Bowel Sonography Research Articles

New Score Models for Assessing Disease Activity in Crohn's Disease Based on Bowel Ultrasound and Biomarkers: Ideal Surrogates for Endoscopy or Imaging.

Disease activity evaluation is important in Crohn's disease (CD). We aimed to establish new disease activity indices for CD based on noninvasive parameters. The data of 110 CD patients were retrospectively analyzed. Parameters from bowel ultrasound and biomarkers were measured to select the variables included in the models by univariate analysis. Logistic regression analysis was performed to predict mucosal and transmural activities defined by ileocolonoscopy or computed tomography enterography (CTE), respectively. The models' performance was measured by the area under the receiver operating characteristic (ROC) curve (AUC). Leave-one-out cross validation (LOOCV) was applied to adjust for overconfidence in the newly established score models. To predict mucosal activity, erythrocyte sedimentation rate (ESR) and (LimG × BWT)-SUM (the sum of the product of Limberg grade [LimG] and bowel wall thickness [BWT] of each bowel segment) were selected for Model A, and the equation was A=2 × ESR + 9.3 × (LimG × BWT)-SUM. The AUC of ROC, sensitivity, and specificity were 0.927, 89.8%, and 86.4%, respectively. The AUC of the ROC curve verified by LOOCV was 0.913. To predict transmural activity, albumin (ALB) and LimG-SUM (the sum of the LimG of all the bowel segments) were selected for Model B, which was established as B=-1.3 × ALB + 1.7 × LimG-SUM. The AUC of ROC, sensitivity, and specificity were 0.851, 78.0%, and 84.2%, respectively. The AUC of the ROC curve verified by LOOCV was 0.833. Nomograms were developed for two score models. New score models based on noninvasive parameters established in this study showed good abilities in detecting active disease and performed well in the validation phase.

Clinical Outcome of Ultrasound-Detected Perforated Necrotizing Enterocolitis without Radiographic Pneumoperitoneum in Very Preterm Infants

To investigate the clinical outcomes of ultrasound (US)-detected perforated necrotizing enterocolitis (NEC) without radiographic pneumoperitoneum in very preterm infants. In this single-center retrospective study, very preterm infants who underwent a laparotomy for perforated NEC during their neonatal intensive care unit stay were classified into two groups according to the absence or presence of pneumoperitoneum on radiographs (the case versus the control groups). The primary outcome was death before discharge, and the secondary outcomes included major morbidities and body weight at 36 weeks postmenstrual age (PMA). Of the 57 infants with perforated NEC, 12 (21%) had no pneumoperitoneum on the radiographs and were diagnosed with perforated NEC on the US. In the multivariable analyses, the primary outcome of death before discharge was significantly lower in infants with perforated NEC without radiographic pneumoperitoneum than in those with perforated NEC and radiographic pneumoperitoneum (8% [1/12] vs. 44% [20/45]; adjusted odds ratio [OR], 0.02; 95% confidence interval [CI], 0.00-0.61; p = 0.025). The secondary outcomes (short bowel syndrome, total parenteral nutrition dependence for 3 months or more, the length of their hospital stay, a bowel stricture requiring surgery, sepsis after the laparotomy, acute kidney injury after the laparotomy, and body weight at 36 weeks PMA) did not differ significantly between the two groups. Very preterm infants with US-detected perforated NEC without radiographic pneumoperitoneum had a lower risk of death before discharge than those with perforated NEC and radiographic pneumoperitoneum. Bowel USs may have a potential role in surgical decision-making in infants with advanced NEC.

External validation and comparison of simple ultrasound activity score and international bowel ultrasound segmental activity score for Crohn’s disease

Background Intestinal ultrasound (IUS) is a non-invasive tool for monitoring Crohn’s disease (CD) activity. Recently, sonographic activity scores, including the International Bowel Ultrasound Segmental Activity Score (IBUS-SAS) and Simple Ultrasound Activity Score for CD (SUS-CD), were developed. This study aimed to assess their clinical application value. Methods This retrospective study enrolled patients with CD from March 2021 to June 2022. The diagnostic performance of the ultrasound scores was evaluated using the simplified endoscopic score for CD (SES-CD). Correlations of ultrasound scores with SES-CD, CD activity index (CDAI), and inflammatory biomarkers were assessed. Inter-rater reliability was compared. Results In total, 140 patients were included. The IBUS-SAS for evaluating disease activity had an area under the curve (AUC) of 0.895, sensitivity of 85.4%, and specificity of 82.4% for the cut-off value of 48.7. The SUS-CD revealed an AUC of 0.835, sensitivity of 92.7%, and specificity of 64.7% for the cut-off value of 2.5. The IBUS-SAS and SUS-CD were positively correlated with SES-CD (r = 0.511 and 0.534, respectively). The scores correlated significantly with the CDAI and inflammatory biomarkers (all p < 0.01). The IBUS-SAS was more strongly correlated with CDAI (r = 0.666 vs 0.486) and C-reactive protein (r = 0.645 vs 0.434) than the SUS-CD. The intraclass correlation coefficient (ICC) of the IBUS-SAS and SUS-CD between the two sonologists was excellent (ICC = 0.96 and 0.78, respectively). Conclusion Both the IBUS-SAS and SUS-CD can evaluate disease activity in CD and exhibited a significant correlation with activity indices and inflammatory biomarkers. Clinical trial registration ChiCTR2200055221

