Bowel Sonography Research Articles

Bowel Ultrasound State of the Art: Grayscale and Doppler Ultrasound, Contrast Enhancement, and Elastography in Crohn Disease.

Bowel ultrasound (US) is accurate for assessing bowel inflammation and complications in Crohn disease. Additionally, contrast-enhanced US provides a quantitative, objective measurement of inflammatory activity in inflammatory bowel disease, and shear wave elastography predicts the stiffness of bowel, an increase of which suggests less response to medical therapy, often necessitating surgery. Overall, bowel US is an excellent, safe, and repeatable choice for routine surveillance and for urgent imaging. We describe an approach to evaluating inflammatory bowel disease and review its features on standard grayscale US with Doppler imaging and show how contrast-enhanced US and shear wave elastography can distinguish between inflammatory and fibrostenotic bowel.

Bowel Ultrasound: No Longer a Cinderella of Bowel Imaging

Bowel Ultrasound: No Longer a Cinderella of Bowel Imaging

The Role of Bowel Ultrasound in Detecting Subclinical Inflammation in Pregnant Women with Crohn's Disease.

Background and AimsMaintaining disease remission improves outcomes for pregnant women with Crohn’s disease (CD). As symptoms may correlate poorly with disease activity in the gravid state, we investigated the utility of bowel sonography during pregnancy to assess disease activity.MethodsWe conducted a prospective observational cohort study of pregnant women with CD undergoing bowel sonography between July 1, 2012, and December 1, 2016. Clinically active disease was defined using standardized clinical indices (Harvey Bradshaw Index >4 for active disease). Sonographic findings were graded as inactive (normal, mild) or active (moderate, severe) by expert radiologists.ResultsThere were 91 pregnancies in 82 CD patients. Symptoms were present in 12 pregnancies; however, eight (67%) had sonographic findings of inactive disease, and escalation of therapy was not initiated. Conversely, sonographically active disease in seven asymptomatic pregnancies resulted in four women escalating therapy. The remaining three women declined escalation of therapy, one had a miscarriage, and the other two women had persistently active disease on sonography and endoscopy at one-year postpartum.ConclusionsBowel ultrasound may detect subclinical inflammation in asymptomatic pregnant women with CD and stratify CD activity in symptomatic patients. Therefore, bowel sonography should be considered as a useful adjunct for the assessment of the pregnant woman with Crohn’s disease.

Bowel Ultrasound for the Diagnosis of Necrotizing Enterocolitis: A Meta-analysis.

Radiographic evaluation for necrotizing enterocolitis (NEC) often yields nonspecific findings. Bowel ultrasound (BUS) provides additional information beyond that of abdominal radiographs and may be helpful in the diagnosis of NEC in neonates. We systematically reviewed and aggregated existing literature to get a better estimate of diagnostic accuracy of BUS in the diagnosis of NEC. A literature search was performed using PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature to identify studies in which infants with clinically suspected NEC were evaluated using BUS. Studies that used modified Bell staging criteria as the reference standard were included. Study quality was assessed, and pooled sensitivity and specificity of various BUS findings for diagnosing NEC were determined. Six articles with a total of 462 patients met eligibility and inclusion criteria. There was heterogeneity in BUS findings evaluated across studies. Ultrasound detection of classic signs of NEC (portal venous gas, pneumatosis, and free air) had pooled sensitivities ranging from 0.27 to 0.48 and pooled specificities ranging from 0.91 to 0.99. Bowel wall thinning and absent peristalsis had overall low sensitivity (0.22 and 0.30) but high specificity (0.96 and 0.96) for NEC. Assessment of abdominal fluid, which included ascites and focal fluid collection, also had overall low sensitivity and high specificity (simple ascites: 0.45 and 0.92; focal fluid collection: 0.19 and 0.98). In summary, individual BUS findings have low sensitivity and high specificity for diagnosis of NEC. Bowel ultrasound may be a useful adjunct to plain abdominal radiographs in the evaluation of infants with clinical suspicion of NEC.

