate in up to half of cases. A possible role of new biological drugs in this context (vedolizumab, ustekinumab) is an area of ongoing investigation, as is the local application of autologous or allogeneic mesenchymal stem cells. These are non-hematopoietic multipotent cells with anti-inflammatory and immunomodulatory properties, the use of which may successfully treat refractory patients, and seem to be a promising and safe alternative to achieving fistula healing in Crohn's disease, without known systemic effects.
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Affiliation(s)
- Fernando Bermejo
- Department of Gastroenterology, University Hospital of Fuenlabrada, Madrid, Spain. .,Department of Medicine and Surgery, Universidad Rey Juan Carlos, Madrid, Spain.
| | - Iván Guerra
- Department of Gastroenterology, University Hospital of Fuenlabrada, Madrid, Spain
| | - Alicia Algaba
- Department of Gastroenterology, University Hospital of Fuenlabrada, Madrid, Spain
| | - Antonio López-Sanromán
- Department of Gastroenterology and Hepatology, University Hospital Ramón y Cajal, Madrid, Spain
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Yan X, Zhu M, Feng Q, Yan Y, Peng J, Xu X, Xu A, Ran Z. Evaluating the effectiveness of infliximab on perianal fistulizing Crohn's disease by magnetic resonance imaging. Gastroenterol Rep (Oxf) 2018; 7:50-56. [PMID: 30792866 PMCID: PMC6375345 DOI: 10.1093/gastro/goy036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/11/2018] [Accepted: 07/05/2018] [Indexed: 12/23/2022] Open
Abstract
Background and aim Data on the radiologic evaluation of perianal fistulizing Crohn’s disease (PFCD) naïve to anti-tumor necrosis factor therapy are scarce, especially in Asian populations. We assessed the effectiveness of infliximab (IFX) on PFCD and explored predictors of ‘deep remission’ based on clinical and radiologic assessments. Methods Patients with Crohn’s disease and active anal fistulas attending our care center for IFX therapy were prospectively enrolled. Each patient underwent clinical examination according to the Fistula Drainage Assessment Index, endoscopy for assessment of Crohn’s Disease Activity Index (CDAI) and Perianal Crohn’s Disease Activity Index (PCDAI), magnetic resonance imaging (MRI) to determine Van Assche score and Ng score, and laboratory tests up to 2 weeks prior to the start of and up to 2 weeks after the sixth IFX therapy (Week 32). Results Among 38 patients treated with IFX, 52.6% achieved clinical remission based on the Fistula Drainage Assessment Index and 42.1% achieved deep remission based on Ng score. Van Assche score (from 14.5 ± 4.26 to 7.36 ± 7.53), CDAI (from 170 ± 92 to 71 ± 69) and PCDAI (from 7.45 ± 2.65 to 2.44 ± 3.20) decreased significantly after six IFX treatments. The only predictor of deep remission was simple fistula (P = 0.004, odds ratio = 3.802, 95% confidence interval: 1.541–9.383). Conclusions IFX has been shown to have appreciable effectiveness in Chinese patients with PFCD. MRI is the gold standard for evaluating PFCD, but Van Assche score has some limitations.