P295 Hocus Pocus: The Role Of Hand-Held Ultrasonography In Predicting Disease Extension And Endoscopic Activity In Ulcerative Colitis

Abstract Background Ulcerative colitis (UC) diagnosis and monitoring still require ileo-colonoscopy (IC) as the reference standard. Bowel sonography (BS) has recently emerged as a non-invasive assessment tool, and Milan Ultrasound Criteria (MUC) score has been validated to estimate and predict UC disease activity. Recently, hand-held BS (HHBS) has been used effectively in several clinical settings (e.g. cardiology, orthopedy, gynaecology), while data about its use in UC are still limited. We aimed to evaluate the diagnostic accuracy of HHBS compared to conventional bowel sonography (BS) in predicting UC extension and activity compared to endoscopy. Methods From November 2021 to September 2022, we prospectively enrolled consecutive UC patients afferent to our third-level IBD Unit for IC evaluation. Patients underwent IC, HHBS, and BS, and the operators were blinded by the other procedure results. Endoscopy was considered the reference standard for UC extension. Cohen’s k test was applied after MUC dichotomization to test the concordance between BS-MUC and HHBS-MUC following Allocca et al. (MUC &amp;gt;6.2: yes/no). Results At the end of the study, 86 patients with UC were examined. No significant difference was recorded between BS and HHBS in terms of UC at the per-segment extension (p: N.S.) (table 1), and both procedures were comparable regarding colonic wall thickness (CWT) and colonic wall pattern (CWP) assessment (figure 1 and 2). Regarding the prediction of endoscopic activity, BS and HHBS displayed excellent agreement when applying the MUC score system (k = 0.86, p&amp;lt;0.01) (figure 3). Conclusion Hand-held bowel sonography and BS are comparable in defining UC extension and MUC evaluation in the UC setting. HHBS could be reliable for detecting disease activity and estimating its extension, providing close monitoring of the treat-to-target paradigm. It also represents a non-invasive, easily practicable investigation during a physical examination, allowing immediate medical decisions with significant time and cost advantages.

P594 Bowel ultrasound is useful in predicting relapse in patients with Ulcerative Colitis in remission

Abstract Background Endoscopic remission is associated with better long-term outcomes of ulcerative colitis (UC), and therefore, it is considered a treatment target. However, endoscopy is invasive and frequent monitoring is not feasible. We have reported that bowel ultrasound (BUS) is useful in predicting endoscopic and histologic severity and in determining response to treatment (Sagami S et al, APT 2020 &amp; 2022). However, it is unclear whether BUS can predict the relapse of UC in remission. Methods We conducted a retrospective cohort study enrolling UC patients who underwent BUS from Jul 2018 to Jul 2021 during clinical remission (Patient Reported Outcome-2 ≦ 1 and no rectal bleeding) for at least 3 months and followed for 1 year. Spearman rank correlation coefficient was used to analyse the correlation between BUS and Mayo endoscopic subscore (MES) (evaluation of the most severe part of the colon). The association between BUS findings (bowel wall thickness (BWT), bowel wall flow (BWF), bowel wall stratification (BWS), enlarged lymph nodes), Milan Ultrasound Criteria (MUC = 1.4 × colonic BWT + 2 × colonic BWF (0 = absence, 1 = presence of colour Doppler signal)) (Allocca M et al, UEGJ 2021), MES, CRP and faecal calprotectin (FC) and subsequent clinical relapse was evaluated. Relapse was defined as rectal bleeding score ≧ 1, stool frequency score ≧ 2, or treatment intensification for symptoms. Results A total of 58 patients were included in the study. The median age was 46 years, 37 (63.8%) were male, 39 (67.2%) were pancolitis, and the median disease duration was 116 months. BWT and BWF were moderately correlated with MES but MUC showed a numerically highest coefficiency (0.61) when evaluated for the colon. Overall, 18 patients (31.0%) relapsed within 1 year. Neither BWT, BWF, BWS, enlarged lymph nodes, nor CRP was predictive for relapse. The log-rank test showed MUC &amp;gt; 6.2 (p = 0.019), MES ≥ 1 (p = 0.013), and FC ≥ 250 μg/g (p = 0.040) were associated with a shorter time to relapse. Cox proportional hazards model showed MUC &amp;gt; 6.2 (HR 3.22: 95%CI 1.14-9.08, p = 0.027), MES ≥1 (HR 8.70: 95%CI 1.11-68.1, p = 0.040) had a higher risk of relapse in 1 year. Sensitivity, specificity, PPV, and NPV of MUC &amp;gt; 6.2 for relapses of different time points (3, 6, and 12 months) showed high specificity of 0.90-0.91 and NPV of 0.74-0.90. Interestingly, 4 out of 9 patients with MUC &amp;gt; 6.2 relapsed within 3 months, suggesting MUC &amp;gt; 6.2 is a risk of short-term relapse. Conclusion BUS in UC patients in remission can predict relapse using MUC. In particular, the MUC score ≤ 6.2 is associated with a lower risk of relapse and could be a treatment-target alternative to endoscopic healing.

