Advances in Radiologic Imaging in Crohn’s Disease Kathryn J. Fowler, MD Director Abdominal-Pelvic MRI Mallinckrodt Institute of Radiology Inflammatory Bowel Disease Symposium
Advances in Radiologic Imaging in Crohnrsquos Disease
Kathryn J Fowler MD Director Abdominal-Pelvic MRI
Mallinckrodt Institute of Radiology
Inflammatory Bowel Disease Symposium
Disclosures
bull Speakerrsquos bureau for Lantheus bull Bracco research support
ObjectivesTeaching Points
bull Radiology contribution to clinical picture bull Overviewcomparison of radiology studies
ndash SBFT CTE MRE bull Comparison of diagnostic accuracy bull Interpretation of imaging findings and
reports ndash Stratify patients by disease activity and
phenotype
Not discussing enterocolysis techniques
Radiology Work-up bull Support diagnosis when clinically suspected bull Identify complications bull Assess disease activityresponse to treatment bull Stratify patientsphenotype
ndash Location ndash Transmural aggressiveness (inflammatory
stricturing penetrating)
Normal Mild Severe with ulceration Moderate
Small bowel follow-through ndash Patient drinks barium and we fluoroscopically take
pictures of small bowel ndash Strictures inflammation obstruction fistulae motility
(bowel transit time delineate stricture vs peristalsis) ndash Best mucosal detail
bull Ulcerations cobblestoning
bull Crohnrsquos Disease bull Large gastric
ulceration
Stricture of the ileum resulting in obstruction of passage of capsule endoscope
SBFT vs CTMR
bull SBFT most sensitive to mucosal abnormalities
bull SBFT may be superior in determining functional significance of strictures
bull CTMRE both superior to SBFT in detecting extra-enteric disease and complications
CTE and MRE bull Bowel prep-NPO x 4-6 h bull Oral contrast
ndash Volumen (biphasic) 15 L oral contrast bull May not be necessary if obstructed
bull 1 mg IV glucagon ndash Paralyze bowel movement
bull IV contrast ndash Screen renal function (GFR gt30 for MR Cr lt18 for CT)
bull CTE bull Ionizing radiation bull Fast accessible bull Standard CT for acutely ill
bull MRE bull No radiation bull Ideal for routine follow-up bull Better for fistulizing disease (especially perianal) bull Some contraindications (pacemakers claustrophobia etc)
bull MRE may be superior in detecting strictures over CTE bull Sensitivitiesspecificities for detecting diseased bowel
gt80-90 in most studies
CTE vs MRE
Studies show CTE and MRE are comparable in diagnostic accuracy
Long segment inflammatory stricture on CT and MRE
Long-segment Stricture with combination of active inflammation and chronic fibrostenosing
Perianal Fistulae MR has superior soft tissue resolution compared to CT
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Disclosures
bull Speakerrsquos bureau for Lantheus bull Bracco research support
ObjectivesTeaching Points
bull Radiology contribution to clinical picture bull Overviewcomparison of radiology studies
ndash SBFT CTE MRE bull Comparison of diagnostic accuracy bull Interpretation of imaging findings and
reports ndash Stratify patients by disease activity and
phenotype
Not discussing enterocolysis techniques
Radiology Work-up bull Support diagnosis when clinically suspected bull Identify complications bull Assess disease activityresponse to treatment bull Stratify patientsphenotype
ndash Location ndash Transmural aggressiveness (inflammatory
stricturing penetrating)
Normal Mild Severe with ulceration Moderate
Small bowel follow-through ndash Patient drinks barium and we fluoroscopically take
pictures of small bowel ndash Strictures inflammation obstruction fistulae motility
(bowel transit time delineate stricture vs peristalsis) ndash Best mucosal detail
bull Ulcerations cobblestoning
bull Crohnrsquos Disease bull Large gastric
ulceration
Stricture of the ileum resulting in obstruction of passage of capsule endoscope
SBFT vs CTMR
bull SBFT most sensitive to mucosal abnormalities
bull SBFT may be superior in determining functional significance of strictures
bull CTMRE both superior to SBFT in detecting extra-enteric disease and complications
CTE and MRE bull Bowel prep-NPO x 4-6 h bull Oral contrast
ndash Volumen (biphasic) 15 L oral contrast bull May not be necessary if obstructed
bull 1 mg IV glucagon ndash Paralyze bowel movement
bull IV contrast ndash Screen renal function (GFR gt30 for MR Cr lt18 for CT)
bull CTE bull Ionizing radiation bull Fast accessible bull Standard CT for acutely ill
bull MRE bull No radiation bull Ideal for routine follow-up bull Better for fistulizing disease (especially perianal) bull Some contraindications (pacemakers claustrophobia etc)
