Clermont Score Research Articles

Development and Validation of a Score to Assess Transmural Healing and Response in Patients With Crohn’s Disease

As transmural healing (TH) could be the best therapeutic target in Crohn's disease (CD), we aimed to build and validate a score to assess TH and transmural response (TR), and to confirm their association with favorable CD outcomes. DEVISE-CD project encompassed two retrospective cohorts (274 and 224 CD patients for development and validation phase, retrospectively) and one multicenter prospective validation cohort (N=46 patients). A step-by-step process was used to build the modified Clermont score (C-score). The primary endpoints were time to bowel damage progression, and steroid-free clinical remission with fecal calprotectin < 250 (CFREM) at one year for retrospective and prospective validation cohorts, respectively. Edema, ulcer, contrast enhancement, diffusion-weighted hyperintensity, fat wrapping, bowel thickening (>3 mm), and enlarged lymph nodes were associated to higher risk of bowel damage progression (p<0.01). Edema, diffusion-weighted hyperintensity, post-gadolinium contrast enhancement, and bowel thickening were highly coexistent (>95%) and collinear (p<0.0001). Bowel thickness had the highest sensitivity to change after treatment (SMD=0.30±1.0)(p=0.001). C-score was calculated as 0.2x(bowel thickness-3mm) + 1.5x enlarged lymph nodes + 2x ulcer. TH (C-score<0.5) (HR=0.28[0.13-0.63],p=0.002; aHR=0.15[0.04-0.53], p=0.003), TR50 (50%-decrease of C-score)(HR=0.30[0.15-0.63], p=0.001; aHR = 0.36[0.14-0.88], p=0.025) or TR25(25%-decrease of C-score)(HR=0.37[0.19-0.71], p=0.003; aHR=0.46[0.23-0.94], p=0.034) prevented bowel damage progression in development and validation cohorts, respectively. In the prospective validation cohort, achieving TH (OR=4.6[1.3-15.6], p=0.016), TR50 (OR=6.9[1.8-26.0], p=0.008) or TR25 (OR=6.0[1.6-22.3], p=0.008) after 12 weeks of anti-TNF therapy led to higher rate of CFREM at one year. C-score is a validated, reliable and easy-to-use tool to assess TH and TR in CD patients.

Leaving behind a diseased small bowel during surgery for Crohn's disease: Long-term outcomes.

Stricture is a common complication of Crohn's disease (CD) and may be treated with bowel-sparing procedures. Our study analyzed what happens in terms of intestinal and systemic inflammation when the diseased bowel is left behind following surgery. In this retrospective study, we enrolled 42 consecutive patients who underwent strictureplasty (alone or with resection) for stricturing CD. Control patients who underwent complete diseased bowel resection were identified and propensity score-matched for the sex, age, and history of abdominal surgery. Biohumoral values were collected at follow-up examinations at 1, 6, and 12months after surgery. Magnetic resonance imaging (MRI) was performed before and after strictureplasty in 19 patients. In the strictureplasty group, fecal calprotectin levels were decreased at 12months (p = 0.03), whereas in the resectiongroup, they were decreased at 6months (p = 0.02). On MRI, the ADC [apparent diffusion coefficient] (p < 0.001), wall thickness (p = 0.046) and Magnetic Resonance Index of Activity (MaRIA) (p < 0.001) and Clermont (p < 0.001) scores were improved after strictureplasty. Surgical recurrence was more frequent in the strictureplasty group than in the resection group (p = 0.003). Our retrospective study showed that even if the diseased bowel was left behind after surgery, the intestinal inflammatory activity still decreased. However, the permanence of the diseased bowel still increased the risk of reoperation, probably because of the fibrotic nature of the stenosis and the multifocality of CD.

MR Enterography Scores Correlate with Degree of Mucosal Healing in Pediatric Crohn's Disease: A Pilot Study.

