Bowel Sonography Research Articles

Defining the ultrasound longitudinal natural history of newly diagnosed pediatric small bowel Crohn disease treated with infliximab and infliximab-azathioprine combination therapy.

Little is known about changes in the imaging appearances of the bowel and mesentery over time in either pediatric or adult patients with newly diagnosed small bowel Crohn disease treated with anti-tumor necrosis factor-alpha (anti-TNF-α) therapy. To define how bowel ultrasound findings change over time and correlate with laboratory inflammatory markers in children who have been newly diagnosed with pediatric small bowel Crohn disease and treated with infliximab. We included 28 pediatric patients treated with infliximab for newly diagnosed ileal Crohn disease who underwent bowel sonography prior to medical therapy and at approximately 2weeks, 1month, 3months and 6months after treatment initiation; these patients also had laboratory testing at baseline, 1month and 6months. We used linear mixed models to compare mean results between visits and evaluate whether ultrasound measurements changed over time. We used Spearman rank correlation to assess bivariate relationships. Mean subject age was 15.3±2.2years; 11 subjects were girls (39%). We observed decreases in mean length of disease involvement (12.0±5.4 vs. 9.1±5.3cm, P=0.02), maximum bowel wall thickness (5.6±1.8 vs. 4.7±1.7mm, P=0.02), bowel wall color Doppler signal (1.7±0.9 vs. 1.2±0.8, P=0.002) and mesenteric color Doppler signal (1.1±0.9 vs. 0.6±0.6, P=0.005) at approximately 2weeks following the initiation of infliximab compared to baseline. All laboratory inflammatory markers decreased at 1month (P-values<0.0001). There was strong correlation between bowel wall color Doppler signal and fecal calprotectin (ρ=0.710; P<0.0001). Linear mixed models confirmed that maximum bowel wall thickness (P=0.04), length of disease involvement (P=0.0002) and bowel wall color Doppler signal (P<0.0001) change over time in response to infliximab, when adjusted for age, sex, azathioprine therapy, scanning radiologist and baseline short pediatric Crohn's disease activity index score. The ultrasound appearance of the bowel changes as early as 2weeks after the initiation of infliximab therapy. There is strong correlation between bowel wall color Doppler signal and fecal calprotectin.

P.11.13: Bowel Ultrasound and Faecal Calprotectin as Predictors of Response to Infliximab in Ulcerative Colitis

P.11.13: Bowel Ultrasound and Faecal Calprotectin as Predictors of Response to Infliximab in Ulcerative Colitis

P.11.8: Inter-Observer Agreement in Bowel Ultrasonography for Diagnostic Assessment in Patients with Crohn’s Disease

P.11.8: Inter-Observer Agreement in Bowel Ultrasonography for Diagnostic Assessment in Patients with Crohn’s Disease

Cross-sectional evaluation of transmural healing in patients with Crohn’s disease on maintenance treatment with anti-TNF alpha agents

BackgroundTransmural healing (TH) of Crohn’s disease (CD) is a still unexplored and interesting outcome correlated to concept of deep remission. AimTo assess the rate of TH in CD patients treated with anti-TNF alpha agents using two cross-sectional procedures: bowel sonography (BS) and magnetic resonance enterography (MRE). MethodsWe performed a 2-year observational longitudinal study, evaluating steroid-free clinical remission (CR), mucosal healing (MH), and TH in CD patients who would complete a 2-year treatment period with anti-TNFs. All patients underwent endoscopy, BS, and MRE before and after 2 years of treatment. ResultsForty out of 80 CD patients were treated with anti-TNFs for 2 years. CR was achieved in 24 patients (60%) while MH in 14 (35%). Using BS, TH was observed in 10 patients (25%), while using MRE, TH was observed in 9 patients (23%) (k=0.90; P<0.01). A good agreement was observed between MH and TH, both using BS (k=0.63; P<0.01) and MRE (k=0.64; P<0.01). A poor agreement was found between CR and TH, with both BS and MRE (k=0.27 and 0.29, respectively; P<0.01); even though all patients with TH had achieved CR. ConclusionsTH can be achieved in about 25% of CD patients treated with anti-TNFs, as shown by BS and MRE. BS could be used as the first cross-sectional procedure to detect TH.