bull MRE may be superior in detecting strictures over CTE bull Sensitivitiesspecificities for detecting diseased bowel
gt80-90 in most studies
CTE vs MRE
Studies show CTE and MRE are comparable in diagnostic accuracy
Long segment inflammatory stricture on CT and MRE
Long-segment Stricture with combination of active inflammation and chronic fibrostenosing
Perianal Fistulae MR has superior soft tissue resolution compared to CT
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
ObjectivesTeaching Points
bull Radiology contribution to clinical picture bull Overviewcomparison of radiology studies
ndash SBFT CTE MRE bull Comparison of diagnostic accuracy bull Interpretation of imaging findings and
reports ndash Stratify patients by disease activity and
phenotype
Not discussing enterocolysis techniques
Radiology Work-up bull Support diagnosis when clinically suspected bull Identify complications bull Assess disease activityresponse to treatment bull Stratify patientsphenotype
ndash Location ndash Transmural aggressiveness (inflammatory
stricturing penetrating)
Normal Mild Severe with ulceration Moderate
Small bowel follow-through ndash Patient drinks barium and we fluoroscopically take
pictures of small bowel ndash Strictures inflammation obstruction fistulae motility
(bowel transit time delineate stricture vs peristalsis) ndash Best mucosal detail
bull Ulcerations cobblestoning
bull Crohnrsquos Disease bull Large gastric
ulceration
Stricture of the ileum resulting in obstruction of passage of capsule endoscope
SBFT vs CTMR
bull SBFT most sensitive to mucosal abnormalities
bull SBFT may be superior in determining functional significance of strictures
bull CTMRE both superior to SBFT in detecting extra-enteric disease and complications
CTE and MRE bull Bowel prep-NPO x 4-6 h bull Oral contrast
ndash Volumen (biphasic) 15 L oral contrast bull May not be necessary if obstructed
bull 1 mg IV glucagon ndash Paralyze bowel movement
bull IV contrast ndash Screen renal function (GFR gt30 for MR Cr lt18 for CT)
bull CTE bull Ionizing radiation bull Fast accessible bull Standard CT for acutely ill
bull MRE bull No radiation bull Ideal for routine follow-up bull Better for fistulizing disease (especially perianal) bull Some contraindications (pacemakers claustrophobia etc)
bull MRE may be superior in detecting strictures over CTE bull Sensitivitiesspecificities for detecting diseased bowel
gt80-90 in most studies
CTE vs MRE
Studies show CTE and MRE are comparable in diagnostic accuracy
Long segment inflammatory stricture on CT and MRE
Long-segment Stricture with combination of active inflammation and chronic fibrostenosing
Perianal Fistulae MR has superior soft tissue resolution compared to CT
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Radiology Work-up bull Support diagnosis when clinically suspected bull Identify complications bull Assess disease activityresponse to treatment bull Stratify patientsphenotype
ndash Location ndash Transmural aggressiveness (inflammatory
stricturing penetrating)
Normal Mild Severe with ulceration Moderate
Small bowel follow-through ndash Patient drinks barium and we fluoroscopically take
pictures of small bowel ndash Strictures inflammation obstruction fistulae motility
(bowel transit time delineate stricture vs peristalsis) ndash Best mucosal detail
bull Ulcerations cobblestoning
bull Crohnrsquos Disease bull Large gastric
ulceration
Stricture of the ileum resulting in obstruction of passage of capsule endoscope
SBFT vs CTMR
bull SBFT most sensitive to mucosal abnormalities
bull SBFT may be superior in determining functional significance of strictures
bull CTMRE both superior to SBFT in detecting extra-enteric disease and complications
CTE and MRE bull Bowel prep-NPO x 4-6 h bull Oral contrast
ndash Volumen (biphasic) 15 L oral contrast bull May not be necessary if obstructed
bull 1 mg IV glucagon ndash Paralyze bowel movement
bull IV contrast ndash Screen renal function (GFR gt30 for MR Cr lt18 for CT)
bull CTE bull Ionizing radiation bull Fast accessible bull Standard CT for acutely ill
bull MRE bull No radiation bull Ideal for routine follow-up bull Better for fistulizing disease (especially perianal) bull Some contraindications (pacemakers claustrophobia etc)
bull MRE may be superior in detecting strictures over CTE bull Sensitivitiesspecificities for detecting diseased bowel
gt80-90 in most studies
CTE vs MRE
Studies show CTE and MRE are comparable in diagnostic accuracy
Long segment inflammatory stricture on CT and MRE
Long-segment Stricture with combination of active inflammation and chronic fibrostenosing