MR enterography (MRE) Index of Activity (MaRIA) and Clermont are validated scores that correlate with Crohn's disease (CD) activity; however, the Clermont score has not been validated to correlate with the degree of change in mucosal inflammation post induction treatment in children. This pilot study evaluated if MaRIA and Clermont scores can serve as surrogates to ileocolonoscopy for assessing interval change in mucosal inflammation in pediatric CD post-induction treatment. Children with known or newly diagnosed ileocolonic CD starting or changing therapy underwent ileocolonoscopy, scored with simple endoscopic score for Crohn's disease (SES-CD), and MRE on the same day at two time points (Week 0 and 12). Accuracy of global MaRIA and Clermont indices relative to ileocolonoscopy in detecting degree of post-treatment interval change in mucosal inflammation was assessed through correlational coefficients (r). Inter-reader agreement was calculated for imaging scores through intraclass correlation (ICC). Sixteen children (mean age 11.5 ± 2.8) were evaluated. Global MaRIA/Clermont correlated with SES-CD in detecting the degree of change in mucosal inflammation (r = 0.676 and r = 0.677, P < 0.005, respectively). Correlation for pooled timepoint assessments between SES-CD and global MaRIA/Clermont was moderate (r = 0.546, P < 0.001 and r = 0.582, P < 0.001, respectively). Inter-rater reliability for global MaRIA and Clermont was good (ICC = 0.809 and ICC = 0.768, respectively, P < 0.001). MRE-based global scores correlate with endoscopic indices and may be used to monitor disease changes in children with CD undergoing induction treatment, which can advise the physician if treatment changes should be made.

Early transmural healing and its predictors assessed by magnetic resonance enterography in patients with Crohn's disease receiving ustekinumab.

Transmural healing (TH) is a potential therapeutic goal of Crohn's disease (CD) and is associated with better clinical outcomes. However, few studies have described early TH and its predictors. We aimed to evaluate early TH and its predictors using magnetic resonance enterography (MRE) in patients with CD receiving ustekinumab (UST). This was a retrospective observational study. Patients with active CD treated with UST and their intestinal segments with bowel wall thickness (BWT) ⩽ 3 mm at baseline were included. Clinical characteristics, laboratory indicators, endoscopic manifestations, and MRE indices were evaluated at baseline and week 26 (W26) of the therapy. The following MRE parameters were assessed: BWT, edema, apparent diffusion coefficient (ADC), Clermont score, Magnetic Resonance Index of Activity score, fat stranding, comb sign, and stricture. TH was defined as BWT ⩽ 3 mm without any signs of inflammation (i.e., ulceration, edema, diffusion-weighted hyperintensity, and increased contrast enhancement) at W26. The study included 37 patients with 106 intestinal segments (including 15 proximal small intestines, 33 terminal ilea, and 58 colons). Clinical features, laboratory indicators, endoscopic results, and MRE parameters at W26 were significantly improved after UST treatment in both patient-based and intestinal segment-based analysis. Seven (18.9%) patients and 26 (24.5%) intestinal segments achieved TH at W26. Baseline BWT [odds ratio (OR) = 0.287, 95% confidence interval (CI), 0.090-0.918, p = 0.035] and ADC (OR = 2.997, 95% CI, 1.009-8.908, p = 0.048) predict TH of patients at W26. Baseline ADC (OR = 2.857, 95% CI, 1.285-6.349, p = 0.010) and presence of stenosis (OR = 0.196, 95% CI, 0.052-0.735, p = 0.016) were associated with TH of segments at W26. Early TH assessed by MRE was observed in nearly one-fifth of patients with CD and intestinal segments after UST treatment for 26 weeks. Baseline MRE indices such as BWT and presence of stenosis might negatively predict TH, while ADC might positively predict early TH.

Early Transmural Response Assessed Using Magnetic Resonance Imaging Could Predict Sustained Clinical Remission and Prevent Bowel Damage in Patients with Crohn's Disease Treated with Anti-Tumour Necrosis Factor Therapy.

Magnetic resonance imaging [MRI] is a promising tool to evaluate therapeutic efficacy in ileocolonic Crohn's disease [CD]. We aimed to assess the feasibility of early MRI evaluation (week 12 [W12]) to predict corticosteroid-free remission [CFREM] at W52 and prevent long-term bowel damage. All patients with active CD needing anti-tumour necrosis factor [anti-TNF] therapy were consecutively enrolled in this multicentre prospective study. MRI was performed before starting therapy, at W12 and W52. CFREM was defined as Crohn's Disease Activity Index < 150, C-reactive protein < 5 mg/L and faecal calprotectin < 250 µg/g, with no switch of anti-TNF agents, no bowel resection and no therapeutic intensification between W12 and W52. Among 46 patients, 22 [47.8%] achieved CFREM at W52. Anti-TNF agents were able to heal almost all CD lesions as soon as W12 [p < 0.05]. Early transmural response defined as a 25% decrease of either Clermont score (odds ratio [OR] = 7.7 [1.7-34.0], p < 0.001) or Magnetic Resonance Index of Activity (OR = 4.2 [1.3-13.3], p = 0.015) was predictive of CFREM at W52. Achieving at least two items on W12-MRI among ulceration healing, disappearance of enlarged lymph nodes or sclerolipomatosis, ΔADC [apparent diffusion coefficient] > +10% or ΔRCE [relative contrast enhancement] > -30% was associated with a likelihood of CFREM at W52 of 84.6% vs 37.5% in patients without transmural response [p < 0.001]. Early transmural response could prevent bowel damage progression over time using Clermont score (hazard ratio = 0.21 [0.0-0.9]; p = 0.037). Evaluation of early transmural response by MRI is feasible and is a promising end point to monitor therapeutic efficacy in patients with CD.