Unmet needs of Italian physicians managing patients with inflammatory bowel disease

BackgroundLittle is known about the unmet needs of physicians caring for patients with inflammatory bowel disease (IBD). AimsThis study explored the practical difficulties and needs for professional updating of Italian IBD physicians. MethodsA questionnaire was distributed to 600 physicians attending IG-IBD meetings. Results280 physicians completed the questionnaire (46.7%). On a 5-point Likert scale (from 1, strongly disagree to 5, strongly agree), they identified the most problematic issues in managing IBD patients as increasing bureaucracy (3.9), lack of extra-gastroenterological IBD expertise (3.4), lack of diagnostic techniques (3.1) and budget limitations (2.9). The most lacking techniques, ranked from 1 (greatest need) to 9 (lowest need), were: anti-drug antibody and trough level assays (2.7), device-assisted enteroscopy (3.1), exploration under anaesthesia (3.2), MR enterography (3.2), and bowel ultrasonography (3.3). About professional updating, respondents indicated (on a 5-point Likert scale) that helpful topics were practical medicine (4.3), managing difficult patients (4.1), and guidelines (4.0). The most desired modality for updating was residential courses on clinical practice (4.3). ConclusionSeveral factors potentially limit the best management of IBD patients in Italy. Satisfying these unmet needs could improve care for IBD patients.

Intestinal Ultrasound Course Module 1 in Calgary 2018

The International Bowel Ultrasound Group (IBUS-Group) was created in 2016 with the aim promoting gastrointestinal ultrasound (GIUS) on the international stage and to advance research, teaching and clinical use of GIUS in the field of inflammatory bowel disease (IBD).

Bedside Sonography Performed by Emergency Physicians to Detect Appendicitis in Children.

The aim of this study was to evaluate the ability of emergency physicians with various levels of point-of-care ultrasound (POCUS) experience to detect appendicitis with POCUS among children visiting a pediatric emergency department (ED). A prospective cohort study was conducted in an urban, tertiary care pediatric ED. Children aged 2 to 18 years old who presented with acute abdominal pain suggesting appendicitis were included. Patients were excluded if they had a history of appendectomy or hemodynamic instability requiring resuscitation or were transferred with proven diagnosis of appendicitis. Participating physicians had various levels of POCUS experience. Four of the 22 physicians were experienced in bowel sonography while the others had basic experience in abdominal POCUS. All the participating physicians received a 1-hour didactic and practical training session on appendix ultrasound. The treating physician performed POCUS following initial physical examination, before further radiologic evaluation. POCUS examinations were recorded as positive for appendicitis, normal, or inconclusive, with normal or inconclusive studies considered negative. Final outcomes were determined by pathology and/or operative reports for surgical cases and telephone follow-up at 3 weeks for those who did not have surgery. The primary analysis was a simple proportion for sensitivity and specificity for POCUS. Expecting a sensitivity of 80% based on previous studies, we calculated that a sample size of 50 cases would provide a 95% confidence interval (CI) ranging from 66% to 90%. Of the 140 approached patients, 121 accepted to participate and were recruited. After four patients were excluded for missing POCUS data, 117 patients were included in the primary analysis, of whom 51 (44%) had appendicitis. Twenty-two physicians performed between one and 20 POCUS procedures. The POCUS was positive in 39, negative in nine, and inconclusive in 69 patients. POCUS was interpreted as positive in 27 of 51 appendicitis for a sensitivity of 0.53 (95% CI= 0.40-0.66). A negative or inconclusive POCUS was reported for 54 of 66 patients without appendicitis (specificity= 0.82; 95% CI= 0.71-0.89). This study shows limited sensitivity and specificity of POCUS for appendicitis in children, with a high proportion of inconclusive examinations, when performed by emergency physicians with various level of experience in POCUS.

Sa1780 - Bowel Ultrasound is Accurate in Assessing Disease Activity in Ulcerative Colitis

Sa1780 - Bowel Ultrasound is Accurate in Assessing Disease Activity in Ulcerative Colitis

Tu1703 - Monitoring Reponse to Adalimumab Therapy in Crohn's Disease Patients by Bowel Ultrasound: Sub-Analysis from Trust

Tu1703 - Monitoring Reponse to Adalimumab Therapy in Crohn's Disease Patients by Bowel Ultrasound: Sub-Analysis from Trust

Bowel Ultrasound for Predicting Surgical Management of Necrotizing Enterocolitis in Preterm Infants: A Meta-Analysis