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Affiliation(s)
- Xiaohan Yan
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health; Shanghai Inflammatory Bowel Disease Research Center; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mingming Zhu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health; Shanghai Inflammatory Bowel Disease Research Center; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qi Feng
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yunqi Yan
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jiangchen Peng
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health; Shanghai Inflammatory Bowel Disease Research Center; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xitao Xu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health; Shanghai Inflammatory Bowel Disease Research Center; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Antao Xu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health; Shanghai Inflammatory Bowel Disease Research Center; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhihua Ran
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health; Shanghai Inflammatory Bowel Disease Research Center; Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Steinhart AH, Panaccione R, Targownik L, Bressler B, Khanna R, Marshall JK, Afif W, Bernstein CN, Bitton A, Borgaonkar M, Chauhan U, Halloran B, Jones J, Kennedy E, Leontiadis GI, Loftus EV, Meddings J, Moayyedi P, Murthy S, Plamondon S, Rosenfeld G, Schwartz D, Seow CH, Williams C. Clinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn's Disease: The Toronto Consensus. J Can Assoc Gastroenterol 2018; 1:141-154. [PMID: 31799497 DOI: 10.1093/jcag/gwy047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Fistulas occur in about 25% of patients with Crohn's disease (CD) and can be difficult to treat. The aim of this consensus was to provide guidance for the management of patients with perianal fistulizing CD. Methods A systematic literature search identified studies on the management of fistulizing CD. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform using a modified Delphi process, then finalized, and voted on by a group of specialists. Results The quality of evidence for treatment of fistulizing CD was generally of very low quality, and because of the scarcity of good randomized controlled trials (RCTs), these consensus statements generally provide conditional suggestions (5 of 7 statements). Imaging and surgical consultations were recommended in the initial assessment of patients with active fistulizing CD, particularly those with complicated disease. Antibiotic therapy is useful for initial symptom control. Antitumor necrosis factor (anti-TNF) therapy was recommended to induce symptomatic response, and continued use was suggested to achieve and maintain complete remission. The use of concomitant immunosuppressant therapies may be useful to optimize pharmacokinetic parameters when initiating anti-TNF therapy. When there has been an inadequate symptomatic response to medical management strategies, surgical therapy may provide effective fistula healing for some patients. Conclusions Optimal management of perianal fistulizing CD requires a collaborative effort between gastroenterologists and surgeons and may include the evidence-based use of existing therapies, as well as surgical assessments and interventions when needed.
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Affiliation(s)
- A Hillary Steinhart
- Division of Gastroenterology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Remo Panaccione
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Laura Targownik
- Section of Gastroenterology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brian Bressler
- Department of Medicine, Division of Gastroenterology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Reena Khanna
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Waqqas Afif
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Charles N Bernstein
- Section of Gastroenterology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mark Borgaonkar
- Faculty of Medicine, Memorial University, St John's, Newfoundland, Canada
| | - Usha Chauhan
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Brendan Halloran
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Erin Kennedy
- Division of General Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Edward V Loftus
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan Meddings
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Moayyedi
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sanjay Murthy
- Division of Gastroenterology, University of Ottawa, Ottawa, Ontario, Canada
| | - Sophie Plamondon
- Department of Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Greg Rosenfeld
- Division of Gastroenterology, Pacific Gastroenterology Associates, Vancouver, British Columbia, Canada
| | - David Schwartz
- Inflammatory Bowel Disease Center, Vanderbilt University, Nashville, Tennessee, USA
| | - Cynthia H Seow
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Chadwick Williams
- Division of Digestive Care & Endoscopy, Department of Medicine, Dartmouth General Hospital, Halifax, Nova Scotia, Canada
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Tozer PJ, Lung P, Lobo AJ, Sebastian S, Brown SR, Hart AL, Fearnhead N. Review article: pathogenesis of Crohn's perianal fistula-understanding factors impacting on success and failure of treatment strategies. Aliment Pharmacol Ther 2018; 48:260-269. [PMID: 29920706 DOI: 10.1111/apt.14814] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 01/22/2018] [Accepted: 04/30/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Evidence from groups who have studied fistula aetiology and extrapolation from interventional studies supports a multifactorial hypothesis of Crohn's perianal fistula, with several pathophysiological elements that may contribute to fistula formation, persistence and resistance to treatment. AIM An evidence synthesis of current understanding of pathophysiological factors underlying Crohn's perianal fistula is presented, exploring the fundamental reasons why some treatments succeed and others fail, as a means of focussing clinical knowledge on improving treatment of Crohn's perianal fistula. METHODS Evidence to support this review was gathered via the Pubmed database. Studies discussing pathophysiological factors underpinning perianal fistula, particularly in Crohn's disease, were reviewed and cross-referenced for additional reports. RESULTS Pathophysiological factors that impact on success or failure of interventions for Crohn's perianal fistulae include the high-pressure zone, obliterating the dead space, disconnecting the track from the anus, removing epithelialisation, eradicating sepsis and by-products of bacterial colonisation, correcting abnormalities in wound repair and removing the pro-inflammatory environment which allows fistula persistence. Most current interventions for Crohn's perianal fistulae tend to focus on a single, or at best two, aspects of the pathophysiology of Crohn's anal fistulae; as a result, failure to heal fully is common. CONCLUSIONS For an intervention or combination of interventions to succeed, multiple factors must be addressed. We hypothesise that correct, timely and complete attention to all of these factors in a multimodal approach represents a new direction that may enable the creation of an effective treatment algorithm for Crohn's anal fistula.