P641 Bowel Doppler Signal, the most important ultrasonographic feature in clinical practice in managing Inflammatory Bowel Diseases patients

Abstract Background IBD are chronic diseases that require multiple endoscopic and imaging assessments, being diseases that not only involve a multitude of medical resources but patient compliance too. Bowel ultrasound (BUS) is a useful imaging tool in monitoring inflammatory bowel diseases (IBD) patients. Current guidelines recommend BUS altogether with other cross-sectional imaging methods to diagnose, monitor IBD patients and also for detecting complications and post-surgery recurrence. A multitude of ultrasonographic features are used to describe pathologic findings related to IBD but not all of them are easy to integrate in clinical practice, especially in unexperienced hands. Methods Our study included 117 IBD patients of which 28 were diagnosed with ulcerative colitis and 89 with Crohn’s disease. Diagnosis was established endoscopically and histologically and both patients with active and inactive disease were included. Exclusion criteria consisted in patients with other causes of inflammatory syndrome, patients with solely rectal localization of the disease or a surgical history. Subjects were prospectively evaluated using BUS and several sonographic aspects of the bowel wall were monitored: bowel wall thickness, bowel echo pattern, Doppler signal (DS) presence, hypertrophic mesenteric fat, and the presence of lymph nodes. Biological markers of inflammation were obtained including faecal calprotectin. Patients were followed up for the next 6 months and data regarding treatment intensification was noted. All patients signed an informed consent, and the study was approved by the Ethics Committee of the Fundeni Clinical Institute. Results Significantly higher values of clinical and biological markers were associated with the presence of parietal DS (p&amp;lt;0.0001) suggesting that this BUS feature is an important bowel wall inflammation surrogate. Higher Limberg scores (a subjective Doppler signal score used in BUS) correlated with increased values of biological markers of inflammation (p=0.002). A multivariate analysis showed that DS and a thicker than 5 mm bowel wall were independent predictors of step-up therapy. The presence of parietal DS raised the patient risk of switching therapy 7.6 times, while bowel wall thickness only 2.4 times, making DS the most useful BUS feature in evaluating inflammatory activity and predicting the need for step-up therapy. Conclusion DS is one of the most important BUS features to use in evaluating and monitoring IBD patients and could have a role in disease decision making. This finding should advocate for this imaging method in clinical practice, and even low BUS-experience practitioners are encouraged to use it.

P388 Shear wave elastography predicts short-term response to induction therapy in patients with Crohn’s disease

Abstract Background Endoscopy has been used to assess the disease activity of Crohn's disease (CD) but may not be sufficient considering the transmural nature of its inflammation. Bowel ultrasonography (BUS) has been reported to reflect disease activity of CD and long-term outcomes. We performed a prospective study to determine whether BUS can predict short-term clinical response to induction therapy. Methods Consecutive CD patients with active ulcers in endoscopy requiring induction therapy (Anti-TNF antibody, IL-12/23 p40 antibody, integrin inhibitor, prednisolone) were prospectively enrolled at a single center from October 2018 to July 2022. Short-term clinical response was defined by a reduction of Crohn’s disease activity index &amp;gt; 70 at week 8. Ultrasonographic findings (bowel wall thickness (BWT), colour Doppler signal (CDS), and shear wave elastography (SWE) were recorded for the most severely affected segment at baseline, week 1, and 8 and compared between responders and non-responders. Results Seventeen out of 29 patients were classified as responders at week 8. There was no difference in BWT and CDS at baseline, week 1, and 8 between responders and non-responders (Table 1). In contrast, responders had lower baseline SWE compared with non-responders (2.7±0.3 vs. 3.8±0.3, p=0.02). Adjusted by the prior exposure to biologics, the lower SWE at baseline was associated with clinical response at week 8 (adjusted odds ratio associated with 0.1 m/s increase: 0.9, p=0.018) (Table 2). SWE did not change over time regardless of response for 8 weeks. Conclusion Lower intestinal wall stiffness as measured by SWE is an independent predictor of short-term clinical response.

