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Jensen LJ, Loch FN, Kamphues C, Shahryari M, Marticorena Garcia SR, Siegmund B, Weidinger C, Kühl AA, Hamm B, Braun J, Sack I, Asbach P, Reiter R. Feasibility of in vivo magnetic resonance elastography of mesenteric adipose tissue in Crohn's disease. Quant Imaging Med Surg 2023; 13:4792-4805. [PMID: 37581033 PMCID: PMC10423387 DOI: 10.21037/qims-23-41] [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: 01/08/2023] [Accepted: 05/22/2023] [Indexed: 08/16/2023]
Abstract
Background Although there is growing evidence that functional involvement and structural changes of mesenteric adipose tissue (MAT) influence the course of Crohn's disease (CD), its viscoelastic properties remain elusive. Therefore, we aimed to investigate the viscoelastic properties of MAT in CD using magnetic resonance elastography (MRE), providing reference values for CD diagnosis. Methods In this prospective proof-of-concept study, 31 subjects (CD: n=11; healthy controls: n=20) were consecutively enrolled in a specialized care center for inflammatory bowel diseases (tertiary/quaternary care). Inclusion criteria for the CD patients were a clinically and endoscopically established diagnosis of CD based on the clinical record, absence of other concurrent bowel diseases, scheduled surgery for the following day, and age of at least 18 years. Diagnoses were confirmed by histological analysis of the resected bowel the day after MRE. Subjects were investigated using MRE at 1.5-T with frequencies of 40-70 Hz. To retrieve shear wave speed (SWS), volumes of interest (VOIs) in MAT were drawn adjacent to CD lesions (MATCD) and on the opposite side without adjacent bowel lesions in patients (MATCD_Opp) and controls (MATCTRL). The presented study is not registered in the clinical trial platform. Results A statistically significant decrease in mean SWS of 7% was found for MATCD_Opp vs. MATCTRL (0.76±0.05 vs. 0.82±0.04 m/s, P=0.012), whereas there was a nonsignificant trend with an 8% increase for MATCD vs. MATCD_Opp (0.82±0.07 vs. 0.76±0.05 m/s, P=0.098) and no difference for MATCD vs. MATCTRL. Preliminary area under the receiver operating characteristic curve (AUC) analysis showed diagnostic accuracy in detecting CD to be excellent for SWS of MATCD_Opp [AUC =0.82; 95% confidence interval (CI): 0.64-0.96] but poor for SWS of MATCD (AUC =0.52; 95% CI: 0.34-0.73). Conclusions This study demonstrates the feasibility of MRE of MAT and presents preliminary reference values for CD patients and healthy controls. Our results motivate further studies for the biophysical characterization of MAT in inflammatory bowel disease.
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Affiliation(s)
- Laura J. Jensen
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Florian N. Loch
- Department of Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | - Mehrgan Shahryari
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Stephan R. Marticorena Garcia
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Britta Siegmund
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Carl Weidinger
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anja A. Kühl
- iPATH.Berlin-Immunopathology for Experimental Models, Core Facility, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bernd Hamm
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jürgen Braun
- Department of Medical Informatics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ingolf Sack
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Patrick Asbach
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Rolf Reiter
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Berlin, Germany
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Xu C, Jiang W, Wang L, Mao X, Ye Z, Zhang H. Intestinal Ultrasound for Differentiating Fibrotic or Inflammatory Stenosis in Crohn's Disease: A Systematic Review and Meta-analysis. J Crohns Colitis 2022; 16:1493-1504. [PMID: 35390137 DOI: 10.1093/ecco-jcc/jjac052] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Intestinal ultrasound [IUS] has been increasingly reported to distinguish inflammatory or fibrotic intestinal stenosis in Crohn's disease [CD] patients. However, the diagnostic value is unclear. This systematic review and meta-analysis aimed to assess the diagnostic role of different modes of IUS parameters. METHODS We searched PubMed, Embase, Web of Science, and Cochrane Library from inception to August 2021. Regarding effect sizes, weighted mean differences [WMDs] or standardised mean differences [SMDs] were used. We pooled data using a random-effects or fixed-effects model according to heterogeneity. The diagnostic accuracy of IUS for distinguishing fibrosis was pooled. RESULTS A total of 19 studies were retained for qualitative analysis, and 14 were included in the meta-analysis [with 511 total subjects and 635 bowel segments]. In patients with fibrotic stenosis, the pooled WMDs for bowel wall thickness were 1.30 mm (95% confidence interval [CI]: 0.69-1.91) thicker than in patients with inflammatory stenosis, and the pooled SMDs for strain value and strain ratio were 0.80 [95% CI: 0.41-1.20] and 1.08 [95% CI: 0.55-1.60] harder than in patients with inflammatory stenosis, respectively. The percentage of maximal enhancement of fibrotic stenosis was lower than that of inflammatory stenosis [WMD -10.03; 95% CI: -17.91- -2.16]. The diagnostic accuracy of IUS was not performed because only a few studies provided relevant diagnostic indicators, and these studies used different modes and parameters. CONCLUSIONS IUS currently is inaccurate to differentiate fibrotic or inflammatory stenosis in CD patients, and more studies assessing the significance of each parameter and its cut-off value in different modes of IUS are needed to be conducted in the future.