Perianal Fistulae MR has superior soft tissue resolution compared to CT
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Small bowel follow-through ndash Patient drinks barium and we fluoroscopically take
pictures of small bowel ndash Strictures inflammation obstruction fistulae motility
(bowel transit time delineate stricture vs peristalsis) ndash Best mucosal detail
bull Ulcerations cobblestoning
bull Crohnrsquos Disease bull Large gastric
ulceration
Stricture of the ileum resulting in obstruction of passage of capsule endoscope
SBFT vs CTMR
bull SBFT most sensitive to mucosal abnormalities
bull SBFT may be superior in determining functional significance of strictures
bull CTMRE both superior to SBFT in detecting extra-enteric disease and complications
CTE and MRE bull Bowel prep-NPO x 4-6 h bull Oral contrast
ndash Volumen (biphasic) 15 L oral contrast bull May not be necessary if obstructed
bull 1 mg IV glucagon ndash Paralyze bowel movement
bull IV contrast ndash Screen renal function (GFR gt30 for MR Cr lt18 for CT)
bull CTE bull Ionizing radiation bull Fast accessible bull Standard CT for acutely ill
bull MRE bull No radiation bull Ideal for routine follow-up bull Better for fistulizing disease (especially perianal) bull Some contraindications (pacemakers claustrophobia etc)
bull MRE may be superior in detecting strictures over CTE bull Sensitivitiesspecificities for detecting diseased bowel
gt80-90 in most studies
CTE vs MRE
Studies show CTE and MRE are comparable in diagnostic accuracy
Long segment inflammatory stricture on CT and MRE
Long-segment Stricture with combination of active inflammation and chronic fibrostenosing
Perianal Fistulae MR has superior soft tissue resolution compared to CT
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
bull Crohnrsquos Disease bull Large gastric
ulceration
Stricture of the ileum resulting in obstruction of passage of capsule endoscope
SBFT vs CTMR
bull SBFT most sensitive to mucosal abnormalities
bull SBFT may be superior in determining functional significance of strictures
bull CTMRE both superior to SBFT in detecting extra-enteric disease and complications
CTE and MRE bull Bowel prep-NPO x 4-6 h bull Oral contrast
ndash Volumen (biphasic) 15 L oral contrast bull May not be necessary if obstructed
bull 1 mg IV glucagon ndash Paralyze bowel movement
bull IV contrast ndash Screen renal function (GFR gt30 for MR Cr lt18 for CT)
bull CTE bull Ionizing radiation bull Fast accessible bull Standard CT for acutely ill
bull MRE bull No radiation bull Ideal for routine follow-up bull Better for fistulizing disease (especially perianal) bull Some contraindications (pacemakers claustrophobia etc)
bull MRE may be superior in detecting strictures over CTE bull Sensitivitiesspecificities for detecting diseased bowel
gt80-90 in most studies
CTE vs MRE
Studies show CTE and MRE are comparable in diagnostic accuracy
Long segment inflammatory stricture on CT and MRE
Long-segment Stricture with combination of active inflammation and chronic fibrostenosing
Perianal Fistulae MR has superior soft tissue resolution compared to CT
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Stricture of the ileum resulting in obstruction of passage of capsule endoscope
SBFT vs CTMR
bull SBFT most sensitive to mucosal abnormalities
bull SBFT may be superior in determining functional significance of strictures
bull CTMRE both superior to SBFT in detecting extra-enteric disease and complications
CTE and MRE bull Bowel prep-NPO x 4-6 h bull Oral contrast
ndash Volumen (biphasic) 15 L oral contrast bull May not be necessary if obstructed
bull 1 mg IV glucagon ndash Paralyze bowel movement
bull IV contrast ndash Screen renal function (GFR gt30 for MR Cr lt18 for CT)
bull CTE bull Ionizing radiation bull Fast accessible bull Standard CT for acutely ill
bull MRE bull No radiation bull Ideal for routine follow-up bull Better for fistulizing disease (especially perianal) bull Some contraindications (pacemakers claustrophobia etc)
bull MRE may be superior in detecting strictures over CTE bull Sensitivitiesspecificities for detecting diseased bowel
gt80-90 in most studies
CTE vs MRE
Studies show CTE and MRE are comparable in diagnostic accuracy
Long segment inflammatory stricture on CT and MRE
Long-segment Stricture with combination of active inflammation and chronic fibrostenosing
Perianal Fistulae MR has superior soft tissue resolution compared to CT
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
SBFT vs CTMR
bull SBFT most sensitive to mucosal abnormalities
