Radiation exposure in patients with inflammatory bowel disease--primum non nocere?

Radiation Exposure among Patients with Inflammatory Bowel Disease: A Single-Medical-Center Retrospective Analysis in Taiwan

Inflammatory bowel disease (IBD) is a chronic and relapsing disease that can be complicated by abscesses, fistulas, or strictures of the damaged bowel. Endoscopy or imaging studies are required to diagnose and monitor the treatment response or complications of the disease. Due to the low incidence of the disease in Taiwan, the pattern of radiation exposure from medical imaging has not been well studied previously. This retrospective study aimed to evaluate the pattern of radiation exposure in 134 Taiwanese IBD patients (45 CD and 89 UC) diagnosed and followed at Changhua Christian Hospital from January 2010 to December 2020. We reviewed the patient demographic data and radiation-containing image studies performed during the follow-up. The cumulative effective dose (CED) was calculated for each patient. During a median follow-up of 4 years, the median CED was higher for patients with CD (median CED 21.2, IQR 12.1−32.8) compared to patients with UC (median CED 2.1, IQR 0−5.6) (p < 0.001). In addition, the CD patients had a trend of a higher rate of cumulative ≥50 mSv compared with the UC patients (6.7% vs. 1.1%, p = 0.110). In conclusion, our study found a higher radiation exposure among CD patients compared to patients with UC, representing the complicated nature of the disease. Therefore, increasing the use of radiation-free medical imaging such as intestinal ultrasound or magnetic resonance imaging should be advocated in daily practice to decrease the risk of excessive radiation exposure in these patients.

Radiation risk issues in recurrent imaging

Millions of patients benefit from medical imaging every single day. However, we have entered an unprecedented era in imaging practices wherein 1 out of 125 patients can be exposed to effective dose >50 mSv from a single CT exam and 3 out of 10,000 patients undergoing CT exams could potentially receive cumulative effective doses > 100 mSv in a single day. Recurrent imaging with CT, fluoroscopically guided interventions, and hybrid imaging modalities such as positron emission tomography/computed tomography (PET/CT) is more prevalent today than ever before. Presently, we do not know the cumulative doses that patients may be receiving across all imaging modalities combined. Furthermore, patients with diseases with longer life expectancies are being exposed to high doses of radiation enabling radiation effects to manifest over a longer time period. The emphasis in the past on improving justification of imaging and optimization of technique and practice has proved useful. While that must continue, the current situation requires imaging device manufacturers to urgently develop imaging technologies that are safer for patients as high doses have been observed in patients where imaging has been justified through clinical decision-support and optimized by keeping doses below the national benchmark doses. There is a need to have a critical look at the fundamental principles of radiation protection as cumulative doses are likely to increase in the coming years.

First United Arab Emirates consensus on diagnosis and management of inflammatory bowel diseases: A 2020 Delphi consensus

Ulcerative colitis and Crohn's disease are the main entities of inflammatory bowel disease characterized by chronic remittent inflammation of the gastrointestinal tract. The incidence and prevalence are on the rise worldwide, and the heterogeneity between patients and within individuals over time is striking. The progressive advance in our understanding of the etiopathogenesis coupled with an unprecedented increase in therapeutic options have changed the management towards evidence-based interventions by clinicians with patients. This guideline was stimulated and supported by the Emirates Gastroenterology and Hepatology Society following a systematic review and a Delphi consensus process that provided evidence- and expert opinion-based recommendations. Comprehensive up-to-date guidance is provided regarding diagnosis, evaluation of disease severity, appropriate and timely use of different investigations, choice of appropriate therapy for induction and remission phase according to disease severity, and management of main complications.

Higher patient doses through X-ray imaging procedures

Medical imaging using X-rays has been one of the most popular imaging modalities ever since the discovery of X-rays 125 years ago. With unquestionable benefits, concerns about radiation risks have frequently been raised. Computed tomography (CT) and fluoroscopic guided interventional procedures have the potential to impart higher radiation exposure to patients than radiographic examinations. Despite technological advances, there have been instances of increased doses per procedure mainly because of better diagnostic information in images. However, cumulative dose from multiple procedures is creating new concerns as effective doses >100 mSv are not uncommon. There is a need for action at all levels. Manufacturers must produce equipment that can provide a quality diagnostic image at substantially lesser dose and better implementation of optimization strategies by users. There is an urgent need for the industry to develop CT scanners with sub-mSv radiation dose, a goal that has been lingering. It appears that a new monochromatic X-ray source will lead to replacement of X-ray tubes all over the world in coming years and will lead to a drastic reduction in radiation doses. This innovation will impact all X-ray imaging and will help dose reduction. For interventional procedures, the likely employment of robotic systems in practice may drastically reduce radiation exposures to operators- but patient exposure will still remain an issue. Training needs always need to be emphasized and practiced.