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Affiliation(s)
- Chenjing Xu
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Wenyu Jiang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lu Wang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xiaqiong Mao
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Ziping Ye
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hongjie Zhang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
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Extracellular Matrix Components as Diagnostic Tools in Inflammatory Bowel Disease. BIOLOGY 2021; 10:biology10101024. [PMID: 34681123 PMCID: PMC8533508 DOI: 10.3390/biology10101024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/14/2021] [Accepted: 09/30/2021] [Indexed: 12/20/2022]
Abstract
Simple Summary For decades, the extracellular matrix (ECM) has been defined as a structure component playing a rather neglected role in the human body. In recent years, research has shed light on the role of ECM within cellular processes, including proliferation, migration and differentiation, as well as in inflammation. In inflammation, ECM composition is constantly being remodeled and undergoes dynamic and rapid changes. Tracking these changes could serve as a novel diagnostic tool. Inflammatory bowel disease is accompanied by complications such as fibrosis, stenosis and fistulas. All of these structural complications involve excessive synthesis or degradation of ECM. With this review, we explored whether the analysis of ECM composition can be of support in diagnosing inflammatory bowel disease and whether changes within ECM can help to predict a complicated disease course early on. Abstract Work from the last years indicates that the extracellular matrix (ECM) plays a direct role in various cellular processes, including proliferation, migration and differentiation. Besides homeostatic processes, its regulatory function in inflammation becomes more and more evident. In inflammation, such as inflammatory bowel disease, the ECM composition is constantly remodeled, and this can result in a structuring of fistulizing disease course. Thus, tracking early ECM changes might bear the potential to predict the disease course. In this review, we provide an overview of relevant diagnostic methods, focusing on ECM changes.
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Role of Intestinal Ultrasound in the Management of Patients with Inflammatory Bowel Disease. Life (Basel) 2021; 11:life11070603. [PMID: 34201630 PMCID: PMC8305052 DOI: 10.3390/life11070603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/13/2021] [Accepted: 06/18/2021] [Indexed: 12/11/2022] Open
Abstract
Intestinal ultrasound (IUS) has gained popularity as a first line technique for the diagnosis and monitoring of patients with inflammatory bowel diseases (IBD) due to its many advantages. It is a non-invasive imaging technique with non-ionizing radiation exposure. It can be easily performed not only by radiologists but also by trained gastroenterologists at outpatient clinics. In addition, the cost of IUS equipment is low when compared with other imaging techniques. IUS is an accurate technique to detect inflammatory lesions and complications in the bowel in patients with suspected or already known Crohn’s disease (CD). Recent evidence indicates that IUS is a convenient and accurate technique to assess extension and activity in the colon in patients with ulcerative colitis (UC), and can be a non-invasive alternative to endoscopy. In patients with IBD, several non-specific pathological ultrasonographic signs can be identified: bowel wall thickening, alteration of the bowel wall echo-pattern, loss of bowel stratification, increased vascularization, decreased bowel peristalsis, fibro-fatty proliferation, enlarged lymph nodes, and/or abdominal free fluid. Considering the transmural CD inflammation, CD complications such as presence of strictures, fistulae, or abscesses can be detected. In patients with UC, where inflammation is limited to mucosa, luminal inflammatory ultrasonographic changes are similar to those of CD. As the technique is related to the operator’s experience, adequate IUS training, performance in daily practice, and a generalized use of standardized parameters will help to increase its reproducibility.