Which MRI Score and Technique Should Be Used for Assessing Crohn's Disease Activity?

Magnetic resonance (MR) enterography is assuming an increasingly important and central role in the management of patients with Crohn’s disease, as it is not only involved in diagnosis and staging of the disease but also allows for patients’ follow-up, evaluating the response to therapy, and predicting disease outcomes. Several MR scores have been developed but unfortunately there is no globally accepted score. The most widely used scores are the Magnetic Resonance Index of Activity (MaRIA) score, the London score, the Nancy score, and the Clermont score; however, there are multiple differences between these tools in terms of the assessed radiological items, fasting, administration of oral or intravenous contrast, and the use of diffusion-weighted images. Here we reviewed the main characteristics of each MR scoring system to clarify which is the most appropriate score for monitoring disease activity in both clinical practice and clinical trials.

Comparison between Diffusion-Weighted Sequences with Selective and Non-Selective Fat Suppression in the Evaluation of Crohn's Disease Activity: Are They Equally Useful?

Background: We compared the efficiency of two MRI diffusion weighted imaging (DWI) techniques: DWI with SPIR (DWISPIR) and DWI with STIR (DWISTIR), to estimate their eligibility for quantitative assessment of Crohn’s disease activity in children and adults. Methods: In inflamed terminal ileum segments (n = 32 in adults, n = 46 in children), Magnetic Resonance Index of Activity (MaRIA) was calculated, ADC values of both DWI techniques were measured, and the corresponding Clermont scores calculated. ADC values of both DWI techniques were compared between both and within each patient group, assessing their mutual correlation. Correlations between MaRIA and the corresponding ADC values, and Clermont scores based on both DWI techniques were estimated. Results: No correlation between ADC of DWISPIR and DWISTIR was observed (rho = 0.27, p = 0.13 in adults, rho = 0.20, p = 0.17 in children). The correlation between MaRIA and Clermont scores was strong in both techniques—in SPIR, rho = 0.93; p < 0.0005 in adults, rho = 0.98, p < 0.0005 in children, and, in STIR, rho = 0.89; p < 0.0005 in adults, rho = 0.95, p < 0.0005 in children. The correlation between ADC and MaRIA was moderate negative for DWISTIR (rho = 0.93, p < 0.0005 in adults, rho = 0.95, p < 0.0005 in children), but, in DWISTIR, no correlation between ADC and MaRIA score was observed in adults (rho = −0.001, p = 0.99), whereas children presented low negative correlation (rho = −0.374, p = 0.01). Conclusions: DWISTIR is not suitable for quantitative assessment of Crohn’s disease activity both in children and adult patients.

Repeatability of Magnetic Resonance Measurements Used for Estimating Crohn’s Disease Activity

Abstract The MR activity indices used for quantification and follow-up of Crohn’s disease are composed of a number of subjectively determinable components with equivocal repeatability. The purpose of this article was to assess the repeatability of measurements used for quantitative estimation of Crohn’s disease activity in the terminal ileum. In five adults (23–57 y.o.) and 12 children (10–17 y.o.) with active terminal ileitis, the inflamed bowel was divided into 3 cm segments (n = 32 in adults, n = 46 in children), and measurements for the calculation of MaRIA and Clermont scores were performed. Parameters included apparent diffusion coefficients (ADC) for diffusion-weighted imaging (DWI) sequences with selective and non-selective fat suppression, wall signal enhancement before (WSI-preGd) and after (WSI-preGd) gadolinium enhancement, bowel thickness, and presence of ulcers. The measurements were standardised (accurate site-to-site comparison, exact ROI size, where applicable) and repeated by the same researcher after two months. Intra-observer agreement for ADC, WSI-preGd and WSI-postGd, bowel thickness was assessed with a paired t-test, and the significant difference in presence/absence of ulcers was assessed by the Pearson 2 test. Absolute difference was not found between the 1st and 2nd measurements of ADC, WSI-preGd, WSI-postGd and wall thickness. There was systematic difference in the presence of bowel ulcers. In standardised conditions the repeatability of ADC, WSI-preGd and WSI-postGd is high. Efforts must be made to precisely define the size and appearance of ulcers that may be included in the index calculation.