Purpose: To evaluate, through a meta-analysis, abdominal ultrasound (AUS) findings that can be predictive for surgical management of necrotizing enterocolitis (NEC) in preterm infants. Methods: A literature search was performed using Embase, PubMed, and Cumulative Index of Nursing and Allied Health Literature. Studies reporting on AUS findings associated with surgical management of NEC were selected. We defined surgical management to include laparotomy …

Bowel Ultrasound for Predicting Surgical Management of Necrotizing Enterocolitis in Preterm Infants: A Meta-Analysis

Bowel Ultrasound for Predicting Surgical Management of Necrotizing Enterocolitis in Preterm Infants: A Meta-Analysis

Real-time Interobserver Agreement in Bowel Ultrasonography for Diagnostic Assessment in Patients With Crohn’s Disease: An International Multicenter Study

The unavailability of standardized parameters in bowel ultrasonography (US) commonly used in Crohn's disease (CD) and the shortage of skilled ultrasonographers are 2 limiting factors in the use of this imaging modality around the world. The aim of this study is to evaluate interobserver agreement among experienced sonographers in the evaluation of bowel US parameters in order to improve standardization in imaging reporting and interpretation. Fifteen patients with an established diagnosis of CD underwent blinded bowel US performed by 6 experienced sonographers. Prior to the evaluation, the sonographers and clinical and radiological IBD experts met to formally define the US parameters. Interobserver agreement was tested with the Quatto method (s). All operators agreed on the presence/absence of CD lesions and distinguished absence of/mild activity or moderate/severe lesions in all patients. S values were moderate for bowel wall thickness (s = 0.48, P = n.s.), bowel wall pattern (s = 0.41, P = n.s.), vascularization (s = 0.52, P = n.s.), and presence of lymphnodes (s = 0.61, P = n.s.). Agreement was substantial for lesion location (s = 0.68, P = n.s.), fistula (s = 0.74, P = n.s.), phlegmon (s = 0.78, P = 0.04), and was almost perfect for abscess (s = 0.95, P = 0.02). Poor agreement was observed for mesenteric adipose tissue alteration, lesion extent, stenosis, and prestenotic dilation. In this study, the majority of the US parameters used in CD showed moderate/substantial agreement. The development of shared US imaging interpretation patterns among sonographers will lead to improved comparability of US results among centers and facilitate the development of multicenter studies and the spread of bowel US training, thereby allowing a wider adoption of this useful technique.

Diagnostic Accuracy of Ultrasonography in the Detection of Postsurgical Recurrence in Crohn's Disease: A Systematic Review with Meta-analysis.

The postoperative course of Crohn's disease (CD) is best predicted by ileocolonoscopy. Ultrasonography (US) has been proposed as indicator for postsurgical recurrence (PSR), but further confirmation is needed. We performed a systemic review with meta-analysis to assess the pooled diagnostic accuracy of US in the evaluation of PSR. The systematic review was performed in PubMed/MEDLINE, EMBASE, SCOPUS, and Cochrane databases to identify studies assessing the US accuracy in PSR diagnosis. A sub-analysis between bowel sonography (BS), small-intestine contrast ultrasound (SICUS), and contrast-enhanced ultrasound (CEUS) was performed. Pooling was performed using diagnostic fixed or random-effect model according with heterogeneity. Ten studies (536 patients) met the inclusion criteria. There was no publication bias. Pooled sensitivity and specificity of US in detecting PSR were 0.94 (95% CI, 0.86-0.97) and 0.84 (95% CI, 0.62-0.94; diagnostic accuracy 90%), respectively. At sub-analysis, pooled sensitivity and specificity were 0.82 (95% CI, 0.76-0.88) and 0.88 (95% CI, 0.74-0.95) respectively for BS, with 0.99 (95% CI, 0.99-1.00) and 0.74 (95% CI, 0.73-0.74) for SICUS. Finally, an SROC curve was built to establish the best bowel wall thickness (BWT) cutoff able to predict the presence of severe PSR (Rutgeerts ≥3): a BWT ≥5.5 mm at US revealed sensitivity of 83.8% (95% CI, 73.6%-90.6%), specificity of 97.7% (95% CI, 93%-99%). US shows high sensitivity and specificity for the diagnosis of PSR. SICUS appears more sensitive-but less specific-than BS, while the role of CEUS needs further investigation. A cutoff value of BWT ≥5.5 mm is strongly indicative of severe PSR. 10.1093/ibd/izy012_video1izy012.video15775249754001.

