Magnetic resonance enterography predicts the prognosis of Crohn's disease

BACKGROUND/AIMS: Magnetic resonance enterography (MRE) has emerged as an important tool in the diagnosis and follow-up of Crohn's disease (CD). The aim of this study was to evaluate whether MRE findings could predict the prognosis of CD. METHODS: In this retrospective study, a total of 173 patients with clinical remission of CD (n=61) or active CD (n=112) were identified. The outcomes of clinical relapse, admission, surgery, and need for other medications according to the MRE findings were evaluated. RESULTS: The presence of active inflammation on MRE was observed in 93 (83%) patients with clinically active CD and in 44 (72.1%) patients with clinical remission of CD, without a statistically significant difference (P=0.091). In multivariate analysis, active inflammation on MRE increased the risk for clinical relapse (hazard ratio [HR], 6.985; 95% confidence interval [CI], 1.024–47.649) in patients with clinical remission of CD. In patients with clinically active CD, active inflammation on MRE increased the risk for CD-related hospitalization (HR, 2.970; 95% CI, 1.006–8.772). CONCLUSIONS: The presence of active inflammation on MRE was significantly associated with poor prognosis both in patients with clinical remission of CD and in those with active CD.

Magnetic resonance enterography in pediatric celiac disease / A enterografia por ressonância magnética na doença celíaca pediátrica

Abstract Objective: To assess if magnetic resonance enterography is capable of showing evidence/extent of disease in pediatric patients with biopsy-proven celiac disease by comparing with a control group, and to correlate the magnetic resonance enterography findings with anti-endomysial antibody level, which is an indicator of gluten-free dietary compliance. Methods: Thirty-one pediatric patients (mean age 11.7 ± 3.1 years) with biopsy-proven celiac disease and 40 pediatric patients as a control group were recruited in the study. The magnetic resonance enterography images of both patients with celiac disease and those of the control group were evaluated by two pediatric radiologists in a blinded manner for the mucosal pattern, presence of wall thickening, luminal distention of the small bowel, and extra-intestinal findings. Patient charts were reviewed to note clinical features and laboratory findings. The histopathologic review of the duodenal biopsies was re-conducted. Results: The mean duration of the disease was 5.6 ± 1.8 years (range: 3-7.2 years). In 24 (77%) of the patients, anti-endomysial antibody levels were elevated (mean 119.2 ± 66.6 RU/mL). Magnetic resonance enterography revealed normal fold pattern in all the patients. Ten (32%) patients had enlarged mesenteric lymph nodes. Conclusion: Although a majority of the patients had elevated anti-endomysial antibody levels indicating poor dietary compliance, magnetic resonance enterography did not show any mucosal abnormality associated with the inability of magnetic resonance enterography to detect mild/early changes of celiac disease in children. Therefore, it may not be useful for the follow-up of pediatric celiac disease.

Resumo Objetivo: Avaliar se a enterografia por ressonância magnética (ERM) consegue comprovar/mostrar a extensão da doença em pacientes pediátricos com doença celíaca (DC) comprovada por biópsia, comparar com um grupo de controle e correlacionar os achados da ERM com o nível de anticorpo antiendomísio (EMA) indicador de dieta sem glúten. Métodos: Foram recrutados 31 pacientes pediátricos (idade média entre 11,7 ± 3,1 anos) com DC comprovada por biópsia e 40 pacientes pediátricos em um grupo de controle. As imagens da ERM dos pacientes com DC e no grupo de controle foram avaliadas por dois radiologistas pediátricos às cegas para o padrão da mucosa, presença de espessamento da parede, dilatação luminal do intestino delgado e achados extraintestinais. Os prontuários dos pacientes foram revisados para anotação de características clínicas e achados laboratoriais. A avaliação histopatológica das biópsias duodenais foi feita novamente. Resultados: A duração média da doença foi 5,6 ± 1,8 anos (faixa de 3-7,2 anos). Em 24 (77%) dos pacientes, os níveis EMA estavam elevados (média 119,2 ± 66,6 RU/mL). A ERM revelou um padrão de pregas normal em todos os pacientes; 10 (32%) dos pacientes apresentaram gânglios linfáticos mesentéricos aumentados. Conclusão: Apesar de a maioria dos pacientes ter níveis elevados de EMA, o que indica uma dieta pobre, a ERM não mostrou anomalia na mucosa associada à incapacidade de a ERM detectar alterações leves/precoces de DC nas crianças. Portanto, ela pode não ser útil no acompanhamento da DC pediátrica.