Safety and effectiveness of MRE in comparison with CTE in diagnosis of adult Crohn's disease

Background: Crohn's disease (CD) is a chronic inflammatory disease of the gastrointestinal tract that is characterized by recurrent attacks and frequent recovery. The lifelong course of this disease requires frequent assessment of the disease activity. The aim of this study was to compare the effectiveness and safety of computed tomography enterography (CTE) to magnetic resonance enterography (MRE) in adults with CD.

Methods: A systematic review of the literatures was performed to evaluate the effectiveness and safety of CTE in comparison with MRE. PubMed, Cochrane Library, Scopus, Web of Science, and Embase were searched. Effectiveness outcomes included were sensitivity, specificity, diagnosis difference, diagnostic odds ratio, and positive and negative likelihood. Quality assessment of the studies was conducted using the QADAS score. Meta-analysis was done by RevMan 5.3 for selected outcomes.

Results: Five studies had eligibility for analyzing effectiveness. The meta-analysis results showed that diagnosis difference of MRE and CTE, for diagnosing active CD (0.03 CI 95% -0.07–0.13), fistula (-0.01 CI 95% -0.09–0.07), and cramping (-0.02 CI 95% -0.1– 0.06) were not statistically significant. Six studies were finally selected for safety assessment. The results showed that people who are examined with CTE frequently are at increased risk of developing cancer significantly, as they receive more than 50 msv of radiation per year.

Conclusion: There was no significant difference between MRE and CTE in diagnosis of Crohn’s activity, detection of bowel obstruction, and detection of fistula and stenosis of the alimentary canal. However, the assessment of the safety profile of MRE and CTE showed that MRE is meaningfully safer than CTE for evaluating the recurrence of CD.

Multinational data on cumulative radiation exposure of patients from recurrent radiological procedures: call for action

OBJECTIVES

To have a global picture of the recurrent use of CT imaging to a level where cumulative effective dose (CED) to individual patients may be exceeding 100 mSv at which organ doses typically are in a range at which radiation effects are of concern METHODS: The IAEA convened a meeting in 2019 with participants from 26 countries, representatives of various organizations, and experts in radiology, medical physics, radiation biology, and epidemiology. Participants were asked to collect data prior to the meeting on cumulative radiation doses to assess the magnitude of patients above a defined level of CED.

RESULTS

It was observed that the number of patients with CED ≥ 100 mSv is much larger than previously known or anticipated. Studies were presented in the meeting with data from about 3.2 million patients who underwent imaging procedures over periods of between 1 and 5 years in different hospitals. It is probable that an additional 0.9 million patients reach the CED ≥ 100 mSv every year globally.

CONCLUSIONS

There is a need for urgent actions by all stakeholders to address the issue of high cumulative radiation doses to patients. The actions include development of appropriateness criteria/referral guidelines by professional societies for patients who require recurrent imaging studies, development of CT machines with lower radiation dose than today by manufacturers, and development of policies by risk management organizations to enhance patient radiation safety. Alert values for cumulative radiation exposures of patients should be set up and introduced in dose monitoring systems.

KEY POINTS

• Recurrent radiological imaging procedures leading to high radiation dose to patients are more common than ever before. • Tracking of radiation exposure of individual patients provides useful information on cumulative radiation dose. • There is a need for urgent actions by all stakeholders to address the issue of high cumulative radiation doses to patients.

Reliability of Measuring Ileo-Colonic Disease Activity in Crohn's Disease by Magnetic Resonance Enterography

BACKGROUND

Magnetic resonance enterography is increasingly utilized for assessment of luminal Crohn's disease activity. The Magnetic Resonance Index of Activity and the London Index are the most commonly used outcome measures in clinical trials. We assessed the reliability of these indices and several additional items.

METHODS

A consensus process clarified scoring conventions and identified additional items based on face validity. Four experienced radiologists evaluated 50 images in triplicate, in random order, at least 1 month apart, using a central image management system. Intra- and interrater reliability were assessed by calculating and comparing intraclass correlation coefficients.