Combined Endoscopic/Sonographic-based Risk Matrix Model for Predicting One-year Risk of Surgery: A Prospective Observational Study of a Tertiary Centre Severe/Refractory Crohn's Disease Cohort.

In the management of Crohn's disease [CD] patients, having a simple score combining clinical, endoscopic, and imaging features to predict the risk of surgery could help to tailor treatment more effectively. We aimed to prospectively evaluate the 1-year risk factors for surgery in refractory/severe CD and to generate a risk matrix for predicting the probability of surgery at 1 year. CD patients needing a disease re-assessment at our tertiary inflammatory bowel disease [IBD] centre underwent clinical, laboratory, endoscopic, and bowel sonography [BS] examinations within 1 week. The optimal cut-off values in predicting surgery were identified using receiver operating characteristic [ROC] curves for the Simple Endoscopic Score for CD [SES-CD], bowel wall thickness [BWT] at BS, and small bowel CD extension at BS. Binary logistic regression and Cox regression were then carried out. Finally, the probabilities of surgery were calculated for selected baseline levels of covariates and results were arranged in a prediction matrix. Of 100 CD patients, 30 underwent surgery within 1 year. SES-CD ≥9 (odds ratio [OR] 15.3; p <0.001], BWT ≥7 mm [OR 15.8; p <0.001], small bowel CD extension at BS ≥33 cm [OR 8.23; p <0.001], and stricturing/penetrating behaviour [OR 4.3; p <0.001] were the only independent factors predictive of surgery at 1 year, based on binary logistic and Cox regressions. Our matrix model combined these risk factors, and the probability of surgery ranged from 0.48% to 87.5% [16 combinations]. Our risk matrix combining clinical, endoscopic, and ultrasonographic findings can accurately predict the 1-year risk of surgery in patients with severe/refractory CD requiring a disease re-evaluation. This tool could be of value in clinical practice, serving as the basis for a tailored management of CD patients.

P276 Risk matrix model for prediction of one-year surgery in Crohn’s disease

Having a simple score able to predict the risk of surgery, combining clinical, endoscopic and imaging features, could tailor the management of patients with Crohn’s disease (CD). Aim: to prospectively evaluate the one-year risk factors for surgery in CD and to build a risk matrix model for predicting the 1-year probability of surgery. Enrolled CD patients underwent prospectively clinical, laboratory, endoscopy and bowel sonography (BS) examinations within one week. Firstly, the optimal cut-off values for Simple Endoscopic Score for CD (SES-CD), bowel wall thickness (BWT) at BS and disease extension at BS in predicting surgery were identified by ROC curves; then binary logistic regression and Cox’s regression were conducted. Finally, the probabilities of surgery were computed for selected baseline levels of covariates and results were arranged in a prediction matrix model. Among 100 CD patients included in the study (males 58%, mean age 36.2 ± 11.5), 30% underwent surgery within one year. SES-CD>9 (OR 15.3; p < 0.001), BWT >7 mm (OR 15.8; p < 0.001), disease extension >33 cm (OR 8.23; p < 0.001) and stricturing/penetrating behaviour (OR 4.3; p < 0.001) were the only independent factors for one-year surgery both at binary logistic and Cox’s regression. Finally the matrix model combined these risk factors, and the probability of surgery ranged from 0.48% to 87.5% (16 combinations) (Figure 1). The risk matrix model, combining clinical, endoscopic and ultrasonographic findings, can accurately predict the one-year risk of surgery in CD. This tool could be of relevance into clinical practice, as it could be the basis for a tailored management of CD patients.