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Affiliation(s)
- P J Tozer
- St Mark's Hospital and Imperial College London, London, UK
| | - P Lung
- St Mark's Hospital and Imperial College London, London, UK
| | - A J Lobo
- Academic Unit of Gastroenterology, University of Sheffield, Sheffield, UK
| | - S Sebastian
- IBD Unit, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - S R Brown
- Sheffield Teaching Hospitals, Sheffield, UK
| | - A L Hart
- St Mark's Hospital and Imperial College London, London, UK
| | - N Fearnhead
- Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Williams G, Williams A, Tozer P, Phillips R, Ahmad A, Jayne D, Maxwell-Armstrong C. The treatment of anal fistula: second ACPGBI Position Statement - 2018. Colorectal Dis 2018; 20 Suppl 3:5-31. [PMID: 30178915 DOI: 10.1111/codi.14054] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 02/16/2018] [Indexed: 02/08/2023]
Abstract
It is over 10 years since the first ACPGBI Position Statement on the management of anal fistula was published in 2007. This second edition is the result of scrutiny of the literature published during this time; it updates the original Position Statement and reviews the published evidence surrounding treatments for anal fistula that have been developed since the original publication.
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Affiliation(s)
- G Williams
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - A Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - P Tozer
- St Mark's Hospital, Harrow, London, UK
| | | | - A Ahmad
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Jayne
- University of Leeds, Leeds, UK
| | - C Maxwell-Armstrong
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
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40
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Gallego JC, Echarri A. Role of magnetic resonance imaging in the management of perianal Crohn's disease. Insights Imaging 2018; 9:47-58. [PMID: 29143190 PMCID: PMC5825308 DOI: 10.1007/s13244-017-0579-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 09/05/2017] [Accepted: 09/26/2017] [Indexed: 12/18/2022] Open
Abstract
Perianal fistulas are a major problem in many patients with Crohn's disease. These are usually complex fistulas that adversely affect patients' quality of life, and their clinical management is difficult. Medical treatment sometimes achieves cessation of discharge and closure of the external opening; however, it is difficult to assess the status of the rest of the fistula tract. Magnetic resonance imaging is the method of choice with which to evaluate the condition of perianal fistulas and allows for assessment of the status of inaccessible areas. Magnetic resonance imaging also allows the clinician to evaluate other perianal manifestations of Crohn's disease that differ from the fistulas. This imaging technique is therefore a fundamental means of patient monitoring. When used in conjunction with assessment of the patient's morphological findings, it provides information that allows for both quantification of disease severity and evaluation of the response to treatment. New types of magnetic resonance sequences are emerging, such as diffusion, perfusion, and magnetisation transfer. These sequences may serve as biomarkers because they provide information reflecting the changes taking place at the molecular level. This will help to shape a new scenario in the early assessment of the response to treatments such as anti-tumour necrosis factor drugs. TEACHING POINTS • MRI is the method of choice with which to evaluate perianal fistulas. • In perianal Crohn's disease, MRI is a fundamental means of patient monitoring. • The usefulness of the Van Assche score for patient monitoring remains unclear. • New MRI sequences' diffusion, perfusion, and magnetisation transfer may serve as biomarkers.
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Affiliation(s)
- Jose C Gallego
- Department of Radiology, Complexo Hospitalario Universitario de Ferrol, Av. da Residencia s/n, 15405, Ferrol, Spain.