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Marin AM, Calapod OP, Moldoveanu AC, Tribus LC, Fierbințeanu-Braticevici C. Non-invasive Ultrasonographic Score for Assessment of the Severity of Inflammatory Bowel Disease. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:932-940. [PMID: 33388210 DOI: 10.1016/j.ultrasmedbio.2020.11.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/28/2020] [Accepted: 11/22/2020] [Indexed: 06/12/2023]
Abstract
Intestinal ultrasound and shear wave elastography have gained increasing interest because of their promising results in the assessment of inflammatory bowel disease. The aim of this study was to find an ultrasonographic score to replace invasive endoscopic procedures for the management of these patients. The score includes ultrasound parameters that correlate well with clinical severity scales and inflammatory markers: bowel wall thickness, the Limberg score, disease extension and acoustic radiation force impulse measurements. The score proved to be well correlated with the Harvey Bradshaw Index, the Mayo score, C-reactive protein and fecal calprotectin. For Crohn's disease, a cutoff value of 8 points could identify active disease with 81.81% sensitivity and 83% specificity, while for ulcerative colitis, a cutoff value of 7 points could discriminate between remission and relapse with 86.85% sensitivity and 94% specificity. In conclusion, our ultrasonographic score can differentiate relapse from remission in inflammatory bowel disease.
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Affiliation(s)
- Andreea Maria Marin
- Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest, Romania
| | - Ovidiu Paul Calapod
- Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest, Romania; Gastroenterology Department, Bucharest Emergency University Hospital, Bucharest, Romania
| | - Alexandru Constantin Moldoveanu
- Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest, Romania; Gastroenterology Department, Bucharest Emergency University Hospital, Bucharest, Romania
| | - Laura Carina Tribus
- Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest, Romania; Gastroenterology Department, Bucharest Emergency University Hospital, Bucharest, Romania.
| | - Carmen Fierbințeanu-Braticevici
- Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest, Romania; Gastroenterology Department, Bucharest Emergency University Hospital, Bucharest, Romania
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Allocca M, Fiorino G, Bonifacio C, Peyrin-Biroulet L, Danese S. Noninvasive Multimodal Methods to Differentiate Inflamed vs Fibrotic Strictures in Patients With Crohn's Disease. Clin Gastroenterol Hepatol 2019; 17:2397-2415. [PMID: 30995529 DOI: 10.1016/j.cgh.2019.04.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 04/08/2019] [Accepted: 04/10/2019] [Indexed: 02/07/2023]
Abstract
Fibrotic strictures occur in 30% of patients with Crohn's disease (CD). However, there are no therapeutic agents that prevent or reverse fibrotic strictures. Strictures are treated by endoscopic dilatation procedures and surgical procedures, but there are high rates of recurrence. Two antifibrotic agents (nintedanib and pirfenidone) recently were approved for the treatment of idiopathic pulmonary fibrosis and inhibitors of Rho-associated protein kinases 1 and 2 reversed fibrosis in mice with chronic intestinal inflammation. Cross-sectional imaging techniques, such as magnetic resonance (MR) enterography, computed tomography enterography, and bowel ultrasound, are used to assess small-bowel and CD-related complications, including strictures. It is important to be able to determine the degree of inflammation and fibrosis in strictures to select the best therapy; this can be a challenge because inflammation and fibrosis co-exist to varying degrees in a damaged bowel segment. Delayed gadolinium enhancement, magnetization transfer MR imaging, and ultrasound elastography seem to be promising tools for assessing fibrosis in patients with CD. We review noninvasive techniques for fibrosis assessment, including analyses of genetic, epigenetic, and protein markers. We discuss the potential of imaging techniques such as diffusion-weighted and magnetization transfer MR imaging, strain elastography, shear-wave imaging, and positron emission tomography to guide therapeutic decisions for patients with stricturing CD.
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Affiliation(s)
- Mariangela Allocca
- Inflammatory Bowel Disease Centre, Humanitas Clinical and Research Centre, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Gionata Fiorino
- Inflammatory Bowel Disease Centre, Humanitas Clinical and Research Centre, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Cristiana Bonifacio
- Division of Diagnostic Radiology, Humanitas Clinical and Research Centre, Rozzano, Milano, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm U954, University Hospital of Nancy, Lorraine University, Nancy, France
| | - Silvio Danese
- Inflammatory Bowel Disease Centre, Humanitas Clinical and Research Centre, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.
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Mozzini C, Pesce G, Casadei A, Girelli D, Soresi M. Ultrasound as First Line Step in Anaemia Diagnostics. Mediterr J Hematol Infect Dis 2019; 11:e2019066. [PMID: 31700591 PMCID: PMC6827602 DOI: 10.4084/mjhid.2019.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/17/2019] [Indexed: 12/25/2022] Open
Abstract
This review covers the role of ultrasonography as an essential non-invasive diagnostic approach when facing patients with anaemia, a common clinical problem. Abdomen ultrasound is well recognised as a first-line examination in the setting of blood loss, both acute and chronic. Less is clear about the additional opportunities, given by ultrasound in anaemia, due to the many other possible causes. Here we provide information on the utility of ultrasound in different contexts and a practical guide for clinicians facing anaemic patients.