P473 How to monitor the withdrawal of maintenance treatment with azathioprine in IBD patients with deep remission: results from a prospective study on multiple non invasive tests

Background: There is uncertainty regarding the optimal duration of maintenance treatment with azathioprine (AZA) in Crohn's disease (CD) and ulcerative colitis (UC), with some studies suggesting durations up to 4–5 years and others supporting long-term indefinite use. More recent guidelines state that for patients in long term remission, cessation of treatment may be considered in the absence of objective signs of inflammation, but no data are available on how to monitor these patients after AZA withdrawal. Methods: A prospective observational study was performed on consecutive patients with CD or UC who stopped their maintenance treatment with AZA while being in steroid-free, deep remission, defined as normal clinical and endoscopic indexes, normal C-reactive protein (CRP) and normal fecal calprotectin. After AZA withdrawal, all patients received maintenance treatment with salicylates. Every 3 months, blood samples were collected for standard biochemical tests (including CRP, full blood count and protein electrophoresis), as well as stool samples for fecal calprotectin dosage. Bowel ultrasonography and ileocolonoscopy were performed every 6 and 12 months, respectively, as well as in case of clinical relapse. Multiple logistic regression and Cox proportional-hazards models were used to assess the predictors of disease relapse. Results: 41 patients (23 males, median age 45 years) who stopped AZA after median 7 years (range 5–14) were enrolled. After a mean follow-up of 24 months (range 5–48), 19 patients (46%; 7/19 CD, 12/22 UC) relapsed, within median 13 months (range 2–35). Predictors of clinical relapse at the time of AZA withdrawal were female gender (p=0.045) and age ≤45 years (p=0.035) only for UC. Fecal calprotectin was the only predictor of clinical relapse during the non invasive monitoring performed after AZA withdrawal, both in UC (p=0.019) and in CD (p=0.017). Moreover, fecal calprotectin was positive in all patients with UC and in 57% of CD patients at the time of relapse. Conclusions: Up to half of patients with IBD relapses after AZA withdrawal at different times. Fecal calprotectin can predict subsequent clinical relapse after AZA withdrawal. This can be useful in the non invasive monitoring of patients to detect preclinical relapse and to early correct our therapeutic strategy after AZA withdrawal. Prospective randomized studies are needed to validate such strategy.

P652 Unmet needs of physicians managing inflammatory bowel disease. A Survey of the Italian Group for Inflammatory Bowel Disease (IG-IBD)

Background: It is known that patients affected by Inflammatory Bowel Disease (IBD) present several unmet needs about the management of their illness and its consequences on their Health Related Quality of Life. However, little is known about the unmet needs of physicians caring IBD patients. The aim of the study was to investigate the difficulties and the problems of Italian physicians managing IBD. Methods: A questionnaire was submitted to physicians attending the National Congress and the Residential Courses of IG-IBD. Results: 280 physicians (156 men) completed the questionnaire. Mean age ± SD was 44.4±10.7 years; 95 (33.9%) were working in Academic hospitals. On a 5-point Likert scale, the most problematic issues in managing IBD patients were: increasing bureaucratic charge (3.9±1.2), lacking of extra-gastroenterological IBD expertise (3.4±1.4), lacking of diagnostic techniques (3.1±1.4), budget limitations (2.9±1.3), drugs safety (2.9±1.2), difficulties in guidelines application (2.7±1.2), pharmacy's limitations (2.2±1.1). Ranking from 0 to 9 the most lacking extra-gastroenterological IBD specialist figures led to the following classification: surgeon (2.5±2.5), nobody (3.3±3.4), rheumatologist (3.8±2.3), nutritionist (3.8±2.0), psychologist (3.8±2.2), dermatologist (4.2±2.0), pathologist 4.3±2.5), radiologist (4.8±2.6), stoma therapist (5.4±2.4). Ranking from 0 to 9 the most lacking techniques led to the following classification: nothing (1.6±1.8), anti-drug antibody and trough levels assays (2.7±3.0), enteroscopy (3.1±2.0), exploration under anesthesia of perianal disease (3.2±2.1), entero-MR (3.2±2.4), bowel ultrasonography (3.3±2.8), videocapsule endoscopy (3.9±2.1), entero-CT scan (4.4±2.1), fecal calprotectin (4.7±3.0). Conclusions: In Italy, several situations appear to potentially limit the best management of IBD patients. However, most of them appear to be correctable.