| | - Ana Echarri
- Department of Gastroenterology, Complexo Hospitalario Universitario de Ferrol, Ferrol, Spain
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Lefrançois P, Zummo-Soucy M, Olivié D, Billiard JS, Gilbert G, Garel J, Visée E, Manchec P, Tang A. Diagnostic performance of intravoxel incoherent motion diffusion-weighted imaging and dynamic contrast-enhanced MRI for assessment of anal fistula activity. PLoS One 2018; 13:e0191822. [PMID: 29370278 PMCID: PMC5784995 DOI: 10.1371/journal.pone.0191822] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 01/11/2018] [Indexed: 12/14/2022] Open
Abstract
Objective To evaluate intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) sequences for quantitative characterization of anal fistula activity. Methods This retrospective study was approved by the institutional review board. One hundred and two patients underwent MRI for clinical suspicion of anal fistula. Forty-three patients with demonstrable anal fistulas met the inclusion criteria. Quantitative analysis included measurement of DCE and IVIM parameters. The reference standard was clinical activity based on medical records. Statistical analyses included Bayesian analysis with Markov Chain Monte Carlo, multivariable logistic regression, and receiver operating characteristic analyses. Results Brevity of enhancement, defined as the time difference between the wash-in and wash-out, was longer in active than inactive fistulas (p = 0.02). Regression coefficients of multivariable logistic regression analysis revealed that brevity of enhancement increased and normalized perfusion area under curve decreased with presence of active fistulas (p = 0.03 and p = 0.04, respectively). By cross-validation, a logistic regression model that included quantitative perfusion parameters (DCE and IVIM) performed significantly better than IVIM only (p < 0.001). Area under the curves for distinguishing patients with active from those with inactive fistulas were 0.669 (95% confidence interval [CI]: 0.500, 0.838) for a model with IVIM only, 0.860 (95% CI: 0.742, 0.977) for a model with IVIM and brevity of enhancement, and 0.921 (95% CI: 0.846, 0.997) for a model with IVIM and all DCE parameters. Conclusion The inclusion of brevity of enhancement measured by DCE-MRI improved assessment of anal fistula activity over IVIM-DWI only.
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Affiliation(s)
- Philippe Lefrançois
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Mathieu Zummo-Soucy
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Damien Olivié
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Jean-Sébastien Billiard
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Guillaume Gilbert
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
- MR Clinical Science, Philips Healthcare Canada, Markham, Ontario, Canada
| | - Juliette Garel
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Emmanuel Visée
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
- Centre Hospitalier Départemental de Vendée, Les Oudairies, La Roche-Sur-Yon, France
| | - Perrine Manchec
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
- Norimagerie, 1,3 chemin du Penthod, Caluire et Cuire, France
| | - An Tang
- Department of Radiology, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
- * E-mail:
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Doherty G, Katsanos KH, Burisch J, Allez M, Papamichael K, Stallmach A, Mao R, Berset IP, Gisbert JP, Sebastian S, Kierkus J, Lopetuso L, Szymanska E, Louis E. European Crohn's and Colitis Organisation Topical Review on Treatment Withdrawal ['Exit Strategies'] in Inflammatory Bowel Disease. J Crohns Colitis 2018; 12:17-31. [PMID: 28981623 DOI: 10.1093/ecco-jcc/jjx101] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 07/31/2017] [Indexed: 12/12/2022]
Abstract
Clinically effective therapies now exist for remission maintenance in both ulcerative colitis [UC] and Crohn's Disease [CD]. For each major class of IBD medications [5-aminosalicyclates, immunomodulators, and biologic agents], used alone or in combination, there is a risk of relapse following reduction or cessation of treatment. A consensus expert panel convened by the European Crohn's and Colitis Organisation [ECCO] reviewed the published literature and agreed a series of consensus practice points. The objective of the expert consensus is to provide evidence-based guidance for clinical practice so that physicians can make informed decisions in partnership with their patients. The likelihood of relapse with stopping each class of IBD medication is reviewed. Factors associated with an altered risk of relapse with withdrawal are evaluated, and strategies to monitor and allow early identification of relapse are considered. In general, patients in clinical, biochemical, and endoscopic remission are more likely to remain well when treatments are stopped. Reintroduction of the same treatment is usually, but not always, successful. The decision to stop a treatment needs to be individualized, and shared decision making with the patient should take place.