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Affiliation(s)
- Chiara Mozzini
- Department of Medicine, Section of Internal Medicine, University of Verona, Piazzale L.A. Scuro, 10, 37134 Verona, Italy
| | - Giancarlo Pesce
- Sorbonne Universitè INSERM UMR-S1136 Institut Pierre Louis d’ Epidemiologie et de Sanitè Publique, Team EPAR F75012, Paris, France
| | - Alder Casadei
- Ultrasound Association of South-Tyrol, Bolzano Health District, Piazza W.A. Loew-Cadonna 12, 39100 Bolzano, Italy
| | - Domenico Girelli
- Department of Medicine, Section of Internal Medicine, University of Verona, Piazzale L.A. Scuro, 10, 37134 Verona, Italy
| | - Maurizio Soresi
- Department of Health Promotion Sciences Maternal and Infant Care, Internal Medicine and Medical Specialities, University of Palermo, Via del Vespro, 141-90127 Palermo, Italy
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Nair A, Liu CH, Das S, Ho T, Du Y, Soomro S, Mohan C, Larin KV. Detecting murine Inflammatory Bowel Disease using Optical Coherence Elastography. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2018:830-833. [PMID: 30440520 DOI: 10.1109/embc.2018.8512295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) that causes regions of ulceration within the interior of the colon. UC is estimated to afflict hundreds of thousands of people in the United States alone. Ultrasonic techniques can detect colitis, but have limited spatial resolution, which frequently results in underdiagnoses. Nevertheless, clinical diagnosis of colitis is still generally performed via colonoscopy. Optical techniques such as confocal microscopy and optical coherence tomography (OCT) have been proposed as higher resolution alternative imaging modalities to detect colitis. Additionally, IBD can potentially alter tissue biomechanical properties, which cannot be quantified from structural imaging alone. Elastography is a potential method to assess colon biomechanical properties to provide additional contrast for distinguishing healthy and diseased colon tissue. In this work, we induced elastic waves in ex vivo mouse colon tissue using a focused air-pulse. The elastic waves were detected using a phase-stabilized swept source optical coherence elastography system, and the wave velocity was translated into stiffness. Measurements were taken at six random positions for each sample in order to assess regional sample elasticity. The results show distinct differences ($p \lt 0.05$) in the stiffness between healthy and IBD-diseased samples, with a Young's Modulus of $10.2 \pm 3.7$ kPa and $4.9 \pm 0.3$ kPa, respectively. Dispersion analysis presents another parameter to distinguish tissue health. The high frequency components of the phase velocity dispersion curve indicate a variation between healthy and IBD colonic tissue. Our results show that OCE may be useful for detecting IBD noninvasively.
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Strain elastography in Crohn's disease: the role of visual observation and semiquantitative parameters. J Ultrasound 2018; 22:227-239. [PMID: 30343355 DOI: 10.1007/s40477-018-0324-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/28/2018] [Indexed: 12/17/2022] Open
Abstract
Strain elastography is a recently developed ultrasound method that seems to contribute to the diagnosis and monitoring of inflammatory bowel diseases. This pictorial essay aims to present the feasibility of strain elastography in clinical practice by comparing visual observation and semiquantitative parameters with endoscopic or radiological images in some common cases of Crohn's disease. In our opinion, strain elastography with visual observation is easily performed in connection with B-mode ultrasound and color Doppler imaging and may provide relevant information. Strain elastography with the elaboration of semiquantitative parameters is not as immediate as the visual observation method, but it seems to provide more objective data and seems more appropriate for monitoring the evolution of the disease. However, for the elastographic method to extensively contribute in inflammatory bowel diseases, standardization and further studies are required to confirm the promising results already reported in the literature.
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Park SH, Ye BD, Lee TY, Fletcher JG. Computed Tomography and Magnetic Resonance Small Bowel Enterography: Current Status and Future Trends Focusing on Crohn's Disease. Gastroenterol Clin North Am 2018; 47:475-499. [PMID: 30115433 DOI: 10.1016/j.gtc.2018.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) are presently state-of-the-art radiologic tests used to examine the small bowel for various indications. This article focuses on CTE and MRE for the evaluation of Crohn disease. The article describes recent efforts to achieve more standardized interpretation of CTE and MRE, summarizes recent research studies investigating the role and impact of CTE and MRE more directly for several different clinical and research issues beyond general diagnostic accuracy, and provides an update on progress in imaging techniques. Also addressed are areas that need further exploration in the future.
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Affiliation(s)
- Seong Ho Park
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea.
| | - Byong Duk Ye
- Department of Gastroenterology, Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea
| | - Tae Young Lee
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea
| | - Joel G Fletcher
- Department of Radiology, Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55905, USA
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