Small Bowel Ultrasound among Undernourished Children

Small Bowel Ultrasound among Undernourished Children

Ultrasound and MRI predictors of surgical bowel resection in pediatric Crohn disease.

Imaging predictors for surgery in children with Crohn disease are lacking. To identify imaging features of the terminal ileum on short-interval bowel ultrasound (US) and MR enterography (MRE) in children with Crohn disease requiring surgical bowel resection and those managed by medical therapy alone. This retrospective study evaluated patients 18years and younger with Crohn disease undergoing short-interval bowel US and MRE (within 2months of one another), as well as subsequent ileocecectomy or endoscopy within 3months of imaging. Appearance of the terminal ileum on both modalities was compared between surgical patients and those managed with medical therapy, with the following parameters assessed: bowel wall thickness, mural stratification, vascularity, fibrofatty proliferation, abscess, fistula and stricture on bowel US; bowel wall thickness, T2 ratio, enhancement pattern, mesenteric edema, fibrofatty proliferation, abscess, fistula and stricture on MRE. A two-sided t-test was used to compare means, a Mann-Whitney U analysis was used for non-parametric parameter scores, and a chi-square or two-sided Fisher exact test compared categorical variables. Imaging findings in surgical patients were correlated with location-matched histopathological scores of inflammation and fibrosis using a scoring system adapted from the Simple Endoscopic Score for Crohn Disease, and a Spearman rank correlation coefficient was used to compare inflammation and fibrosis on histopathology. Twenty-two surgical patients (mean age: 16.5years; male/female: 13/9) and 20 nonsurgical patients (mean age: 14.8; M/F: 8/12) were included in the final analysis. On US, the surgical group demonstrated significantly increased mean bowel wall thickness (6.1mm vs. 4.7mm for the nonsurgical group; P = 0.01), loss of mural stratification (odds ratio [OR] = 6.3; 95% confidence interval [CI]: 1.4-28.4; P = 0.02) and increased fibrofatty proliferation (P = 0.04). On MRE, the surgical group showed increased mean bowel wall thickness (9.1mm vs. 7.2mm for the nonsurgical group; P = 0.02), increased mean T2 ratio (4.6 vs. 3.6 for the nonsurgical group; P = 0.03), different enhancement patterns (P = 0.03), increased mesenteric edema (P = 0.001) and increased stricture formation (OR = 8.2; 95% CI: 1.8-36.4; P = 0.005). Nineteen of 22 ileocecectomy specimens showed severe inflammation and 21/22 showed severe fibrosis, with significant correlation between inflammation and fibrosis scores (ρ = 0.55; P = 0.008); however, correlation with imaging findings was limited by the uniformity of findings on histopathology. Children with terminal ileal Crohn disease requiring surgical bowel resection demonstrate more severe manifestations of imaging features traditionally associated with both active inflammation and chronic fibrosis than those managed medically on US and MRE, findings that are corroborated by histopathology. These features may potentially serve as imaging biomarkers indicating the necessity for surgical intervention.

Bowel Ultrasonography in the Management of Crohn's Disease. A Review with Recommendations of an International Panel of Experts.