P330 Ultrasound remission after biologic induction predicts long-term endoscopic remission in Crohn’s disease

Abstract Background Intestinal ultrasound (IUS) is accurate and non-invasive to detect and monitor disease activity in Crohn’s disease (CD). The Bowel Ultrasound Score (BUSS= 0.75 × bowel wall thickness + 1.65 × presence (1) or absence (0) of bowel wall flow) demonstrated high accuracy in detecting therapy-related changes, and good correlation with the Simple Endoscopic Score for CD (SES-CD). The most accurate cutoff value for BUSS was 3.52 for endoscopic remission (SES-CD ≤ 2).This study aimed to prospectively evaluate ultrasound remission as a relevant treatment target. Methods Consecutive patients with active CD (SES-CD &amp;gt; 2) starting biologic treatments were included. Patients underwent colonoscopy and IUS at baseline and after 1 year of treatment. Clinical, biochemical and ultrasound assessments were additionaly performed at week 12. Primary outcome was to evaluate whether ultrasound remission at week 12 could predict endoscopic remission at week 54. Endoscopic remission was defined as SES-CD ≤ 2, ultrasound remission was defined by BUSS ≤ 3.52, clinical remission was defined by HBI (Harvey-Bradshaw Index) &amp;lt; 5, and biochemical remission was defined by normalization of C-reactive protein (&amp;lt; 5 mg/L) and fecal calprotectin (three different thresholds were assessed: &amp;lt; 250 µg/g, &amp;lt; 100 µg/g, &amp;lt; 50 µg/g). Results Ninety-three patients were included (8 under infliximab, 40 under adalimumab, 5 under vedolizumab and 40 under ustekinumab). Eighteen patients (19%) and 36 patients (39%) achieved endoscopic remission and ultrasound remission at week 54, respectively. CD patients with ultrasound remission at week 12 were more likely to achieve endoscopic remission (odds ratio [OR] 6.88 [2.14–22.04]; p = 0.001) and ultrasound remission (OR 4.26 [1.61–11.24]; p = 0.003) at week 54. Calprotectin value &amp;lt; 50 µg/g at week 12 predicted endoscopic remission at univariable (OR 3.14 [1.04–9.45]; p = 0.041), but not at multivariable analysis. No other clinical or biochemical variables at week 12 predicted endoscopic and/or ultrasound remission at week 54. Conclusion Ultrasound remission achieved at week 12 may predict long-term endoscopic remission and may be a strategic treatment target, both in clinical practice and in clinical trials.

P332 External validation of intestinal ultrasound scores to detect endoscopic activity in children and adults with Crohn's disease: A prospective cohort study

Abstract Background Intestinal ultrasound (IUS) scores were developed for adults and children with Crohn’s disease (CD) but have not been externally validated with endoscopy. This study aimed to externally validate all CD IUS scores with endoscopy. Methods Prospective cross-sectional study of children and adults with CD who underwent IUS and colonoscopy within 60 days. The International Bowel Ultrasound Segment Activity Score (IBUS-SAS), Simple Ultrasound Score for Crohn’s disease (SUS-CD), Simple Ultrasound Activity Score for Crohn’s disease (SUAS-CD), and Simple Pediatric Activity Ultrasound Score (SPAUSS) were compared to the Simple Endoscopic Score for Crohn’s disease (SES-CD). Primary outcomes were the area under the receiver operating curve (AUROC) for each IUS score for moderate (SES-CD ≥ 5) and any (SES-CD ≥ 3) CD activity. Secondary outcome was the correlation of IUS scores and SES-CD. Results 82 CD patients (53 (65%) children, 29 (35%) adults, 41 (50%) female; 50 (61%) ileocolonic disease location) underwent IUS of 150 (74 (49%) terminal ileum) bowel segments with IUS scores and SES-CD. In both children and adults, all scores performed with high accuracy to detect SES-CD ≥ 5 and moderate accuracy to detect SES-CD ≥ 3. To detect SES-CD ≥ 5 in children, a SUAS-CD ≥ 4.5 had the highest AUROC [95% CI] =0.91 [0.85-0.97] (sensitivity=90%, specificity=81%), followed by an IBUS-SAS ≥ 37.8 (AUROC=0.89 [0.83-0.96]), SPAUSS ≥ 4 (AUROC=0.89 [0.81-0.96]), and SUS-CD ≥ 2 (AUROC=0.88 [0.80-0.95]). To detect SES-CD ≥ 5 in adults, an IBUS-SAS ≥ 34.2 had the highest AUROC=0.85 [0.71-98] (sensitivity=70%, specificity=87%) followed by a SAUS-CD ≥ 5.45 (AUROC =0.84 [0.71-0.98]), SUS-CD ≥ 1 (AUROC=0.81 [0.65-0.97]), and SPAUSS ≥ 5 (AUROC=0.78 [0.65-0.97]). To detect SES-CD ≥ 3, SPAUSS ≥ 4 (AUROC=0.78 [0.69-0.87], sensitivity=56%, specificity=92%) and SUS-CD ≥ 3 (AUROC =0.78 [0.68-0.86], sensitivity=56%, specificity=89%) had the highest accuracy in children followed by a SAUS-CD ≥ 4.5 (AUROC=0.74 [0.63-0.86]) and IBUS-SAS ≥ 34 (AUROC=0.73 [0.62-0.84]). In adults, SAUS-CD ≥ 2.68 and IBUS-SAS ≥ 11.2 (AUROC = 0.68 [0.50-0.85], sensitivity=63%, specificity=72%) had the highest accuracy to detect SES-CD ≥ 3 followed by a SUS-CD ≥ 2.5 (AUROC = 0.65 [0.50-0.81]), and SPAUSS ≥ 6 (AUROC = 0.61 [0.45-0.77]). IUS scores moderately correlated with SES-CD in children and adults, of which the IBUS-SAS had the highest (r=0.66 in children vs. r=0.57 in adults). Conclusion CD IUS scores are accurate for the detection of endoscopic activity in children and adults. IUS scores may be more accurate in children and correlate better with endoscopy but more studies are needed. This data supports the use of IUS as an accurate monitoring tool, reflective of endoscopic activity.