bull SBFT may be superior in determining functional significance of strictures
bull CTMRE both superior to SBFT in detecting extra-enteric disease and complications
CTE and MRE bull Bowel prep-NPO x 4-6 h bull Oral contrast
ndash Volumen (biphasic) 15 L oral contrast bull May not be necessary if obstructed
bull 1 mg IV glucagon ndash Paralyze bowel movement
bull IV contrast ndash Screen renal function (GFR gt30 for MR Cr lt18 for CT)
bull CTE bull Ionizing radiation bull Fast accessible bull Standard CT for acutely ill
bull MRE bull No radiation bull Ideal for routine follow-up bull Better for fistulizing disease (especially perianal) bull Some contraindications (pacemakers claustrophobia etc)
bull MRE may be superior in detecting strictures over CTE bull Sensitivitiesspecificities for detecting diseased bowel
gt80-90 in most studies
CTE vs MRE
Studies show CTE and MRE are comparable in diagnostic accuracy
Long segment inflammatory stricture on CT and MRE
Long-segment Stricture with combination of active inflammation and chronic fibrostenosing
Perianal Fistulae MR has superior soft tissue resolution compared to CT
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
CTE and MRE bull Bowel prep-NPO x 4-6 h bull Oral contrast
ndash Volumen (biphasic) 15 L oral contrast bull May not be necessary if obstructed
bull 1 mg IV glucagon ndash Paralyze bowel movement
bull IV contrast ndash Screen renal function (GFR gt30 for MR Cr lt18 for CT)
bull CTE bull Ionizing radiation bull Fast accessible bull Standard CT for acutely ill
bull MRE bull No radiation bull Ideal for routine follow-up bull Better for fistulizing disease (especially perianal) bull Some contraindications (pacemakers claustrophobia etc)
bull MRE may be superior in detecting strictures over CTE bull Sensitivitiesspecificities for detecting diseased bowel
gt80-90 in most studies
CTE vs MRE
Studies show CTE and MRE are comparable in diagnostic accuracy
Long segment inflammatory stricture on CT and MRE
Long-segment Stricture with combination of active inflammation and chronic fibrostenosing
Perianal Fistulae MR has superior soft tissue resolution compared to CT
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
bull CTE bull Ionizing radiation bull Fast accessible bull Standard CT for acutely ill
bull MRE bull No radiation bull Ideal for routine follow-up bull Better for fistulizing disease (especially perianal) bull Some contraindications (pacemakers claustrophobia etc)
bull MRE may be superior in detecting strictures over CTE bull Sensitivitiesspecificities for detecting diseased bowel
gt80-90 in most studies
CTE vs MRE
Studies show CTE and MRE are comparable in diagnostic accuracy
Long segment inflammatory stricture on CT and MRE
Long-segment Stricture with combination of active inflammation and chronic fibrostenosing
Perianal Fistulae MR has superior soft tissue resolution compared to CT
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Long segment inflammatory stricture on CT and MRE
Long-segment Stricture with combination of active inflammation and chronic fibrostenosing
Perianal Fistulae MR has superior soft tissue resolution compared to CT
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Long-segment Stricture with combination of active inflammation and chronic fibrostenosing
Perianal Fistulae MR has superior soft tissue resolution compared to CT
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Perianal Fistulae MR has superior soft tissue resolution compared to CT
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Stratifying Patients
bull Disease activity ndash Remission ndash Mild ndash Moderate ndash Severe
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
CD Activity bull Movement toward imaging scoring
systems (quantitative results) ndash Pros
bull Clinicians desire quantitative measure of disease bull Useful in monitoring response to therapy bull Good correlation with endoscopic and clinical
scoring systems ndash Cons
bull Cumbersome to employ in clinical practice bull Lots of literaturehellip Gold standard bull No current consensus on single scoring system
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
bull Inactive (0ndash2) bull Mild activity (3ndash6) bull Moderate to severe activity (ge7)
Joseacute CGallegoalowast AnaIEcharrib AnaPortaa VirginiaOllerob Ileal Crohnrsquosdisease MRI with endoscopic correlation Eur J Radiol (2010) doi101016jejrad201005042
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Scoring System ndash Relative contrast enhancement
bull (WSI post- WSI pre)(WSI pre) 100 (SD noise preSD noise post)
Endoscopy as gold standard