Bowel ultrasonography (US) is considered a useful technique for assessing mural inflammation and complications in Crohn's disease (CD). The aim of this review is to appraise the evidence on the accuracy of bowel US for CD. In addition, we aim to provide recommendations for its optimal use. Publications were identified by literature search from 1992 to 2014 and selected based on predefined criteria: 15 or more patients; bowel US for diagnosing CD, complications, postoperative recurrence, activity; adequate reference standards; prospective study design; data reported to allow calculation of sensitivity, specificity, agreement, or correlation values; articles published in English. The search yielded 655 articles, of which 63 were found to be eligible and retrieved as full-text articles for analysis. Bowel US showed 79.7% sensitivity and 96.7% specificity for the diagnosis of suspected CD, and 89% sensitivity and 94.3% specificity for initial assessment in established patients with CD. Bowel US identified ileal CD with 92.7% sensitivity, 88.2% specificity, and colon CD with 81.8% sensitivity, 95.3% specificity, with lower accuracy for detecting proximal lesions. The oral contrast agent improves the sensitivity and specificity in determining CD lesions and in assessing sites and extent. Bowel US is a tool for evaluation of CD lesions in terms of complications, postoperative recurrence, and monitoring response to medical therapy; it reliably detects postoperative recurrence and complications, as well as offers the possibility of monitoring disease progression.

Sa2028 Inter-Observer Agreement in Bowel Ultrasonography for Diagnostic Assessment in Patients With Crohn's Disease

Sa2028 Inter-Observer Agreement in Bowel Ultrasonography for Diagnostic Assessment in Patients With Crohn's Disease

Tu1964 High Rate of Clinically Relevant Findings at Routinely Performed Bowel Ultrasound in Asymptomatic Inflammatory Bowel Disease Patients

Tu1964 High Rate of Clinically Relevant Findings at Routinely Performed Bowel Ultrasound in Asymptomatic Inflammatory Bowel Disease Patients

P168. Interobserver agreement in bowel ultrasonography for diagnostic assessment in patients with Crohn’s disease

P168. Interobserver agreement in bowel ultrasonography for diagnostic assessment in patients with Crohn’s disease

Bowel Sonography and MR Enterography in Children.

The objective of this study was to assess the diagnostic agreement between bowel sonography and MR enterography in children with suspected or confirmed inflammatory bowel disease (IBD). We prospectively studied 33 children undergoing clinically indicated MR enterography. Bowel sonography was performed within 2 hours before MR enterography. The reliability of each modality was assessed by computing the interreader kappa agreement on nine inflammatory markers in eight bowel segments and the interreader intraclass correlation coefficients (ICC) in each bowel segment. The agreement between both modalities in each bowel segment was also calculated using the Kendall coefficient of concordance (KCC) in addition to the sensitivity and specificity of sonography using those of MR enterography as the reference standard. Sonographic readings are substantially reliable in the colon and terminal and distal ileum (ICC = 0.79-0.88) but are highly unreliable in the mid and proximal small bowel. MR enterography has moderate to almost perfect reliability for all bowel segments (ICC = 0.43-0.96). Sonography was in substantial agreement with MR enterography in most of the large bowel (KCC = 0.67-0.83) and terminal and distal ileum (KCC = 0.75) and in moderate agreement in the remaining bowel segments (KCC = 0.45-0.48). Sonographic findings are specific for disease using MR enterography as the reference standard in all bowel segments (0.83-1.00), but sensitivity markedly varies according to disease location. Sonography is highly specific and shows substantial agreement with MR enterography in detecting inflammatory and damage changes in the colon and terminal and distal ileum, the segments most likely to be affected by IBD. Therefore, sonography can be a good complement to MR enterography in evaluations of patients with known or suspected IBD, particularly if MR enterography access is limited.

Distinct management issues with Crohnʼs disease of the small intestine

Small bowel Crohn's disease can present with clinical challenges that are specific to its location. In this review, we address some of the areas that present particular problems in small bowel Crohn's disease. A key issue specific to small bowel Crohn's disease relates to its diagnosis given that access to the small bowel is limited. Radiological advances, particularly in small bowel ultrasonography and MRI, as well as the introduction of capsule endoscopy and balloon enteroscopy are helping to address this. In addition, our ability to differentiate small bowel Crohn's disease from other causes of inflammation, such as tuberculosis, is improving on the basis of better understanding of the features that differentiate these conditions. It is also becoming apparent that jejunal Crohn's disease represents a distinct disease phenotype with potentially worse clinical outcomes. Finally, because it is a rare complication, our understanding of small bowel cancer associated with Crohn's disease remains limited. Recent publications are, however, starting to improve our knowledge of this condition. Although small bowel Crohn's disease presents specific management issues not seen in patients with Crohn's disease elsewhere in the gastrointestinal tract, our knowledge of how to manage these is improving.