P333 Early intestinal ultrasound remission is associated with endoscopic healing after one year of infliximab therapy in Crohn’s disease: a multicentre prospective study

Abstract Background Endoscopic healing (EH) is currently the consensual long-term treatment target to achieve in Crohn’s disease (CD). However, optimization of therapy based on an endoscopic response implies a delay as endoscopy is an invasive procedure and cannot be used longitudinally, stressing the need for non-invasive predictors of EH. We aimed to assess the predictive role of biomarkers and intestinal ultrasound (IUS) parameters after induction therapy to predict EH one year after infliximab (IFX) therapy. Methods Prospective multicentre cohort study including patients with active CD starting IFX. Harvey-Bradshaw index (HBI), C-reactive protein (CRP), faecal calprotectin (FC), and IUS were performed at week (W) 0, 14, 30, and 54. Ileocolonoscopy was performed at W0 and W54. Clinical remission (CR) was defined as HBI&amp;lt;5 and laboratory remission (LR) as CRP &amp;lt;0.5mg/dL and FC &amp;lt;150ug/g. Transmural healing (TH) was defined as the normalization of bowel wall thickness (BWT≤3mm), doppler sign (≤1), wall stratification, and inflammatory fat in the most affected segment. The IBUS-SAS (International Bowel Ultrasound Segmental Activity Score) was used to assess disease activity and includes BWT, doppler sign, loss of stratification, and inflammatory fat. EH was defined as total SES-CD &amp;lt;3. Results We included 52 patients with CD (54% male; mean age 35±14y). Baseline characteristics are available in Table 1. At W14, 89% were in CR, 46% had LR and 19% had TH. After 1 year of IFX therapy, 90% were in CR, 62% had LR, 43% had TH and 37% had EH. At W14, patients with EH had lower BWT (3.3 vs 4.6mm, p=0.01), lower IBUS-SAS (15 vs 61, p&amp;lt;0.01), and lower FC (44 vs 239ug/g, p&amp;lt;0.01). At W14, both TH (OR 11.3, 95%CI 2.1-61.4, p&amp;lt;0.01) and FC remission (OR 7.4, 95%CI 1.8-30.7, p&amp;lt;0.01) were significant predictors for EH. In a multivariate analysis including significant baseline characteristics and early non-invasive monitoring targets at W14 (table 2), TH was an independent predictor of EH (OR 8.6, 95%CI 1.2-61.7, p=0.03). Even after adjusting for the baseline ultrasonographic severity according to the IBUS-SAS, TH at W14 remained a significant predictor of EH (OR 6.5, 95%CI 1.02-40.9, p=0.047). Using a ROC curves analysis, the IBUS-SAS at W14 was the best predictor for EH, with an AUC of 0.81 and the best cut-off value of 32.2 (Table 3). Conclusion Early assessment of ultrasonographic remission at week 14 can help predict EH after one year of therapy and offers an opportunity for early therapy optimization. TH at week 14 assessed by IUS was an independent predictor for EH after one year of therapy. Our results support the use of early IUS monitoring to predict response to therapy in CD patients.

P293 Correlation between clinical measures to capture disease burden and prediction of the initial course of Crohn’s disease - findings from a Copenhagen IBD Inception Cohort Study (IBD Prognosis Study)

Abstract Background The initial disease burden of Crohn’s disease (CD) is dissimilar across patients; however, the ability to capture and predict the disease burden at diagnosis is scarcely investigated. The aim of the current study was to describe the initial disease burden of Crohn’s disease. Methods IBD Prognosis Study is an ongoing prospective population-based inception cohort of newly diagnosed patients with CD between May 1st, 2021, and November 1st, 2022, according to the Copenhagen IBD Criteria.1 We defined an indolent disease presentation as no need for CD-related surgery, hospitalization, nor initiation of steroid, immunomodulatory, or biologic therapies within the first 30 days after diagnosis, while a complicated course was defined as the opposite. Results The study included 134 patients with adult-onset CD, of whom approximately one-third (44/134, 33%) had an early indolent course, with 26 patients (19%) not requiring any medication (Tables 1-2). In demographic factor adjusted analyses, a colonic phenotype (adjusted odds ratio (aOR) =4.5 (95% confidence interval (CI) 1.6-15) and a low symptom load measured with Harvey-Bradshaw Index (HBI) &amp;lt;5 (aOR = 3.1 (CI 1.0-10) were independently associated with an indolent course. In contrast, a C-reactive protein (CRP) level higher than 10 mg/L was the only parameter associated with a complicated onset of CD (aOR = 4.7 (CI 2.1-12)). Pearson’s correlation analyses demonstrated a significant, moderate correlation between fecal (F-) calprotectin, CRP, and endoscopic lesions, measured with Simple Endoscopic Score for CD (SES-CD) (Table 3). HBI and the International Bowel Ultrasound Segmental Activity Score (IBUS-SAS) exhibited a significant but weak correlation with CRP. In a sensitivity analysis allowing exposure to anti-inflammatory therapy for only up to seven days, the platelet count, F-calprotectin, and bowel wall thickness measured in IBUS-SAS demonstrated a significant and moderate correlation with SES-CD. The total IBUS-SAS and CRP showed a significant but weak correlation, and other measures included in the IBUS-SAS did not yield significant correlations. Conclusion Preliminary data from the ongoing population-based cohort indicate that one-third of patients with newly diagnosed CD have an early indolent course. This study identified colonic disease location and CRP levels to be associated with the early course, while platelet count, bowel wall thickness, and CRP were correlated with endoscopic lesions at the onset of CD.