P131 The simplified MARIA score is strongly correlated with the MARIA and Clermont scores to analyse the luminal activity of Crohn’s disease (CD) in magnetic resonance and is easier to calculate

Abstract Background Two scores have shown their interest in evaluating the luminal activity of CD in magnetic resonance (MR), the MARIA and Clermont scores, but their calculation can be complicated in clinical practice. Recently, the Spanish authors validated a new simplified MARIA score (MARIAs) and retrospectively showed a very good correlation with the initial MARIA score (1). The purpose of this study was to validate this correlation in an independent cohort and to compare its feasibility with other scores. Methods This was a retrospective analysis of all MR performed in our department to evaluate the luminal activity of CD. Two independent radiologists each calculated the MARIA, Clermont and MARIAs scores (wall thickness &amp;gt; 3mm, oedema, comb sign, ulcerations), each blind to the other and blind to clinical activity. In case of disagreement between the two radiologists, a third reader analyzed MR activity. Correlations were calculated between these three tests for the entire cohort. In addition, concordance tests were performed for predetermined thresholds of 7 to 11 for the MARIA score, 8.5 to 12.5 for the Clermont score and 1 to 2 for the MARIAs score. The duration of the analysis was reported for each reading. Isolated colonic CD were excluded from the study. Results One hundred and twenty-one CD were included (65 in clinical and biological activity, 33% ileal phenotype, mean age: 38.5 years, sex ratio M/F = 54.5%). The agreement between the MARIA score between 7 and 11, the Clermont score between 8.5 and 12.5 and the MARIAs score between 1 and 2 was 0.92 (Fleiss kappa test). The correlation between the MARIA score and its simplified score was very strong (r = 0.93; 95% CI: 0.9–0.95) as well as between the Clermont score and the MARIAs score (r = 0.92 95% CI: 0.89–0.95). Inter-observer agreement was significantly higher in the calculation of the MARIAs score (96%) compared with 80% for the MARIA and Clermont scores (p = 0.04). Reading time was significantly faster for the MARIAs score (3.45 ± 0.4 min) compared with the MARIA (10.05 ± 1.2 min) and Clermont (13.5 ± −3.5 min) scores (p &amp;lt; 0.01). Positive predictive values for deep remission (clinical remission and calprotectin &amp;lt; 250 µg/g stool) were 95% at thresholds &amp;lt;1, &amp;lt;7 and &amp;lt;8.5 for the MARIAs, MARIA and Clermont scores, respectively. Conclusion In this independent cohort, we confirm the very strong correlation between the simplified MARIA score and the two reference scores (MARIA and Clermont) in the analysis of MC luminal activity as well as its rapid calculation and strong inter-observer agreement.

Evaluation of ileal Crohn’s disease response to TNF antagonists: Validation of MR enterography for assessing response. Initial results

PurposeTo assess the value of MRI obtained before and after treatment in detecting mucosal healing in patients with ileal Crohn’s disease (CD) treated with anti-TNF drugs. MethodsIn this IRB approved retrospective study, 24 patients (M/F 11/13, age 34.0 ± 12.5 years, age range 19–55 years) with ileal CD who underwent anti-TNF treatment, with pre- and post-treatment MRI (mean delay between MRIs 92 ± 57 weeks) were included. All patients underwent routine MR enterography (MRE), which included diffusion-weighted imaging (DWI). Two readers evaluated qualitative features (wall thickness, presence of edema and length of involvement) in consensus and one reader measured the following quantitative variables: relative contrast enhancement (RCE) and apparent diffusion coefficient (ADC) to derive the MaRIA and Clermont scores at baseline, post-treatment and their changes (ΔMaRIA, ΔClermont). Ileocolonoscopy results were used as the reference standard. Data was evaluated using Mann-Whitney U test and receiver operating characteristics analysis to assess the utility of the measures for the detection of mucosal healing. ResultsTwenty-four ileal segments were assessed in 24 patients. Nine patients showed mucosal healing while 15 had no mucosal healing on post-treatment endoscopy. Pre-treatment Clermont score and wall thickness and post-treatment MaRIA and Clermont scores, wall thickness, edema, length of involvement as well as ΔMaRIA and ΔClermont were all significantly different in patients with and without mucosal healing (p-range: 0.001-0.041) while MaRIA pre-treatment and ADC pre- and post-treatment were not. Pre-treatment Clermont score as well as post-treatment MaRIA and Clermont scores, wall thickness and ΔMaRIA were all significantly predictive of detection of mucosal healing (AUC 0.813-0.912; p = 0.003-0.024) after anti-TNF treatment. ConclusionPre-treatment Clermont score as well as post-treatment MaRIA and Clermont scores, wall thickness and ΔMaRIA are significantly predictive of response to anti-TNF drugs in ileal Crohn’s disease. These results need to be verified in a larger study.