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Affiliation(s)
- Glen Doherty
- Centre for Colorectal Disease, St Vincent's University Hospital & University College Dublin, Dublin, Ireland
| | - Konstantinos H Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital, Frederikssund, Denmark
| | - Matthieu Allez
- Department of Gastroenterology and Hepatology, Hôpital Saint-Louis, APHP, INSERM UMRS 1160, Université Denis Diderot, Paris, France
| | | | - Andreas Stallmach
- Department of Internal Medicine IV [Gastroenterology, Hepatology and Infectious Disease], University Hospital Jena, Jena, Germany
| | - Ren Mao
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ingrid Prytz Berset
- Gastroenterology Department, Alesund Hospital, Helse More Romsdal Hospital Trust, Alesund, Norway
| | - Javier P Gisbert
- Department of Gastroenterology, Hospital Universitario de la Princesa, Instituto de Investigaciun Sanitaria Princesa (IIS-IP) and Centro de Investigaciun Biomédica en Red de Enfermedades Heprticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Shaji Sebastian
- IBD Unit, Department of Gastroenterology, Hull & East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Jaroslaw Kierkus
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, Children's Memorial Health Institute, Warsaw, Poland
| | - Loris Lopetuso
- Department of Gastroenterology and Internal Medicine, Catholic University of Rome-A. Gemelli Hospital, Rome, Italy
| | - Edyta Szymanska
- Department of Pediatrics, Nutrition, and Metabolic Disorders, Children's Memorial Health Institute, Warsaw, Poland
| | - Edouard Louis
- Department of Gastroenterology, CHU Liège, Sart Tilman, Liège, Belgium
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Lung PFC, Ng SC. Editorial: challenges in the development of a magnetic resonance imaging index for fistulising Crohn's disease. Aliment Pharmacol Ther 2017; 46:696. [PMID: 28880442 DOI: 10.1111/apt.14235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- P F C Lung
- Department of Radiology, St Mark's Hospital, Middlesex, Harrow, UK
| | - S C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong
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44
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Anoperineal lesions in Crohn's disease: French recommendations for clinical practice. Tech Coloproctol 2017; 21:683-691. [PMID: 28929282 DOI: 10.1007/s10151-017-1684-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/13/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anoperineal lesion (APL) occurrence is a significant event in the evolution of Crohn's disease (CD). Management should involve a multidisciplinary approach combining the knowledge of the gastroenterologist, the colorectal surgeon and the radiologist who have appropriate experience in this area. Given the low level of evidence of available medical and surgical strategies, the aim of this work was to establish a French expert consensus on management of anal Crohn's disease. These recommendations were led under the aegis of the Société Nationale Française de Colo-Proctologie (SNFCP). They report a consensus on the management of perianal Crohn's disease lesions, including fistulas, ulceration and anorectal stenosis and propose an appropriate treatment strategy, as well as sphincter-preserving and multidisciplinary management. METHODOLOGY A panel of French gastroenterologists and colorectal surgeons with expertise in inflammatory bowel diseases reviewed the literature in order to provide practical management pathways for perianal CD. Analysis of the literature was made according to the recommendations of the Haute Autorité de Santé (HAS) to establish a level of proof for each publication and then to propose a rank of recommendation. When lack of factual data precluded ranking according to the HAS, proposals based on expert opinion were written. Therefore, once all the authors agreed on a consensual statement, it was then submitted to all the members of the SNFCP. As initial literature review stopped in December 2014, more recent European or international guidelines have been published since and were included in the analysis. RESULTS MRI is recommended for complex secondary lesions, particularly after failure of previous medical and/or surgical treatments. For severe anal ulceration in Crohn's disease, maximal medical treatment with anti-TNF agent is recommended. After prolonged drainage of simple anal fistula by a flexible elastic loop or loosely tied seton, and after obtaining luminal and perineal remission by immunosuppressive therapy and/or anti-TNF agents, the surgical treatment options to be discussed are simple seton removal or injection of the fistula tract with biological glue. After prolonged loose-seton drainage of the complex anal fistula in Crohn's disease, and after obtaining luminal and perineal remission with anti-TNF ± immunosuppressive therapy, surgical treatment options are simple removal of seton and rectal advancement flap. Colostomy is indicated as a last option for severe APL, possibly associated with a proctectomy if there is refractory rectal involvement after failure of other medical and surgical treatments. The evaluation of anorectal stenosis of Crohn's disease (ARSCD) requires a physical examination, sometimes under anesthesia, plus endoscopy with biopsies and MRI to describe the stenosis itself, to identify associated inflammatory, infectious or dysplastic lesions, and to search for injury or fibrosis of the sphincter. Therapeutic strategy for ARSCD requires medical-surgical cooperation.