P158 Intestinal Ultrasound at IBD diagnosis predicts surgery – a Copenhagen IBD cohort study

Abstract Background The disease course of inflammatory bowel disease (IBD) is heterogeneous and unpredictable. Currently, we are unable to predict which patients will need IBD-related bowel resection in the first year after diagnosis. Intestinal Ultrasound (IUS) has been proven as a non-invasive modality for assessing disease activity in IBD. However, the evidence for IUS as a predictor of disease course is still limited. Here we present novel data on the predictive value of IUS performed at the time of IBD diagnosis. Methods Patients with new-onset IBD are currently being included in the ongoing multicentre prospective inception cohort study, the IBD Prognosis Study (May 2021 – April 2023). IUS is performed at the time of diagnosis and the patients are followed prospectively. Patients with proctitis are not assessed with IUS. The International Bowel Ultrasound Segmental Activity Score (IBUS-SAS) is calculated for the most inflamed segment with a high score indicating severe disease activity. IBUS-SAS (0-100) incorporates the bowel wall thickness (BWT), bowel wall stratification, colour Doppler signal, and inflammatory fat. Surgery was defined as an IBD-related bowel resection. Patients treated with corticosteroids for &amp;gt; 72 hours or with any IBD-treatment &amp;gt; two weeks prior to IUS were excluded from analysis. In this abstract, we report our preliminary results after including patients for 16 months. Results IBUS-SAS at diagnosis was available in 133 patients (out of 242 included). 68 patients were diagnosed with Crohn’s disease (CD) (ilieal: 22, colonic: 23, ileocolonic: 23) and 65 patients were diagnosed with ulcerative colitis (UC) or unclassified IBD (left-sided colitis: 20, extensive colitis: 45). Median follow-up was 226 days. During follow-up 10 patients underwent surgery (7.5%). These included 4 patients with UC (extensive colitis: 3, left-sided colitis: 1) and 6 patients with CD (ileal: 2, colonic: 2, ileocolonic: 2). Mean IBUS-SAS at diagnosis was 92.6 among patients who underwent surgery during follow-up vs. 48.8 for patients who did not undergo surgery (p&amp;lt;0.0001). Distribution of scores is shown in Figure 1. Mean BWT at diagnosis was 8.3 mm among patients who underwent surgery during follow-up vs. 5.0 mm for patients who did not undergo surgery (p&amp;lt;0.0001). In total, 12 patients had an IBUS-SAS &amp;gt; 90 at diagnosis and among these 7 (58.3%) were operated during follow-up. Figure 2 shows a Kaplan-Meier Curve of surgical free survival stratified by IBUS-SAS at diagnosis. Conclusion IUS activity at diagnosis of IBD seems to have the capability to predict short term risk of IBD-related surgery. Our results suggest IUS might be used at diagnosis to identify patients at high risk of IBD-related surgery.

Diagnostic accuracy of bowel ultrasonography in patients with inflammatory bowel disease: a systematic review and meta-analysis

Diagnostic accuracy of bowel ultrasonography in patients with inflammatory bowel disease: a systematic review and meta-analysis

Usefulness of Bowel Ultrasound in the Assessment of Endoscopic Response and Remission of Moderate to Severe Ulcerative Colitis

Usefulness of Bowel Ultrasound in the Assessment of Endoscopic Response and Remission of Moderate to Severe Ulcerative Colitis

Diagnostic accuracy of different cross-sectional imaging techniques for disease location and activity in Crohn's disease and external validation and comparison of MARIAs and IBUS-SAS.