The value of Clermont score in detection intestinal mucosal ulcer of Crohn's disease

Objective: To explore the value of Clermont score in the detection of intestinal mucosal ulcer in Crohn's disease (CD). Methods: From May 2015 to August 2017, 45 patients (28 males and 17 females; median age was 25 years) were confirmed to have ileocolic CD by endoscopic and pathological examinations at Nanjing General Hospital. All patients underwent MRE and DWI examinations. Based on the appearance of intestinal mucosa endoscopically, intestine segments from 45 patients were divided into three groups, namely, no ulceration group (NU), superficial ulceration group (SU), and deep ulceration group (DU). Several factors contribute to Clermont score calculation. These included the measurement of intestinal wall thickness using MRE, evaluation of intestinal wall edema and ulceration by MRE, DWI performance and ADC value of each segment. One-way ANOVA was utilized to compare the Clermont scores and ADC values of the intestine segments among the three groups. The efficacy of the Clermont scores and ADC values in evaluating intestinal mucosal ulcer in CD was verified using ROC analysis. Results: A total of 137 intestine segments were included in the study with 30 cases in NU, 37 cases in SU, and 70 cases in DU.DU had the highest Clermont score (22.5±4.5),following were SU(15.8±3.5) and NU(10.2±1.3)(F=179.935,P<0.01).The ADC values of DU ((1.34±0.17)×10(-3)mm(2)/s) was lower than NU ((2.07±0.52)×10(-3)mm(2)/s) and SU ((1.52±0.23)×10(-3) mm(2)/s) (F=83.822,P<0.01).The AUCs of using Clermont score and ADC value in differentiating deep ulcerations were 0.887 and 0.733, respectively. Conclusions: Either Clermont score or ADC value can be used to evaluate mucosal ulcer in CD. Clermont score demonstrates a better efficacy than ADC value in detecting deep ulcerations.

Diffusion-weighted imaging and apparent diffusion coefficient values for evaluating terminal ileitis in patients with Crohn's disease.

Objective:To determine the accuracy of diffusion-weighted imaging (DWI) in identifying terminal ileitis in patients with Crohn’s disease.Materials and Methods:This was a retrospective study of 38 consecutive patients with Crohn’s disease who underwent magnetic resonance enterography with DWI in a 3.0 T scanner. The patients were divided into two groups, on the basis of colonoscopy and biopsy findings: active inflammation; and inactive disease. Apparent diffusion coefficient (ADC) values were determined, as were the magnetic resonance index of activity (MaRIA) and the Clermont score.Results:Of the 38 patients evaluated, 18 (47%) had active inflammation. The patients with active inflammation showed greater restricted diffusion, more pronounced mucosal edema, greater wall thickening, a higher MaRIA, and a higher Clermont score than did those with inactive disease. The level of interobserver agreement (intraclass correlation coefficient) was excellent for the MaRIA and the Clermont score, whereas it was substantial for the ADC values. For identifying colonoscopy-proven inflammation, the best ADC cut-off point was 2.1 × 10−3 mm2/s, which had a sensitivity of 88.8% and a specificity of 95.0%, whereas DWI presented an overall accuracy of 89.4%, with a sensitivity of 88.9% and a specificity of 90.0%.Conclusion:Visual analysis of the DWI sequence has good accuracy in detecting terminal ileitis in patients with Crohn’s disease. In addition, low ADC values have good sensitivity for detecting colonoscopy-proven inflammation.

Assessment of Ileocolonic Inflammation in Crohn's Disease: Which Surrogate Marker Is Better-MaRIA, Clermont, or PET/MR Index? Initial Results of a Feasibility Trial.

