Papel da ultrassonografia endoscópica na avaliação da fístula perianal na doença de Crohn

The Use of Endoscopic Ultrasonography in Inflammatory Bowel Disease: A Review of the Literature

The diagnosis of inflammatory bowel disease (IBD) can sometimes be challenging. By corroborating clinical, imaging and histological data, the two main entities of IBD, ulcerative colitis and Crohn's disease (CD), can be differentiated in most cases. However, there remains 10-20% of patients where the diagnosis cannot be accurately established, in which case the term "IBD unclassified" is used. The imaging techniques most used to evaluate patients with IBD include colonoscopy, ultrasonography and magnetic resonance imaging. Endoscopic ultrasonography is mainly recommended for the evaluation of perianal CD. Through this work, we aim to identify other uses of this method in the case of patients with IBD.

Consistency of Trans-Abdominal and Water-Immersion Ultrasound Images of Diseased Intestinal Segments in Crohn's Disease

The aim of this study is to clarify whether trans-abdominal ultrasound (TAUS) can reflect actual intestinal conditions in Crohn’s disease (CD) as effectively as water-immersion ultrasound (WIUS) does. This retrospective study enrolled 29 CD patients with 113 intestinal lesions. Five ultrasound (US) parameters (distinct presence/indistinct presence/disappearance of wall stratification in the submucosal and mucosal layers; thickened submucosal layer; irregular mucosal surface; increased fat wrapping around the bowel wall; and fistula signs) that may indicate different states in CD were determined by TAUS and WIUS for the same lesion. Using WIUS as a reference standard, the sensitivity, specificity, and accuracy of TAUS were calculated. The degree of agreement between TAUS and WIUS was evaluated by the kappa coefficient. All US parameters of TAUS had an accuracy >70% (72.6–92.7%). The highest efficacy of TAUS was obtained for fistula signs (sensitivity, specificity, and accuracy values were 63.6%, 96.0%, and 92.7%, respectively). All US parameters between TAUS and WIUS had a definitive (p ≤ 0.001) and moderate-to-substantial consistency (kappa value = 0.446–0.615). The images of TAUS showed substantial similarity to those of WIUS, suggesting that TAUS may function as a substitute to evaluate the actual intestinal conditions of CD.

Magnetic resonance imaging findings in patients with initial manifestations of perianal fistulas

BACKGROUND

Crohn's disease (CD) is a serious cause of perianal disease and the incidence is increasing in Saudi Arabia. MR imaging may document specific features that may help to foresee Crohn's disease in patients making an initial presentation.

OBJECTIVE

Present MR imaging findings of perianal fistulas in patients making an initial presentation.

DESIGN

Retrospective, observational.

SETTING

Radiology clinic in in Dhahran.

PATIENTS AND METHODS

All previously undiagnosed and untreated patients who presented for the first time to the outpatient clinics from September 2015-2018 with perianal fistulas were retrospectively evaluated. Previously diagnosed CD patients, post-surgical or intervention cases were excluded. Fistulas were categorized as low or high anal, simple or complex, and were graded per St. James University Hospital Classification. Imaging was interpreted by two experienced readers based on the Van Assche score.

MAIN OUTCOME MEASURES

Fistula features on MR imaging and diagnosis of CD.

SAMPLE SIZE

171 patients.

RESULTS

Of 171 patients, 139 (81.3%) were males with mean age of 37.2 (12.7) years; the 32 females had a mean age of 35.8 (10.6) years. Twenty-one patients (12.3%) had CD. Fourteen (40.4%) patients with complex fistulas had CD in comparison to only 5 (4.8%) simple fistula patients ( P=.0005). More than half of patients with complex and high anal fistulas had CD ( P=.0005). Females were more affected than males ( P=.0005).

CONCLUSION

Complex or high anal fistula on MR imaging may be the initial presentation of CD and warrant further work up to establish the diagnosis.

LIMITATIONS

Retrospective, small sample, single center, and short duration study.

CONFLICT OF INTEREST

None.

Anorectal Crohn's Disease

Medical treatment remains the mainstay of perianal disease management for CD; however, aggressive surgical management should be considered for severe or recurrent disease. In all cases of perianal CD, medical and surgical treatments should be used in tandem by a multidisciplinary team. Significant development has been made in the treatment of Crohn's-related fistulas, particularly minimally invasive options with recent clinical trials showing success with mesenchymal stem cell applications. Inevitably, some patients with severe refractory disease may require fecal diversion or proctectomy. When considering reversal of a diverting or end ileostomy, cessation of proctitis is the most important factor.