P222 Diagnostic accuracy of ultrasonography in the detection of postsurgical recurrence in Crohn’s disease: A systematic review with meta-analysis

The postoperative course of Crohn’s disease (CD) is best predicted by ileocolonoscopy. Ultrasonography (US) has been proposed as indicator for postsurgical recurrence (PSR), but further confirmation is needed. We performed a systemic review with meta-analysis to assess the pooled diagnostic accuracy of US in the evaluation of PSR. The systematic review was performed in PubMed/MEDLINE, EMBASE, SCOPUS and Cochrane databases to identify studies assessing the US accuracy in the PSR diagnosis. A sub-analysis between bowel sonography (BS), small intestine contrast ultrasound (SICUS) and contrast-enhanced ultrasound (CEUS) was performed. Pooling was performed using diagnostic fixed or random-effect model and bivariate analysis according with heterogeneity. Ten studies (536 patients) met the inclusion criteria. There was no significant publication bias. The pooled sensitivity and specificity of US in detecting PSR were 0.94 (95% CI 0.86–0.97) and 0.84 (95% CI 0.62–0.94) (overall diagnostic accuracy 90%). At sub-analysis, pooled sensitivity and specificity were: 0.82 (95% CI 0.76–0.88) and 0.88 (95% CI 0.74–0.95) for BS; 0.99 (95% CI 0.99–1.00) and 0.74 (95% CI 0.73–0.74) for SICUS. Furthermore, an SROC curve was built to establish the best BWT cut-off able to predict the presence of severe PSR (Rutgeerts ≥3): a BWT≥5.5 mm at US revealed: sensitivity 83.8% (95% CI 73.6%-90.6%), specificity 97.7% (95% CI 93%-99%), whereas a BWT≥7 mm had 100% specificity. US shows high sensitivity and specificity for the diagnosis of PSR. SICUS appears more sensitive-but less specific-than BS, while the role of CEUS needs further investigation. A cut-off value of BWT≥5.5 mm is strongly indicative of severe PSR, while a BWT≥7 mm could replace ileocolonoscopy.

Bowel ultrasound for predicting surgical management of necrotizing enterocolitis: a systematic review and meta-analysis

BackgroundNecrotizing enterocolitis (NEC) is a devastating inflammatory disease of the intestinal tract that represents a significant source of morbidity and mortality in preterm infants. Imaging of the abdomen is valuable for timely diagnosis and close monitoring of disease progression in NEC. Bowel ultrasound (US) is increasingly being recognized as an important imaging tool for evaluating NEC that provides additional detail than plain abdominal radiographs.ObjectiveTo identify bowel US findings associated with surgical management or death in infants with NEC.Materials and methodsWe searched Embase, PubMed, and the Cumulative Index to Nursing and Allied Health Literature for studies investigating the association between bowel US findings and surgical management or death in NEC. Selected articles were evaluated for quality of study methodology using the Newcastle-Ottawa Scale, and aggregate statistics for odds ratio (OR) and 95% confidence interval were calculated.ResultsOf 521 articles reviewed, 11 articles comprising 748 infants were evaluated for quality. Nine of the studies were retrospective and from single-center experiences. Pooled analysis showed that focal fluid collections (OR 17.9, 3.1–103.3), complex ascites (OR 11.3, 4.2–30.0), absent peristalsis (OR 10.7, 1.7–69.0), pneumoperitoneum (OR 9.6, 1.7–56.3), bowel wall echogenicity (OR 8.6, 3.4–21.5), bowel wall thinning (OR 7.11.6–32.3), absent perfusion (OR 7.0, 2.1–23.8), bowel wall thickening (OR 3.9, 2.4–6.1) and dilated bowel (OR 3.5, 1.8–6.8) were associated with surgery or death in NEC. In contrast, portal venous gas (OR 3.0, 0.8–10.6), pneumatosis intestinalis (OR 2.1, 0.9–5.1), increased bowel perfusion (OR 2.6, 0.6–11.1) and simple ascites (OR 0.54, 0.1–2.5) were not associated with surgery or death.ConclusionThis meta-analysis identified several bowel US findings that are associated and not associated with surgery or death in NEC. Bowel US may be useful for early identification of high-risk infants with NEC who may benefit from more aggressive treatment, including surgery. Future studies are needed to determine whether the addition of bowel US in NEC evaluation would improve outcomes.

Capsule Endoscopy, Magnetic Resonance Enterography, and Small Bowel Ultrasound for Evaluation of Postoperative Recurrence in Crohn's Disease: Systematic Review and Meta-Analysis.