The comparative accuracy of cross-sectional imaging techniques for evaluating Crohn's disease (CD) remains uncertain. This study aimed to assess diagnostic accuracy of disease location and activity in different cross-sectional images and validate and compare International Bowel Ultrasound Segmental Activity Score (IBUS-SAS) and Simplified Magnetic Resonance Index of Activity (MARIAs). CD patients were retrospectively included from August 2018 to May 2021. We compared accuracy of B-mode intestinal ultrasound (B-IUS), computed tomography enterography (CTE), and magnetic resonance enterography (MRE) for the identification of disease location. Meanwhile, disease activity was compared on B-IUS, color Doppler imaging, CTE, and MRE. ROC analyses were used to validate MARIAs and IBUS-SAS. Spearman rank correlation was performed to evaluate the relationships between MARIAs/IBUS-SAS and CDAI, SES-CD, and inflammatory indicators. A total of 115 CD patients were evaluated. The diagnostic accuracy of MRE in detecting small bowel disease was superior to that of B-IUS/CTE, showing sensitivity (89.3%), specificity (71.4%), and AUC (0.820). B-IUS had the highest sensitivity (81.2%), specificity (84.8%), and AUC (0.830) for detecting terminal ileal lesions. The diagnostic accuracy for colonic disease and disease activity was not significantly different among these techniques. In the validation of IBUS-SAS, the AUC was 0.860, with an optimal cutoff value to predict active disease of 46.7. MARIAs and IBUS-SAS showed no significant differences in the correlations of CDAI, SES-CD, and inflammatory indicators. MRE and B-IUS are more sensitive for detecting small bowel CD and terminal ileal CD, respectively. IBUS-SAS has potential for precisely defining CD activity.

Combined ultrasonography and CT for prognosis and predicting clinical outcomes of patients with pseudomyxoma peritonei

ObjectivesThis study aimed to identify the diagnostic accuracy of combined ultrasonography (US) and computed tomography (CT) in evaluating the tumor burden of pseudomyxoma peritonei (PMP). Besides, we assessed the ability of this combination to predict the likelihood of complete resection.MethodsThis retrospective study involved 504 patients diagnosed with PMP and scheduled for cytoreduction surgery. We compared tumor burden—quantified as peritoneal cancer index (PCI) by preoperative US and CT (US-CT-PCI)—with surgical findings. Next, we assessed the prognostic value of US-CT PCI and imaging features in determining the completeness of cytoreduction (CCR) score using multivariate analysis.ResultsUS-CT PCI demonstrated a high PCI evaluation accuracy under moderate tumor burden. Higher US-CT PCI could predict incomplete resection. In addition, we identified imaging features such as mesenteric involvement as an independent predictor of incomplete resection (hazard ratio (HR) = 2.006; p = 0.007).ConclusionsUS-CT PCI allowed us to predict the completeness of cytoreductive surgery in patients with PMP. Moreover, the combined US and CT imaging detected several features indicating incomplete cytoreduction.Key Points• Ultrasonography (US) can act as a complementary diagnostic modality in peritoneal cancer index (PCI) evaluation by combining CT in the small bowel area and US in the abdominal area.• A modified peritoneal cancer index (US-CT PCI) helps preoperatively evaluate tumor burden with high accuracy and allows to predict incomplete resection.• US-CT PCI of 20 or above and the involvement of particular structures such as mesentery, independently indicate incomplete resection.

Intestinal Ultrasound for the Pediatric Gastroenterologist: A Guide for Inflammatory Bowel Disease Monitoring in Children: Expert Consensus on Behalf of the International Bowel Ultrasound Group (IBUS) Pediatric Committee.

Crohn disease and ulcerative colitis are chronic inflammatory bowel diseases (IBD) often diagnosed in childhood. A strict monitoring strategy can potentially alter the disease course and facilitate early effective treatment before irreversible bowel damage occurs. Serial colonoscopy in children, the gold standard for monitoring, is impractical. Accurate, real-time, noninvasive markers of disease activity are needed. Intestinal ultrasound is an accurate, noninvasive, real-time, point-of-care, cross-sectional imaging tool used to monitor inflammation in pediatric IBD patients in Europe, Canada, and Australia. It is now emerging in a few expert centers in the United States as a safe, non-radiating, inexpensive, bedside tool used by the treating gastroenterologist for real-time decision-making. Unlike the standard biomarkers of pediatric IBD activity, C-reactive protein, and fecal calprotectin, intestinal ultrasound (IUS) facilitates disease localization, characterizes severity, extent, and accurately detects complications. Perhaps most importantly, IUS may enhance shared understanding and ease the burden of treatment decision-making for both the gastroenterologist and the patient. There is a lack of standardization for bedside IUS among pediatric gastroenterologists. The purpose is to outline a standardized approach to pediatric bedside IUS, including basic equipment requirements and technique, patient selection, preparation and positioning, technical considerations and limitations, documentation of mesenteric and luminal features of IBD, characterization of penetrating disease and strictures, and provide a proposed pediatric IUS monitoring algorithm to guide care.

Pediatric Patient and Caregiver Satisfaction With the Use of Transabdominal Bowel Ultrasound in the Assessment of Inflammatory Bowel Diseases.