US of gastrointestinal tract disease.

The potential use of ultrasonography (US) in evaluating gut disease has been underappreciated in most diagnostic imaging departments in North America. The impression that US has a questionable role in bowel assessment is related to the operator-dependent nature of the modality, the technical challenges of performing bowel US examinations, and the lack of familiarity of radiologists and technologists with the US appearances of normal and abnormal bowel. However, with development of technical experience by the sonographer and integration of a clinical focus at patient evaluation, US can become a powerful tool for bowel assessment. Unlike computed tomography and magnetic resonance imaging, it provides a widely available, noninvasive, inexpensive method for evaluating the gut without the use of ionizing radiation. These factors are of particular importance in young patients and those who require recurrent follow-up imaging. Because US is performed with real-time imaging, the modality also allows the sonographer to view and assess the motility properties of the bowel, a feature that has not been previously used to its full potential. Color Doppler US can yield useful information about mural vascularity in bowel disease when used in conjunction with gray-scale findings and clinical symptoms. Radiologists should be familiar with the static and dynamic US appearances of the normal and abnormal bowel, recognize features of various pathologic conditions, and understand potential errors at imaging interpretation. Online supplemental material is available for this article.

Power Doppler sonography to predict the risk of surgical recurrence of Crohn's disease.

The aim of this work is to investigate the role of power Doppler sonography as an additional predictor of surgical recurrence in Crohn's disease. A sample of 33 patients, with ileal or ileocolonic Crohn's disease, that had underwent intestinal resection, were retrospectively enrolled. All patients had bowel ultrasonography 7-16months after resection. Power Doppler sonography of the preanastomotic ileum was evaluated as a possible prognostication tool to assess the risk of long-term need for reoperation. The absolute incidence of surgical recurrence in those who had a positive power Doppler was 42%, while that of those who had a negative power Doppler was 28.6%. Combining the power Doppler with bowel wall thickness, the surgical recurrence risk grew from 41.2% of those with a positive power Doppler and thickness >3mm to 55.6% of those with a positive power Doppler and thickness >6mm. Power Doppler look to be another useful prediction tool for the personalization of patient's care. It could be useful to perform power Doppler in all patients with a wall thickness >5mm: for those who have a positive power Doppler it may be indicated as a more aggressive prophylactic therapy.

Ultrasonographic findings in Crohn’s disease

In recent years transabdominal bowel sonography has become a first-line modality both in the diagnosis and in the follow-up of inflammatory bowel diseases, especially Crohn's disease, reaching values of sensitivity ranging from 84 to 93%. In particular, its role is very useful in the early diagnosis of complications such as stenosis, phlegmons, abscesses and fistulae. According to the available literature the ability of US to provide information about disease activity is still under debate and further studies are necessary. In this regard, of fundamental importance is the use of additional techniques such as color- and power-Doppler and contrast-enhanced ultrasound. The purpose of this paper is to report the main sonographic intestinal and extraintestinal findings detectable in Crohn's disease.

92 Use of the Patient Reported Outcomes Measurement Information System (PROMIS) in a Pediatric Cohort With Inflammatory Bowel Disease (IBD)