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Thomassin L, Armengol-Debeir L, Charpentier C, Bridoux V, Koning E, Savoye G, Savoye-Collet C. Magnetic resonance imaging may predict deep remission in patients with perianal fistulizing Crohn's disease. World J Gastroenterol 2017; 23:4285-4292. [PMID: 28694669 PMCID: PMC5483503 DOI: 10.3748/wjg.v23.i23.4285] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 04/03/2017] [Accepted: 05/09/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To evaluate the imaging course of Crohn’s disease (CD) patients with perianal fistulas on long-term maintenance anti-tumor necrosis factor (TNF)-α therapy and identify predictors of deep remission.
METHODS All patients with perianal CD treated with anti-TNF-α therapy at our tertiary care center were evaluated by magnetic resonance imaging (MRI) and clinical assessment. Two MR examinations were performed: at initiation of anti-TNF-α treatment and then at least 2 years after. Clinical assessment (remission, response and non-response) was based on Present’s criteria. Rectoscopic patterns, MRI Van Assche score, and MRI fistula activity signs (T2 signal and contrast enhancement) were collected for the two MR examinations. Fistula healing was defined as the absence of T2 hyperintensity and contrast enhancement on MRI. Deep remission was defined as the association of both clinical remission, absence of anal canal ulcers and healing on MRI. Characteristics and imaging patterns of patients with and without deep remission were compared by univariate and multivariate analyses.
RESULTS Forty-nine consecutive patients (31 females and 18 males) were included. They ranged in age from 14-70 years (mean, 33 years). MRI and clinical assessment were performed after a mean period of exposure to anti-TNF-α therapy of 40 ± 3.7 mo. Clinical remission, response and non-response were observed in 53.1%, 20.4%, and 26.5% of patients, respectively. Deep remission was observed in 32.7% of patients. Among the 26 patients in clinical remission, 10 had persisting inflammation of fistulas on MRI (T2 hyperintensity, n = 7; contrast enhancement, n = 10). Univariate analysis showed that deep remission was associated with the absence of rectal involvement and the absence of switch of anti-TNF-α treatment or surgery requirement. Multivariate analysis demonstrated that only the absence of rectal involvement (OR = 4.6; 95%CI: 1.03-20.5) was associated with deep remission.
CONCLUSION Deep remission is achieved in approximately one third of patients on maintenance anti-TNF-α therapy. Absence of rectal involvement is predictive of deep remission.
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Deepak P, Park SH, Ehman EC, Hansel SL, Fidler JL, Bruining DH, Fletcher JG. Crohn's disease diagnosis, treatment approach, and management paradigm: what the radiologist needs to know. Abdom Radiol (NY) 2017; 42:1068-1086. [PMID: 28210767 DOI: 10.1007/s00261-017-1068-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Crohn's disease is one of the major subtypes of idiopathic inflammatory bowel disease and is characterized by chronic transmural intestinal inflammation of the gastrointestinal tract anywhere from mouth to the anus, with a predilection for the small bowel. Cross-sectional imaging with computed tomography and magnetic resonance enterography plays a key role in confirming diagnosis, identifying and managing complications, assessing disease severity, and identifying response to medical therapy. This review will focus on the role of radiologists in the diagnosis and assessment of Crohn's disease. Additionally, a review of current medical therapy approaches, available medications, and side effects will be discussed. The review will also highlight key complications of medical therapy and associated diseases that should be evaluated by the radiologist with cross-sectional imaging.
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Affiliation(s)
- Parakkal Deepak
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Sang Hyoung Park
- Department of Gastroenterology, Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Eric C Ehman
- Division of Abdominal Imaging, Mayo Clinic College of Medicine, 200 First Street, SW, Rochester, MN, 55905, USA
| | - Stephanie L Hansel
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Jeff L Fidler
- Division of Abdominal Imaging, Mayo Clinic College of Medicine, 200 First Street, SW, Rochester, MN, 55905, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Joel G Fletcher
- Division of Abdominal Imaging, Mayo Clinic College of Medicine, 200 First Street, SW, Rochester, MN, 55905, USA.