Application of magnetic resonance enterography and ectopic gastric mucosa imaging in children with lower gastrointestinal hemorrhage / 中华实用儿科临床杂志

Objective To evaluate the diagnostic value of magnetic resonance enterography(MRE)and ectopic gastric mucosa imaging(EGMI)in children with lower gastrointestinal hemorrhage.Methods The clinical data including gender,age,amount of bleeding and preoperative minimum hemoglobin(Hb)levels of 54 children with lower gastrointestinal hemorrhage were collected,who received surgical exploration in Department of Pediatric Surgery,Anhui Provincial Children's Hospital between February 2014 and April 2016.Children were divided into lesion group and non-lesion group according to the findings of surgical exploration.Lesion group were defined as children with Meckel's diverticulum(MD)or duplication of the small intestine by surgery and postoperative pathological findings.A total of 36 cases,25 cases of boys,11 cases of girls,aged(2.86±1.59)years old.Non-lesion group were defined as children,who underwent operation with negative result or with lesions but not MD or duplication of the small intestine.A total of 18 cases,14 cases of boys,4 cases of girls,aged(3.87±1.62)years old.MRE and EGMI were performed when the children stopped bleeding,before the inspection,should fasting for 4-6 h.SPSS 13.0 software was used for statistical processing.The evaluation of EGMI,MRE and the both in diagnosing MD or duplication of the small intestine were conducted by receiver operating characteristic curve(ROC).According to the principles of biggest gain best diagnostic value by Youden index,and the degree of sensitivity and specificity was calculated at this time,P0.05).There were statistically significant differences in age,amount of bleeding and preoperative minimum hemoglobin levels(t=2.179,2.027,2.222,all P<0.05).There were statistically significant differences in classification comparison by EGMI and MRE between 2 groups(x2=15.226,29.121,all P<0.01).The optimal cut-off value of EGMI and MRE in the diagnosis of enteric malformation was more than level 3,and the suspected positive and being positive value was assigned as positive results.According to the cut-off value above,EGMI,MRE and EGMI plus MRE in series and in parallel in the diagnosis of enteric malformation,the areas under curves(AUC)were 0.809,0.917,0.750 and 0.847,respectively.The sensitivity was 61.1％,75.0％,55.6％and 80.6％,respectively.The specificity was 90.4％,94.4％,94.4％and 88.9％,respectively.The Youden's indexes were 0.515,0.694,0.500 and 0.695,respectively.The optimal cut-off value of age and preoperative minimum hemoglobin levels in the diagnosis of enteric malformation were 2.92 years and 80 g/L,respectively.The AUC was 0.761 and 0.672.The Youden's indexes were 0.515 and 0.333.There was no significant differences statistically in AUC compared with age,MRE and EGMI(all P<0.05).Conclusions The high diagnostic value in children with lower gastrointestinal hemorrhage is found by using MRE and EGMI.Then,MRE as a separate diagnosis method is also worthy of clinical application.

Diffusion-Weighted MR Enterography to Monitor Bowel Inflammation after Medical Therapy in Crohn's Disease: A Prospective Longitudinal Study

OBJECTIVE: To prospectively evaluate the performance of diffusion-weighted imaging (DWI) to monitor bowel inflammation after medical therapy for Crohn's disease (CD). MATERIALS AND METHODS: Before and following 1–2 years of medical therapy, between October 2012 and May 2015, 18 randomly selected adult CD patients (male:female, 13:5; mean age ± SD, 25.8 ± 7.9 years at the time of enrollment) prospectively underwent MR enterography (MRE) including DWI (b = 900 s/mm²) and ileocolonoscopy. Thirty-seven prospectively defined index lesions (one contiguous endoscopy-confirmed inflamed area chosen from each inflamed anatomical bowel segment; 1–4 index lesions per patient; median, 2 lesions) were assessed on pre- and post-treatment MRE and endoscopy. Visual assessment of treatment responses on DWI in 4 categories including complete remission and reduced, unchanged or increased inflammation, and measurements of changes in apparent diffusion coefficient (ΔADC), i.e., pre-treatment–post-treatment, were performed by 2 independent readers. Endoscopic findings and CD MRI activity index (CDMI) obtained using conventional MRE served as reference standards. RESULTS: ΔADC significantly differed between improved (i.e., complete remission and reduced inflammation) and unimproved (i.e., unchanged or increased inflammation) lesions: mean ± SD (× 10⁻³ mm²/s) of -0.65 ± 0.58 vs. 0.06 ± 0.15 for reader 1 (p = 0.022) and -0.68 ± 0.56 vs. 0.10 ± 0.26 for reader 2 (p = 0.025). DWI accuracy for diagnosing complete remission or improved inflammation ranged from 76% (28/37) to 84% (31/37). A significant negative correlation was noted between ΔADC and ΔCDMI for both readers with correlation coefficients of -0.438 and -0.461, respectively (p < 0.05). CONCLUSION: DWI is potentially a feasible tool to monitor quantitatively and qualitatively bowel inflammation of CD after medical treatment.