RESULTS

Intrarater intraclass correlation coefficients (95% confidence intervals) for the Magnetic Resonance Index of Activity, London, and London "extended" indices and a visual analogue scale were 0.89 (0.84 to 0.91), 0.87 (0.83 to 0.90), 0.89 (0.85 to 0.92), and 0.86 (0.81 to 0.90). Corresponding interrater intraclass correlation coefficients were 0.71 (0.61 to 0.77), 0.67 (0.55 to 0.75), 0.70 (0.61 to 0.76), and 0.71 (0.62 to 0.77). Reliability for each index was greatest in the terminal ileum and poorest in the rectum. All 3 indices were highly correlated with the visual analogue scale; 0.79 (0.71 to 0.85), 0.78 (0.71 to 0.84), and 0.79 (0.72 to 0.85) for the Magnetic Resonance Index of Activity, London, and the London "extended" indices, respectively.

CONCLUSIONS

"Substantial" interrater reliability was observed for all 3 indices. Future studies should assess responsiveness to treatment in order to confirm their utility as evaluative indices in clinical trials and clinical practice.

Ionizing diagnostic radiation exposure in patients with Crohn's disease: A retrospective study in a medium hospital and its predictive factors

INTRODUCTION

It is estimated that diagnostic medical radiation exposure may be responsable for 0.5-2% of cancers worldwide. Because of the relapsing course of Crohn's disease (CD), these patients usually requiere multiple ionizing radiation test.

OBJECTIVE

Stimating the total cumulative effective dose received by our CD patients and identifying the risk factors associated with the exposure to a cumulative effective dose due to the disease (CEED) > 50mSv.

MATERIALS AND METHODS

Retrospective cohort study (2001-2014).

POPULATION

patients with CD. Risk dose >50mSv. For calculating de cumulative effective dose and the CEED, all the ionizing test done were taken. For identifying predictive factors for receiving a CEDD >50mSv, an univariate and a multivariate logistic regression analyses were performed using a >50mSv dose as dependent variable.

RESULTS

Of the 267 patients analyzed the 24.6% of them received a cumulative effective dose > 50mSv and the 15.2% a CEED>50mSv. In the multivariate analysis, the following variables were identified as independent predictors associated with a CEDD >50mSv: major surgery (OR= 2.1; IC_95% [1.1-3.8]; p=.019) and severity (OR= 20.6; IC_95% [4.5-94.8]; p<.01).

CONCLUSIONS

Patients with CD are more at risk of receiving risk CEED, so it would be advisable to monitor the cumulative effective dose received to anticipate our intervention in order to avoid reaching that dose. The ultrasounds and abdominal resonance enterography are alternatives in these cases, although their accessibility is limited in some centers.

Radiation Exposure in Patients with Inflammatory Bowel Disease: a Fourteen-Year Review at a Tertiary Care Centre in Malaysia

Background and Aims:

Patients with inflammatory bowel disease (IBD) are subjected to a large amount of ionizing radiation during the course of their illness. This may increase their risk of malignancy to a greater level than that due to the disease itself. In Caucasian patients with Crohn’s disease, this has been well documented and recommendations are in place to avoid high radiation imaging protocols. However, there are limited data available on radiation exposure in Asian IBD patients. We therefore sought to identify total radiation exposure and any differences between ethnically diverse ulcerative colitis (UC) and Crohn’s disease (CD) patients at our centre along with determining factors that may contribute to any variation.

Methods:

The cumulative effective dose (CED) was calculated retrospectively from 2000 to 2014 using data from our online radiology database and patients’ medical records. Total CED in the IBD population was measured. High exposure was defined as a radiation dose of greater than 0.2mSv (equivalent to slightly less than ½ a year of background radiation).

Results:

A total of 112 cases of IBD (36 CD and 76 UC) were reviewed. Our CD patients were diagnosed at an earlier age than our UC cases (mean age 26.1 vs 45.7). The total CED in our IBD population was 8.53 (95% CI: 4.53-12.52). Patients with CD were exposed to significantly higher radiation compared to those with UC. The mean CED was 18.6 (7.30-29.87) and 3.65 (1.74-5.56, p=0.01) for CD and UC patients respectively. 2 patients were diagnosed as having a malignancy during follow up with respective CED values of 1.76mSv and 10mSv.