Our objective was to define an 18F-FDG PET/MR enterography index as a hybrid surrogate marker for active ileocolonic inflammation in Crohn's disease (CD) and assess its diagnostic performance in comparison to validated MR indices (MR index of activity [MaRIA], Clermont score). Methods: Fifty-two CD patients with recurrent symptoms underwent ileocolonoscopy and 18F-FDG PET/MR enterography. Three hundred three ileocolonic segments were assessed for inflammation using MaRIA and the Clermont score as well as the newly defined PET/MR index. On the basis of tobit regression, the PET/MR index was defined as (0.87 × wall thickness) + (1.97 × edema) + (0.83 × ulceration) + (0.55 × SUVmax ratio) + 1.14. The endoscopic activity of inflammation was determined by the simplified endoscopic activity score for CD (SES-CD). Receiver-operating-characteristic curves for each surrogate marker were created and tested against each other using the DeLong test, and diagnostic accuracies were compared using the McNemar test. Correlations between surrogate markers and SES-CD were tested with the Spearman rank correlation test. Results: The PET/MR index showed a comparable sensitivity but a significantly higher specificity and accuracy than MaRIA and the Clermont score in predicting both active and severe inflammation (active inflammation: specificities of 0.933, 0.711, and 0.707 and accuracies of 0.921, 0.739, and 0.736, P < 0.001; severe inflammation: specificities of 0.91, 0.81, and 0.785 and accuracies of 0.914, 0.818, and 0.795, P < 0.01, respectively). All surrogate markers correlated moderately with SES-CD on a segmental basis and a global level (0.5 < ρ < 0.7, all P < 0.001). Conclusion: As a hybrid surrogate marker comprising MR parameters and the PET component, the PET/MR index yielded significantly improved specificity and diagnostic accuracy compared with conventional MR indices (MaRIA and the Clermont score), demonstrating its high potential for noninvasive assessment of CD.

Bowel wall healing assessed using magnetic resonance imaging predicts sustained clinical remission and decreased risk of surgery in Crohn's disease.

Endoscopic mucosal healing is considered as the best therapeutic target in Crohn's disease (CD) as it is associated with better long-term outcomes. We investigated whether bowel wall healing (BWH) assessed using magnetic resonance imaging (MRI) could predict favorable outcomes and could be a potential therapeutic target. We performed a post hoc analysis from two prospective studies (n = 174 patients). All the patients with previous objective signs of bowel inflammation and assessed by MRI for therapeutic efficacy had a standardized and blinded evaluation, and underwent MRI. Complete BWH was defined as no segmental MaRIA > 7 or no segmental Clermont score > 8.4 and BWH as no segmental MaRIA > 11 or no segmental Clermont score > 12.5. Clinical corticosteroid-free remission (CFREM) was defined as no reappearance or worsening of clinical manifestation leading to therapeutic modification, hospitalization or CD-related surgery. Multivariate analyses were performed including all the relevant parameters. Overall, 63 patients with CD were included (mean follow-up = 4.8 ± 3.1 semesters). In multivariate analysis (n = 303 semesters), complete BWH or BWH was associated with sustained CFREM according to MaRIA [OR = 4.42 (2.29-26.54); p = 0.042 and OR = 3.43 (1.02-27.02); p = 0.047, respectively] or Clermont score [OR = 3.09 (1.01-12.91); p = 0.049 and OR = 3.88 (1.40-13.80); p = 0.036, respectively]. In multivariate analysis (n = 63 patients), complete BWH or BWH was associated with decreased risk of surgery using MaRIA [HR = 0.16 (0.043-0.63); p = 0.008 and HR = 0.24 (0.07-0.77); p = 0.017, respectively] or Clermont score [HR = 0.24 (0.07-0.78); p = 0.016 and HR = 0.23 (0.07-0.76); p = 0.016, respectively]. MRI endpoints are predictive of favorable outcomes after medical therapy and could be used as therapeutic target in daily practice and clinical trials.

434 - Fecal Biomarkers Compared to MRI using the Maria and Clermont Scores for Monitoring Infammatory Activity in Patients with Crohns Disease

434 - Fecal Biomarkers Compared to MRI using the Maria and Clermont Scores for Monitoring Infammatory Activity in Patients with Crohns Disease

Faecal calprotectin and magnetic resonance imaging in detecting Crohn's disease endoscopic postoperative recurrence.