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Rayen J, Currie T, Gearry RB, Frizelle F, Eglinton T. The long-term outcome of anti-TNF alpha therapy in perianal Crohn's disease. Tech Coloproctol 2017; 21:119-124. [PMID: 28066859 DOI: 10.1007/s10151-016-1578-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 12/07/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND The aim of the present study was to evaluate the long-term outcomes of anti-tumour necrosis factor alpha therapy in perianal Crohn's disease and identify factors predicting response to treatment. METHODS Data from hospital clinical records and coding databases were retrospectively reviewed from a tertiary care hospital in Christchurch, New Zealand. The study included 75 adult patients with perianal Crohn's disease commenced on anti-tumour necrosis factor alpha therapy from January 2000 to December 2012. Response to treatment was determined from records relating to clinical evaluation, magnetic resonance imaging follow-up and whether further surgical intervention was required. RESULTS 73% (55) of all patients and 38 of the 57 (67%) patients with perianal fistulas responded to anti-tumour necrosis factor alpha therapy. Patients with complex fistulas were less likely to improve as compared to patients without fistulising disease. Five of the 57 (13%) patients with perianal fistulas demonstrated complete healing on clinical evaluation; however, magnetic resonance imaging confirmed complete healing in only two. Patients that had taken antibiotics and those that had previously required abscess drainage were less likely to respond to treatment [relative risk (RR) = 0.707 and 0.615, respectively; p = 0.03, p = 0.0001]. Responders were less likely to require follow-up surgery (RR = 0.658, p = 0.014) including ileostomy or proctectomy. CONCLUSIONS Although anti-tumour necrosis factor alpha tends to improve symptoms of perianal Crohn's disease, in the long term, it rarely achieves complete healing. Perianal fistulising disease, a history of perianal abscess and antibiotic treatment are predictors of poor response to therapy.
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Affiliation(s)
- J Rayen
- Department of Surgery, Middlemore Hospital, Auckland, New Zealand.
| | - T Currie
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - R B Gearry
- Department of Gastroenterology, Christchurch Hospital, Christchurch, New Zealand
| | - F Frizelle
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - T Eglinton
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
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Aguilera-Castro L, Ferre-Aracil C, Garcia-Garcia-de-Paredes A, Rodriguez-de-Santiago E, Lopez-Sanroman A. Management of complex perianal Crohn's disease. Ann Gastroenterol 2016; 30:33-44. [PMID: 28042236 PMCID: PMC5198245 DOI: 10.20524/aog.2016.0099] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 09/21/2016] [Indexed: 12/11/2022] Open
Abstract
Patients with Crohn's disease often develop perianal disease, successfully managed in most cases. However, its most aggressive form, complex perianal disease, is associated with high morbidity and a significant impairment in patients' quality of life. The aim of this review is to provide an updated approach to this condition, reviewing aspects of its epidemiology, diagnosis and therapeutic alternatives. Emerging treatment options are also discussed. A multidisciplinary assessment of these patients with a coordinated medical and surgical approach is crucial.
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Affiliation(s)
- Lara Aguilera-Castro
- Gastroenterology and Hepatology Department, University Hospital Ramón y Cajal (affiliated with Universidad de Alcalá), Madrid, Spain
| | - Carlos Ferre-Aracil
- Gastroenterology and Hepatology Department, University Hospital Ramón y Cajal (affiliated with Universidad de Alcalá), Madrid, Spain
| | - Ana Garcia-Garcia-de-Paredes
- Gastroenterology and Hepatology Department, University Hospital Ramón y Cajal (affiliated with Universidad de Alcalá), Madrid, Spain
| | - Enrique Rodriguez-de-Santiago
- Gastroenterology and Hepatology Department, University Hospital Ramón y Cajal (affiliated with Universidad de Alcalá), Madrid, Spain
| | - Antonio Lopez-Sanroman
- Gastroenterology and Hepatology Department, University Hospital Ramón y Cajal (affiliated with Universidad de Alcalá), Madrid, Spain