Conclusions:

CD patients, particularly those with complicated disease, received a higher frequency of diagnostic imaging over a shorter period when compared to UC patients. Usage of low radiation imaging protocols should be encouraged in IBD patients to reduce their risk of consequent malignancy.

Radiation exposure in patients with inflammatory bowel disease and irritable bowel syndrome in the years 2001-2011

OBJECTIVES

To compare cumulative ionizing radiation in patients with inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) for the years 2001-2011. To study how radiation exposure change over time in patients with newly diagnosed IBD and factors associated with radiation exposure.

MATERIAL AND METHODS

All radiological investigations performed between 1 January 2001 and 31 December 2011 were retrospectively recorded in patients with Crohn's disease (CD) (n = 103), ulcerative colitis (UC) (n = 304) and IBS (n = 149). Analyses were done with Mann-Whitney and Chi-Square test.

RESULTS

The median total cumulative radiation exposure in mSv for CD (20.0, inter quartile range (IQR) 34.8), UC (7.01, IQR 23.8), IBS (2.71, IQR 9.15) and the proportion of patients who had been exposed for more than 50 mSv during the study period (CD 19%, UC 11%, IBS 3%) were significantly higher in the patients with CD compared to patients with UC (p < .001) and IBS (p < .001), respectively. In turn, patients with UC had significantly higher doses than patients with IBS (p = .005). Risk factors for radiation exposure were female gender (CD), early onset (UC), ileocolonic location (CD), previous surgery (CD and UC), depression (IBS) and widespread pain (IBS). In newly diagnosed CD, there was a significant decline in median cumulative radiation dose in mSv (17.2 vs. 12.0; p = .048) during the study period.

CONCLUSIONS

Patients with CD are at greatest risk for high cumulative radiation exposure, but there is a decline in exposure during the late 2000s. Non-colectomized patients with UC and patients with IBS have a relatively low risk of cumulative radiation exposure.

Risk factors for radiation exposure in newly diagnosed IBD patients

PURPOSE

Patients with inflammatory bowel disease (IBD) may be exposed to high doses of diagnostic radiation. The purpose of this study is to identify subsets of this population at risk for significant radiation exposure.

METHODS

This HIPAA compliant, IRB approved study consists of 336 patients (237 adult and 99 pediatric) within the Ocean State Crohn's & Colitis Area Registry (OSCCAR). All were newly diagnosed with IBD and prospectively enrolled between 1/2008 and 12/2012. Comprehensive chart review was performed.

RESULTS

207 (61.6%) patients were diagnosed with Crohn's disease (CD), 120 (35.7%) with ulcerative colitis (UC), and 9 (2.7%) with inflammatory bowel disease, type unspecified (IBDU). 192 (57.1%) patients were exposed to GI-specific radiation. Average GI-specific radiation dose for adult IBD patients was 14.1 mSV and was significantly greater among adult CD than adult UC patients (p = 0.01). Pediatric patients underwent fewer CT scans (p < 0.0001). Risk factors for increased radiation exposure include: GI surgery (p = 0.003), biologic therapy (p = 0.01), pain-predominant symptoms (as compared to diarrhea-predominant symptoms; p < 0.05), and isolated ileal disease (p = 0.02). Patients with stricturing or penetrating disease received higher radiation doses than patients with non-stricturing, non-penetrating disease (p < 0.0001).

CONCLUSIONS

A variety of risk factors are associated with increased exposure to ionizing radiation after diagnosis of IBD. Knowledge of these risk factors can help physicians prospectively identify patients at risk for elevated radiation exposure and consider low-dose or radiation-free imaging.

Ionizing radiation exposure is still increasing in Crohn's disease: Who should be blamed?

BACKGROUND AND AIM

Crohn's disease (CD) patients undergo many radiological studies employing ionizing radiation for diagnosis and management purposes. Our aim was to assess the total radiation exposure of our patients over the years, to estimate the risk factors for exposure to high doses, and to correlate radiation exposure to immunosuppression.

METHODS

The cumulative effective dose of radiation (CEDR) was calculated multiplying the number of imaging studies by the effective dose of each examination.