AIMTo assess magnetic resonance imaging (MRI) and faecal calprotectin to detect endoscopic postoperative recurrence in patients with Crohn’s disease (CD).METHODSFrom two tertiary centers, all patients with CD who underwent ileocolonic resection were consecutively and prospectively included. All the patients underwent MRI and endoscopy within the first year after surgery or after the restoration of intestinal continuity [median = 6 mo (5.0-9.3)]. The stools were collected the day before the colonoscopy to evaluate faecal calprotectin level. Endoscopic postoperative recurrence (POR) was defined as Rutgeerts’ index ≥ i2b. The MRI was analyzed independently by two radiologists blinded from clinical data.RESULTSApparent diffusion coefficient (ADC) was lower in patients with endoscopic POR compared to those with no recurrence (2.03 ± 0.32 vs 2.27 ± 0.38 × 10-3 mm²/s, P = 0.032). Clermont score (10.4 ± 5.8 vs 7.4 ± 4.5, P = 0.038) and relative contrast enhancement (RCE) (129.4% ± 62.8% vs 76.4% ± 32.6%, P = 0.007) were significantly associated with endoscopic POR contrary to the magnetic resonance index of activity (MaRIA) (7.3 ± 4.5 vs 4.8 ± 3.7; P = 0.15) and MR scoring system (P = 0.056). ADC < 2.35 × 10-3 mm²/s [sensitivity = 0.85, specificity = 0.65, positive predictive value (PPV) = 0.85, negative predictive value (NPV) = 0.65] and RCE > 100% (sensitivity = 0.75, specificity = 0.81, PPV = 0.75, NPV = 0.81) were the best cut-off values to identify endoscopic POR. Clermont score > 6.4 (sensitivity = 0.61, specificity = 0.82, PPV = 0.73, NPV = 0.74), MaRIA > 3.76 (sensitivity = 0.61, specificity = 0.82, PPV = 0.73, NPV = 0.74) and a MR scoring system ≥ MR1 (sensitivity = 0.54, specificity = 0.82, PPV = 0.70, and NPV = 0.70) demonstrated interesting performances to detect endoscopic POR. Faecal calprotectin values were significantly higher in patients with endoscopic POR (114 ± 54.5 μg/g vs 354.8 ± 432.5 μg/g; P = 0.0075). Faecal calprotectin > 100 μg/g demonstrated high performances to detect endoscopic POR (sensitivity = 0.67, specificity = 0.93, PPV = 0.89 and NPV = 0.77).CONCLUSIONFaecal calprotectin and MRI are two reliable tools to detect endoscopic POR in patients with CD.

P341 Faecal biomarkers compared with MRI using the MaRIA and Clermont scores for monitoring inflammatory activity in patients with Crohn’s disease

Fecal biomarkers like calprotectin (CAL) and lactoferrin (LF) have been evaluated regarding their capacity to differentiate and monitor disease activity in inflammatory bowel disease (IBD). These non-invasive biomarkers are increasingly popular and used in all-day patient care. Magnetic resonance imaging (MRI) is the gold standard approach to diagnose and monitor small bowel Crohn’s disease (CD). Magnetic Resonance Index of Activity (MaRIA) and the Clermont score are validated MRI activity indices in grading activity and severity of inflammation in patients with CD. The aim was to evaluate the performance of fecal biomarkers compared with the MaRIA and Clermont score in patients with CD. Fecal samples were collected to determine LF, CAL, PMN-elastasis (PMN-e), S100 calcium-binding protein A12 (S100A12), and eosinophil-derived neurotoxin (EDN) by enzyme immunoassay (EIA) and results are reported as µg/g. In every patient, an MRI was performed and MaRIA and the Clermont score were calculated and standard cut-offs were applied by two independent experienced radiologists. Receiver operating characteristic (ROC) curves for each fecal biomarker using MaRIA and Clermont score as reference standard were calculated to determine sensitivity, specificity, and accuracy using optimised cut-offs. A total of 50 patients with CD were included in the study. Sociodemographic and clinical characteristics are shown in Table 1. According the MaRia score n = 41 patients and according to the Clermont score n = 42 patients showed signs of active inflammation. Mean levels for patients with active/inactive inflammation were 12.43 (µg/g)/1.90 (µg/g) in LF, 224.86/ (µg/g) 151.17 (µg/g) in CAL, 0.17 (µg/g)/0.09 (µg/g) in PMN-e, 64.91 (µg/g)/79.09 (µg/g) in S100A12 and 1.4 (µg/g)/0.47 (µg/g) in EDN. Using optimised cut-offs, EDN, LF, and CAL were able to distinguish between active and inactive CD (see Table 2). Fecal Lactoferrin, Calprotectin, and EDN were significantly correlated to the Clermont score; however, only Lactoferrin was correlated to the MaRIA score. These results support the utility of fecal biomarkers for detecting active inflammation in patients with Crohn’s disease.