Modalidades de imagen en la evaluación de enfermedad inflamatoria intestinal / Imaging techniques in the evaluation of inflammatory bowel disease

La enfermedad inflamatoria intestinal es una patología crónica, con una incidencia cada vez mayor. Dentro de este grupo de afecciones, la enfermedad de Crohn y la colitis ulcerosa son las más frecuentes. La enterografía por tomografía computada (ETC) y por resonancia magnética (ERM) son las modalidades de elección para la evaluación y seguimiento de la entidad, permitiendo examinar la apariencia de la mucosa, la pared intestinal, las manifestaciones extraintestinales y las complicaciones asociadas. La elección del estudio debe hacerse de acuerdo con la condición clínica de cada paciente

Inflammatory bowel disease is a chronic condition with increasing incidence. Crohn's disease and ulcerative colitis are the most common pathologies. Computed tomography (CT) enterography and magnetic resonance (MR) enterography are the methods of choice for evaluating and monitoring this entity, assessing the appearance of intestinal wall, mucosa, extra-intestinal manifestations, and associated complications. The preferred imaging methods must be selected according to the clinical conditions of the patient

Magnetic resonance enterography for the evaluation of the deep small intestine in Crohn's disease

For the control of Crohn's disease (CD) a thorough assessment of the small intestine is essential; several modalities may be utilized, with cross-sectional imaging being important. Magnetic resonance (MR) enterography, i.e., MRE is recommended as a modality with the highest accuracy for CD lesions. MRE and MR enteroclysis are the two methods performed following distension of the small intestine. MRE has sensitivity and specificity comparable to computed tomography enterography (CTE); although images obtained using MRE are less clear compared with CTE, MRE does not expose the patient to radiation and is superior for soft-tissue contrast. Furthermore, it can assess not only static but also dynamic and functional imaging and reveals signs of CD, such as abscess, comb sign, fat edema, fistula, lymph node enhancement, less motility, mucosal lesions, stricture, and wall enhancement. Several indices of inflammatory changes and intestinal damage have been proposed for objective evaluation. Recently, diffusion-weighted imaging has been proposed, which does not need bowel preparation and contrast enhancement. Comprehension of the characteristics of MRE and other modalities is important for better management of CD.

Recent trends in diagnostic techniques for inflammatory bowel disease

Although ileocolonoscopy is the gold standard for diagnosis of inflammatory bowel disease and is useful for assessing the disease severity in the colon and terminal ileum, several alternative diagnostic techniques have been developed recently. For ulcerative colitis (UC), magnification colonoscopy, endocytoscopy, and confocal laser endomicroscopy enable assessment of histological inflammation without the need for biopsy. Capsule endoscopy is useful for detection of small intestinal and colonic lesions in both female and male patients. For UC, capsule endoscopy may be useful for evaluating colonic inflammation in patients with a previous poor colonoscopy experience, while it should be used only in Crohn's disease (CD) patients with unexplained symptoms when other examinations are negative. Magnetic resonance enterography (MRE) is particularly useful for detecting transmural inflammation, stenosis, and extraintestinal lesions, including abscesses and fistulas. MRE is also useful when evaluating small and large intestinal lesions, even in cases with severe strictures in which full evaluation of the small bowel would be virtually impossible using other devices. Therefore, the appropriate diagnostic devices for detecting CD lesions in the small and large intestine should be used.

Pediatric Magnetic Resonance Enterography: Focused on Crohn's Disease / 대한소아소화기영양학회지

Crohn's disease is a chronic idiopathic inflammatory disease of the intestines characterized by frequent relapse and remission. It often develops in children and adolescents, who are vulnerable to repeated exposure to ionizing radiations. Magnetic resonance enterography (MRE) is an increasingly important radiation-free imaging modality that is used to evaluate pediatric patients with Crohn's disease. MRE can evaluate extraluminal and extraintestinal abnormalities as well as the status of the bowel wall. In addition, MRE has an advantage in the evaluation of the small bowel involvement. MRE can be used for the initial diagnosis of Crohn's disease, and can aid in the assessment of disease activity and complications such as penetrating and fibrostenotic diseases. The aims of this article are to review the MRE technique for obtaining diagnostic and high-quality images and to discuss interpretations of imaging findings in patients with Crohn's disease.

A Look into the Small Bowel in Crohn's Disease

Crohn's disease (CD) is an inflammatory bowel disease that can affect the entire gastrointestinal tract, with the small bowel (SB) being the most commonly affected site. In some patients, refractory inflammation or chronic strictures of the SB are responsible for a debilitating course of the disease that might lead to severely reduced quality of life. Therefore, SB imaging is a crucial element in diagnosing and/or managing SB CD, and continues to evolve because of technologic advances. SB endoscopy (capsule endoscopy and device-assisted enteroscopy) and cross-sectional radiologic imaging (computed tomography enterography and magnetic resonance enterography) have become key players to diagnose and/or manage CD. In everyday practice, the choice of the imaging modalities is based on the presence and availability of the techniques and of experienced operators in each institute, clinical usefulness, safety, and cost. Here, SB endoscopy and radiologic imaging in suspected or known CD patients will be addressed and discussed.