RESULTS

A total of 451 patients with CD (226 female) were followed during 11.0 years (interquartile range [IQR]: 6.0-16.0), with 52.1% of the patients being classified with penetrating (B3) and 38.6% being steroid-dependent. About 16% were exposed to high-radiation dose levels (CEDR >50 mSv) and 4% were exposed to CEDR >100 mSv. The mean CEDR between age 26 and 35 years was 12.539 mSv and a significant dose of radiation (over 50 mSv) was achieved at a median age of 40 (IQR: 29.0-47.0). Abdominal-pelvic computed tomography scan was the examination that contributed the most for CEDR. Patients with B3 phenotype, previous surgery, azathioprine, and anti-tumor necrosis factor (TNF)-α therapy were exposed earlier on the course of the disease to CEDR >50 mSv (p < 0.001). The value of CEDR in the patients under immunosuppression mainly increased in the first year of immunosuppression.

CONCLUSION

Penetrating phenotype, abdominal surgery, steroid resistance or steroid dependence, and treatment with anti-TNF-α and azathioprine were predictive factors for high CEDR. It was also demonstrated that immunosuppression and anti-TNF-α treatment were followed by a sustained increment of radiation exposure and that a significant dose of radiation was achieved <40 years of age.

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

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

Anti-TNF therapy is associated with a reduction in radiation exposure in patients with Crohn's disease

OBJECTIVE

Patients with Crohn's disease (CD) are often exposed to ionizing diagnostic radiation with inherent risks from protracted exposure. Meanwhile, bolder definitions of disease control have changed treatment paradigms, with earlier introduction of biological therapy in many. Our aim was to compare the effective radiation dose a year before and 1 and 3 years after initiating anti-tumor necrosis factor (anti-TNF) or corticosteroid therapy.

MATERIALS AND METHODS

We performed a retrospective review of CD patients treated with anti-TNF (infliximab or adalimumab) or corticosteroids at our institution from 2005 to 2012.

RESULTS

We analyzed 170 patients with CD (114 treated with anti-TNF and 56 treated with corticosteroid). Between the year preceding and the year following therapy, a significant decrease in the mean number of radiology studies (-2.0 vs. -0.2, P=0.001) and the cumulative radiation dose (-3.1 vs. +0.3 mSv, P=0.01) was seen in the anti-TNF group when compared with the steroid group. Between the year preceding therapy and 3 years following therapy, a significant increase in the mean number of radiology studies (+2.3 vs. +0.3, P=0.003) and the cumulative radiation dose (+6.8 vs. +1.3 mSv, P=0.003) was seen in the steroid group when compared with the anti-TNF group. After adjusting for predictors of high diagnostic radiation exposure, the anti-TNF-treated group had a decrease in the number of imaging studies by 2 within a year of therapy (P<0.001).

CONCLUSION

Anti-TNF but not corticosteroid therapy is associated with a significant reduction in diagnostic radiation exposure a year after treatment, which persisted after 3 years.

Radiation exposure in gastroenterology: improving patient and staff protection

Medical imaging involving the use of ionizing radiation has brought enormous benefits to society and patients. In the past several decades, exposure to medical radiation has increased markedly, driven primarily by the use of computed tomography. Ionizing radiation has been linked to carcinogenesis. Whether low-dose medical radiation exposure will result in the development of malignancy is uncertain. This paper reviews the current evidence for such risk, and aims to inform the gastroenterologist of dosages of radiation associated with commonly ordered procedures and diagnostic tests in clinical practice. The use of medical radiation must always be justified and must enable patients to be exposed at the lowest reasonable dose. Recommendations provided herein for minimizing radiation exposure are based on currently available evidence and Working Party expert consensus.

Cumulative radiation dose from medical imaging in chronic adult patients

Chronic patients require ongoing care that results in repeated imaging and exposure to ionizing radiation for both diagnostic and therapeutic purposes. This is of concern due to the long-term effects of radiation exposure, namely the association between radiation and increased cancer risk. In this study, the scientific literature on cumulated dose of radiation accrued from medical imaging by 4 cohorts of chronic patients (cardiac disease, end-stage kidney disease, inflammatory bowel disease, and patients undergoing endovascular aortic repair) was systematically reviewed. We found that the cumulative effective dose is moderate in cardiac and inflammatory bowel disease patients, high in end-stage kidney disease patients, and very high in endovascular aortic repair patients. We concluded that radiation burden of medical imaging is high in selected cohorts of chronic patients. Efforts should be implemented to reduce this cumulative dose and its potential attendant risks.