BACKGROUND AND AIM. Bowel ultrasonography (US) is a well-established non-invasive tool in the evaluation of pediatric Crohn's disease. There are only few data on its role in Ulcerative Colitis (UC). This is a prospective, blind comparative study versus colonoscopy to evaluate the usefulness of US in assessing the extent and activity of disease in pediatric UC. METHODS. Sixty consecutive pediatric patients (pts) (median age 15 years; range 221) with an established diagnosis of UC and suspected disease flare-up were prospectively enrolled. Fifty pts were finally eligible for the study. All underwent clinical evaluation, bowel US with Color-Doppler examination and colonoscopy. For each patient Pediatric Ulcerative Colitis Activity Index (PUCAI) and Mayo endoscopic subscore (MS) were calculated. Blind US was performed the day before endoscopy in all pts. The US assessed parameters were Bowel Wall Thickness (BWT >3 mm), BW stratification, BW vascularity, presence of haustra coli and enlarged mesenteric lymph nodes. RESULTS. The endoscopic extent of disease was independently confirmed in 47/50 pts by US, that yielded a 90% concordance with endoscopy (95%CI 0.82-0.96). US sensitivity (SE) and specificity (SP) in the different colonic segments are reported in the table. Multiple regression analysis showed that variables with an independent predictive value of severity at endoscopy were increased BWT (p<0.0008), BW vascularity (p<0.002), loss of haustra (p=0.031) and loss of BW stratification (p=0.021). Each variable was assigned a value of 1 if present. The final US score ranged from 0 to 4. The alteration of more than 2 parameters had a SE of 100% and a SP of 93% for severe disease (AUC 0.98). The US score strongly correlated with PUCAI (r=0.94) and MS (r=0.90) (p<0.0001) (Figure 1). CONCLUSIONS. Colonic US is a useful first line diagnostic tool in pediatric UC, particularly in the setting of severe disease. US helps to assess the extent and activity of disease and to estimate the severity of a flare-up, prior to further invasive tests. US SENSITIVITY AND SPECIFICITY IN THE DIFFERENT COLONIC SEGMENTS

Su1297 Direct Comparision of Bowel Ultrasonography and Magnetic Resonance Enterography in Patients With Small Bowel Crohn's Disease

Su1297 Direct Comparision of Bowel Ultrasonography and Magnetic Resonance Enterography in Patients With Small Bowel Crohn's Disease

Sa1210 Bowel Ultrasound Is Useful in Crohn's Disease Monitoring: Preliminary Results From the Trust Study in Germany

Background: MR enterography (MRE) has been developed to detect intestinal lesions in patients with Crohn's disease (CD) without radiation exposure. However, there has been few study to assess the usefulness of MRE in patients who are treated with biologics. The aim of this study was to prospectively evaluate whether MRE could detect any CD lesions in patients with secondary loss of responsiveness for biologics.We also assessed the usefulness of MRE in predicting prognosis of CD patients who are treated with biologics. Methods: MRE were conducted in 36 patients with established CD who are treated with biologics (IFX 29, ADA 7). All patients used biologics at least for >12 months. At the enrollment into the study, clinical symptoms were recorded within 7 days before the procedures of MRE and Crohn's Disease Activity Index (CDAI) was calculated. Clinical remission was defined as CDAI ≤150, and loss of responsiveness (LOR) was defined as CDAI>150 at the entries. To assess the prognosis of CD, clinical characteristics and outcome after MRE for at least 6 months were collected. Clinical relapse was defined that 1) medical treatments were altered due to abdominal symptoms for CD, 2) CDAI>175, or 3) disease related hospitalization was required. Diagnostic ability of MRE was assessed in patients with clinical remission (n=23) and LOR (n=13). Cumulative non-relapse rate was calculated using Kaplan-Meier survival analysis and compared among groups using log-rank test. Results: 1) CD lesions on MRE were found in all patients with LOR (13/13). Inflammatory lesions (markedly increased contrast uptake, wall thickening), small intestinal strictures, and intestinal fistulas were detected in 100%, 69%, and 23% of patients with LOR, respectively. Interestingly, 15 (65%) of 23 patients with clinical remission had also CD lesions on MRE. 2) Among 23 patients with clinical remission, relapse rate was significantly higher (p=0.02) in patients with CD lesion on MRE (8/15, 53%) than that in patients who did not have any lesions on MRE (0/ 8, 0%) over a mean follow-up of 11 months. Log-rank test also demonstrated that the absence of lesion by MREC significantly prolonged the duration to clinical recurrence (p= 0.03) whereas the duration to clinical recurrence was not significantly difference in patients with normal CRP level than those in patients with higher CRP levels (p=0.11). Conclusions: MRE is useful for assessment of CD lesions and strictures in patients with secondary loss of responsiveness for biologics. MRE might predict clinical recurrences even in patients with clinical remission who are treated with biologics.