P189 Diffusion-weighted magnetic resonance enterography for prediction of response to tumour necrosis factor inhibitors in stricturing Crohn’s disease

Patients with Crohn’s disease (CD) frequently develop intestinal strictures that are a major cause of surgical and endoscopic interventions. Predominantly fibrotic strictures are less likely to respond to anti-inflammatory therapy. None of the currently available diagnostic modalities can reliably distinguish between fibrotic and inflammatory strictures. The capacity of diffusion-weighted (DWI) magnetic resonance (MRE) to identify intestinal fibrosis was recently demonstrated; however the therapeutic implications of this association have never been evaluated. The aim of the current study was to identify the imaging factors associated with response to anti-inflammatory treatment in patients with stricturing CD. Consecutive CD patients with intestinal strictures that initiated treatment with anti-tumour necrosis alpha (anti-TNF) between June 2012 and April 2017 with MRE adjacent to treatment ONSET were retrospectively collected. Patients with previous intestinal surgery or active penetrating complications on index MRE were excluded. The primary outcome was treatment failure, defined as drug discontinuation, CD-related surgery or endoscopic dilatation of the stricture. Clinical, demographic and imaging parameters including stricture length, prestenotic dilatation diameter, presence of ulcers, apparent diffusion coefficient (ADC), relative contrast enhancement (RCE), magnetic resonance index of activity (MaRIA) and Clermont score were compared between patients who did and did not develop treatment failure within 12 months of anti-TNF treatment. A total of 21 patients were included in the study; 9/21 (42.8) developed treatment failure. None of the clinical and demographic variables were associated with the likelihood of treatment failure. Among imaging parameters, only ADC (<1 x 10–3 mm2/s) was significantly associated with the risk of treatment failure (66% vs. 0%, p = 0.015, OR-30.1 (95% CI −1.2–785, AUC = 0.81). Our results suggest that ADC value on DWI MRE can predict the risk of treatment failure in stricturing CD. If replicated in larger studies, these results may guide therapeutic decisions and suggest avoiding anti-TNF treatment in patients with intestinal strictures with ADC <1 × 10–3 mm2/s.

A review of magnetic resonance enterography-based indices for quantification of Crohn's disease inflammation.

Magnetic resonance enterography (MRE) is a leading radiological modality in Crohn’s disease (CD) and is used together with laboratory findings and endoscopic examinations for the evaluation of patients during initial diagnosis and follow up. Over the years, there has been great progress in the understanding of CD and there is a continuous strive to achieve better monitoring of patients and to develop new modalities which will predict disease course and thus help in clinical decisions making. An objective evaluation of CD using a quantification score is not a new concept and there are different clinical, endoscopies, radiological and combined indices which are used in clinical practice. Such scores are a necessity in clinical trials on CD for evaluation of disease response, however, there is no consensus of the preferred MRE score and they are not routinely used. This review presents MRE-based indices in use in the last decade: the Magnetic Resonance Index of Activity (MaRIA), the Clermont score, the Crohn’s Disease Magnetic Resonance Imaging (MRI) Index (CDMI), the Magnetic Resonance Enterography Global Score (MEGS) and the Lemann index. We compare the different indices and evaluate the clinical research that utilized them. The aim of this review is to provide a reference guide for researchers and clinicians who incorporate MRE indices in their work. When devising future indices, accumulated data of the existing indices must be taken into account, as each of the current indices has its own strengths and weakness.

Magnetic resonance index of activity (MaRIA) and Clermont score are highly and equally effective MRI indices in detecting mucosal healing in Crohn’s disease

BackgroundMagnetic resonance index of activity (MaRIA) and Clermont score are currently the two main MRI indices that have been validated compared to endoscopy in Crohn’s disease (CD). AimsTo compare the accuracy of MaRIA and Clermont score in assessing CD mucosal healing. MethodsFourty-four CD patients underwent prospectively and consecutively MRI and colonoscopy. ResultsConsidering 207 segments, MaRIA>7 and Clermont score>8.4 demonstrated substantial accuracy to detect endoscopic ulcerations (73.9% and 74.0%, respectively) and presented with high specificity (82.1% and 81.3%) and high negative predictive value (NPV) (82.1% and 82.4%) for MaRIA and Clermont score, respectively. The sensitivity for detecting deep ulcerations was 90.9% for both MaRIA>11 and Clermont score>12.5, with a specificity of 82.0% and 80.0%, respectively.Among 44 patients, deep MRI remission predicted mucosal healing with specificity=85.3% and NPV=85.3% according to Barcelona criteria (no segmental MaRIA>7), and specificity=88.2% and NPV=85.7% according to Clermont criteria (no segmental Clermont score>8.4). In addition, MRI remission predicted mucosal healing with specificity=76.5% and NPV=86.7% according to Barcelona criteria (no segmental MaRIA>11), and specificity=79.4% and NPV=84.4% according to Clermont criteria (no segmental Clermont score>12.5). ConclusionMaRIA and Clermont score are equally effective in detecting CD endoscopic ulcerations supporting their use as therapeutic endpoints.