Anastomotic recurrence is frequent in patients with Crohn's disease (CD) following ileocecal resection. The degree of endoscopic recurrence, quantified by the Rutgeerts score (RS), is correlated with the risk of clinical and surgical recurrence. Noninvasive modalities such as capsule endoscopy (CE), magnetic resonance enterography (MRE), and intestinal ultrasound (US) may yield similar information without the need for ileocolonoscopy (IC). The aim of our meta-analysis was to evaluate the accuracy of those modalities for detection of endoscopic recurrence in postoperative CD patients. We performed a systematic literature search for studies comparing the accuracy of CE, MRE, and US with IC for detection of postoperative recurrence in CD. We calculated pooled diagnostic sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curve (AUC) for each comparison. A total of 135 studies were retrieved; 14 studies were eligible for analysis. For CE, the pooled sensitivity was 100% (95% CI, 91%-100%), specificity was 69% (95% CI, 52%-83%), DOR was 30.8 (95% CI, 6.9-138), and AUC was 0.94. MRE had pooled sensitivity of 97% (95% CI, 89%-100%), specificity of 84% (95% CI, 62%-96%), DOR of 129.5 (95% CI, 16.4-1024.7), and AUC of 0.98. US had pooled sensitivity of 89% (95% CI, 85%-92%), specificity of 86% (95% CI, 78%-93%), DOR of 42.3 (95% CI, 18.6-96.0), and AUC 0.93. CE, MRE, and US provide accurate assessment of postoperative endoscopic recurrence in CD. These modalities should gain wider use for detection of postoperative recurrence; the prognostic value of those diagnostic findings merits evaluation in further prospective studies.

Ultrasound assessment of the bowel: inflammatory bowel disease and conditions beyond.

Ultrasound (US) is a versatile imaging study for the evaluation of the bowel in children. US imaging of the bowel can be used as the initial examination or in follow-up for many common pediatric diseases. In this article, we highlight our bowel US technique and describe how US can depict the features of a select group of bowel pathologies relevant to pediatric practice.

LO88: Bedside sonography performed by emergency physicians to detect acute appendicitis in the pediatric emergency department

Introduction: Previous studies have suggested that emergency physicians (EP) highly experienced in point-of-care ultrasound (POCUS) have similar performance to formal ultrasound to identify appendicitis in children. The aim of this study was to evaluate the ability of EP with various levels of POCUS experience to detect appendicitis with POCUS among children visiting a pediatric ED. Methods: A prospective cohort study was conducted in an urban, tertiary care pediatric ED. Children aged 2 to 18 years old who presented to the ED with acute abdominal pain suggesting appendicitis were included. Patients were excluded if they had a history of appendectomy, hemodynamic instability requiring resuscitation, or were transferred with proven diagnosis of appendicitis. Participating EP had various levels of POCUS experience. Four of the 22 physicians were experienced in bowel sonography (EDU 2 level and higher) while the others were inexperienced in bowel sonography (EDU 1). All the participants received a 1-hour didactical and practical training session on appendix ultrasound. The treating physician performed all POCUS following initial physical exam, before further radiological evaluation. Final outcomes were determined by pathology and/or operative reports for surgical cases, and telephone follow-up at 3 weeks for those who did not have surgery. The primary analysis was a simple proportion for sensitivity and specificity for POCUS. Expecting a sensitivity of 80% based on previous studies, we calculated that a sample size of 50 cases would provide a 95%CI ranging from 66 to 90%. Results: We approached 140 patients, of which 121 accepted to participate and were recruited. After excluding 4 patients for missing POCUS data, 117 patients were included in the primary analysis, of which 51 (44%) had appendicitis. Twenty-two EP performed between 1 and 20 POCUS. The POCUS identified 27 out of 51 appendicitis for a sensitivity of 0.53 (95%CI 0.40-0.66). A negative POCUS was reported for 54 out of 66 patients without appendicitis (specificity of 0.82; 95%CI 0.71-0.89). Conclusion: This study shows limited sensitivity and specificity of POCUS when performed by EP with various level of experience for appendicitis in children. While showing lower sensitivity and specificity than previous studies, the inclusion of a large number of physicians solidifies the external validity of our conclusion.