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Tutein Nolthenius CJ, Bipat S, Mearadji B, Spijkerboer AM, Ponsioen CY, Montauban van Swijndregt AD, Stoker J. MRI characteristics of proctitis in Crohn's disease on perianal MRI. Abdom Radiol (NY) 2016; 41:1918-30. [PMID: 27315072 PMCID: PMC5018025 DOI: 10.1007/s00261-016-0802-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose Multiple features have been described for assessing inflammation in Crohn’s disease (CD) in MR enterography, but have not been validated in perianal magnetic resonance imaging (MRI). Retrospectively, we studied which MRI features are valuable in assessing proctitis. Materials and methods CD patients (≥18 years) who underwent colonoscopy (reference standard) and perianal fistula MRI within 8 weeks were included. Seventeen MRI features were blindly scored by three observers and correlated to endoscopy (regression analysis). Reproducibility (multirater kappa, intraclass correlation coefficient) was determined for all three observer pairs. MRI features were considered relevant when significantly correlated to endoscopy for ≥2 observers, and reproducibility was ≥0.40 for ≥2 observer pairs. Results Perianal MRI of 58 CD patients were included. Wall thickness, rectal mural fat, creeping fat, and size of mesorectal lymph nodes showed a significant correlation with endoscopy for ≥2 observers (p = 0.000–0.023, p = 0.011–0.172, p = 0.007–0.011 and p = 0.000–0.005, respectively) with a kappa/intraclass correlation coefficient of ≥0.60 for ≥2 observer pairs. Perimural T2 signal and perimural enhancement significantly correlated to endoscopy (all p values ≤0.05) for all three observers and the reproducibility was ≥0.40 for ≥2 observer pairs. Mural T2 signal and degree and pattern of T1 enhancement showed significant correlation to endoscopy for two observers, but with poor to moderate reproducibility. Conclusion Wall thickness, mural fat, and mesorectal features (perimural T2 signal, perimural enhancement, creeping fat, and size of mesorectal lymph nodes) had significant correlation to endoscopy and were reproducible in diagnosing proctitis. Some established luminal features in MRE were considered not useful.
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Affiliation(s)
- Charlotte J Tutein Nolthenius
- Department of Radiology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
- Department of Radiology, OLVG, PO Box 99550, 1090 HM, Amsterdam, The Netherlands.
| | - Shandra Bipat
- Department of Radiology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Banafsche Mearadji
- Department of Radiology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Anje M Spijkerboer
- Department of Radiology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 DE, Amsterdam, The Netherlands
| | | | - Jaap Stoker
- Department of Radiology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
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Dohan A, Taylor S, Hoeffel C, Barret M, Allez M, Dautry R, Zappa M, Savoye-Collet C, Dray X, Boudiaf M, Reinhold C, Soyer P. Diffusion-weighted MRI in Crohn's disease: Current status and recommendations. J Magn Reson Imaging 2016; 44:1381-1396. [PMID: 27249184 DOI: 10.1002/jmri.25325] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 05/12/2016] [Indexed: 12/19/2022] Open
Abstract
Over the past years, technological improvements and refinements in magnetic resonance imaging (MRI) hardware have made high-quality diffusion-weighted imaging (DWI) routinely possible for the bowel. DWI is promising for the detection and characterization of lesions in Crohn's disease (CD) and has been advocated as an alternative to intravenous gadolinium-based contrast agents. Furthermore, quantification using the apparent diffusion coefficient may have value as a biomarker of CD activity and has shown promise. In this article we critically review the literature pertaining to the value of DWI in CD for detection, characterization, and quantification of disease activity and complications. Although the body of supportive evidence is growing, it is clear that well-designed, multicenter studies are required before the role of DWI in clinical practice can be fully established. J. Magn. Reson. Imaging 2016;44:1381-1396.
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Affiliation(s)
- Anthony Dohan
- McGill University Health Center, Department of Radiology, McGill University Health Center, Montreal, QC, Canada
- Department of Body and Interventional Imaging, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
- INSERM UMR 965, Paris, France
| | - Stuart Taylor
- Centre for Medical Imaging, University College London, Podium Level 2, University College Hospital, London, UK
| | | | - Maximilien Barret
- Department of Gastroenterology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Matthieu Allez
- Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
- Department of Gastroenterology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Raphael Dautry
- Department of Body and Interventional Imaging, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Magaly Zappa
- Department of Radiology, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | | | - Xavier Dray
- Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
- Department of Gastroenterology, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mourad Boudiaf
- Department of Body and Interventional Imaging, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Caroline Reinhold
- McGill University Health Center, Department of Radiology, McGill University Health Center, Montreal, QC, Canada
| | - Philippe Soyer
- Department of Body and Interventional Imaging, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
- INSERM UMR 965, Paris, France
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