Transabdominal bowel ultrasound (TABUS) is emerging as an attractive, noninvasive tool in inflammatory bowel disease (IBD). Patient and caregiver experience with TABUS is not well described. We aimed to determine pediatric patient and caregiver satisfaction with TABUS and the impact of IBD severity, gender, age, and a history of anxiety on satisfaction. Pediatric patients (0-18 years old) with suspected IBD prospectively underwent baseline TABUS, magnetic resonance enterography (MRE), blood work, stool studies, and endoscopy. Patients and their caregiver each completed a cross-sectional satisfaction questionnaire (5-point Likert scale) after the baseline investigations. There were 54 patients included (67% male). The majority were completely satisfied and strongly agree TABUS was better tolerated than other investigations, regardless of disease severity ( P > 0.05). Patients with higher Simple Endoscopic Score for Crohn Disease (SES-CD) scores felt that TABUS increased their understanding of their IBD ( P < 0.05) and disease location ( P < 0.05). Patients with Crohn disease had similar responses to those with ulcerative colitis, but more strongly agreed that TABUS was better than MRE and endoscopy ( P < 0.05). Those with anxiety did not have an increased level of worry about potential ultrasound findings ( P > 0.05). Pediatric patients and their caregivers were highly satisfied with TABUS, preferring it to other modalities. It did not lead to increased worry, and was particularly important in those with severe IBD. These findings support wider implementation of this well tolerated and preferred monitoring tool in pediatrics.

Feasibility and acceptability of a diagnostic randomized clinical trial of bowel ultrasound in infants with suspected necrotizing enterocolitis.

We conducted a pilot diagnostic randomized clinical trial (RCT) to examine the feasibility, acceptability, and preliminary outcomes of adding bowel ultrasound (BUS) to the diagnostic evaluation for necrotizing enterocolitis (NEC). Infants ≤ 32 weeks’ gestational age with NEC concern were randomized to undergo abdominal X-ray (AXR) or AXR + BUS. The primary outcome was study feasibility. Secondary outcomes included rates of NEC diagnosis and duration of treatment with bowel rest and antibiotics. A total of 56 infants were enrolled; 16 developed NEC concern and were randomized. Rates of recruitment (56/82 = 68%), retention (16/16 = 100%), and protocol compliance (126/127 = 99%) met pre-specified thresholds for feasibility. No significant differences in rates of NEC diagnosis were found between the two groups. Durations of bowel rest and antibiotic treatment were also similar. Conclusion: Our study supports the feasibility of conducting a definitive diagnostic RCT to establish safety and efficacy of BUS for NEC. Clinical trial registration: The study was registered at https://clinicaltrials.gov (NCT03963011). What is Known:• Bowel ultrasound (BUS) is increasingly being utilized as an adjunct to abdominal radiographs in evaluating for necrotizing enterocolitis (NEC).• The impact of BUS on patient outcomes is unknown.What is New:• A diagnostic randomized controlled trial study design to determine safety and effectiveness of adding BUS to NEC evaluation is feasible and acceptable.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00431-022-04526-4.

Ultrasonographic scores for ileal Crohn’s disease assessment: Better, worse or the same as contrast-enhanced ultrasound?

BackgroundIntestinal ultrasound (IUS) is an increasingly used non-invasive tool to evaluate Crohn’s disease (CD) activity. Recently, two IUS scores that evaluate inflammatory activity have emerged: the Simple Ultrasound Activity Score for CD (SUS-CD) and the International Bowel Ultrasound Segmental Activity Score (IBUS-SAS). We aimed to compare the accuracy of SUS-CD, IBUS-SAS and contrast-enhanced ultrasound (CEUS) in predicting inflammatory activity in the terminal ileum in ileocolonoscopy in CD patients.MethodsRetrospective study including all consecutive CD patients submitted to IUS with CEUS directed to the terminal ileum performed by a single operator between April 2016 and March 2020. Segmental SUS-CD and IBUS-SAS were calculated. A time-intensity curve of the contrast bowel wall enhancement was created with measurement of peak intensity using CEUS. The CD endoscopic activity in ileocolonoscopy was graded by Simple Endoscopic Score for CD (SES-CD) as inactive (SES-CD < 7) or active (SES-CD ≥ 7).ResultsFifty patients were included, 54.0% were female, with mean age of 34 ± 12 years, and most had isolated ileal disease (60.0%), and a nonstricturing, nonpenetrating behaviour (44.0%). Most of the patients (60.0%) had active endoscopic disease (SES-CD ≥ 7). SUS-CD and IBUS-SAS were not different between patients with active or inactive endoscopic disease (p = 0.15; 0.57, respectively), having a poor accuracy to correlate endoscopic activity (area under de curve (AUC) 0.62; 0.55, respectively). Peak intensity in CEUS was significantly different in patients with active or inactive endoscopic disease (p = 0.004), having a good accuracy to correlate endoscopic activity (AUC 0.80).ConclusionUnlike CEUS, SUS-CD and IBUS-SAS were not able to accurately correlate endoscopic activity in terminal ileum in CD. Therefore, CEUS is a non-invasive emerging method that should be increasingly integrated in the ultrasonographic evaluation of CD patients.