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Systematic Review of MRE
bull 7 studies 140 patients (16 remission 29 mild 95 frank) ndash MRI correctly graded 91 of frank ds 62
of mild ds and 62 of remission ndash Tended to overstage activity rather than
understage
Hosthuis K Bipat S Stokkers P Stoker Magnetic resonance imaging for evaluation of disease activity in Crohnrsquos disease a systematic review Eur Radiol 2009191450-1460
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Capsule endoscopy versus radiology studies
bull Capsule endoscopy (CE) has highest diagnostic accuracyyield in non-stricturing CD ndash Supported by multiple meta-analyses-
majority comparing CE w SBFT or ileoscopy
ndash Remains controversial as to which patients benefit most
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Stratifying Patients
ACTIVE INFLAMMATORY
CHRONIC FIBROSTENOSING
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
PENETRATING ANTIBIOTICS DRAINAGE SURGICAL MANAGEMENT
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Stratifying patients ACTIVE INFLAMMATORY DS
ndash Bowel wall thickening ndash Mural enhancement
bull Arterial bull Stratified
ndash Bowel wall submucosal edema bull T2 hyperintense (not fat)
ndash Perienteral inflammation and hypervascular mesentery (comb sign)
ndash Enlarged lymph nodes bull Enhancing lymph nodes
may indicate active disease as opposed to fibrostenotic
ndash +- Obstruction
CHRONIC FIBROSTENOSING DS ndash Bowel wall thickening ndash Mural enhancement
ndash Delayed ndash Transmural
ndash Mural fat deposition ndash T2 Hypointense wall ndash +- Obstruction
PENETRATINGFISTULIZING DS ndash Sinus tractsfistulae
ndash Ddx-adhesions (less vascular)
ndash Stellate arrangement of bowel ndash Desmoplastic mesentery ndash Matted loops ndash +- Abscesses
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Stratifying patients bull Active inflammatory
disease ndash Perienteral inflammation ndash Edemamural stratification ndash Hyperemia ndash Lymphadenopathy
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Stratifying patients
bull Chronic fibrostenosing disease ndash Stricture without active signs ndash Fat deposition ndash Characteristic signal and enhancement
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Stratifying patients
bull Penetratingfistulizing disease ndash Sinus tractsFistula ndash Stellate arrangement of bowel ndash Desmoplastic mesentery
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
Summary bull Radiology Contribution
ndash Assess disease severity location phenotype bull Imaging Options
ndash SBFT-evaluate motility functional stricture ndash CT-acutely ill fast accessible ndash MRE-routine follow-up evaluate disease activity
bull Comparative accuracies ndash MRE and CTE equivalent for ds activity ndash MRECT better for extraentericcomplications ndash MR best for fistulae
bull Stratifying patients ndash Active inflammatory fibrostenosing penetratingfistulizing
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
MIR Abdominal Imaging Section
bull Not as scary as we look bull Always happy to review imaging studies
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249
References bull Leyendecker JR et al MR Enterography in the Management of Patients with Crohn Disease RadioGraphics 2009 291827ndash
1846 bull Oommen J Aytekin O Contrast-enhanced MRI of the small bowel in Crohnrsquos disease Abdominal Imaging 2010 bull Lin MF Narra V Developing role of magnetic resonance imaging in Crohnrsquos disease Current Opinion in Gastroenterology 2008
24135-140 bull Cronin CG Delappe E Lohan DG Roche C Murphy JM Normal small bowel wall characteristics on MR enterography Eur J
Radiol (2009) bull Fidler J MR imaging of the small bowel Radiol Clin N Am 45(2007) 317-331 bull Furukawa A et Al Cross-sectional imaging in Crohnrsquos disease Radiographics 2004 24689-702 bull Martin DR Lauenstein T Sitaraman S Utility of magnetic resonance imaging in small bowel Crohnrsquos disease Gastroenterology
2007 133385-390 bull Zhu J et al Updating magnetic resonance imaging of small bowel imaging protocols and clinical indications World J
Gastroenterol 2008 Jun 714(21)3403-9 bull Maccioni F et al MR imaging in patients with Crohn disease value of T2- versus T1-weighted gadolinium-enhanced MR
sequences with use of an oral superparamagnetic contrast agent Radiology 2006 Feb238(2)517-30 bull Martin DR et al Magnetic resonance imaging of the gastrointestinal tract Top Magn Reson Imaging 2005 Feb16(1)77-98 bull Maccioni F et al Evaluation of Crohn disease activity with magnetic resonance imaging Abdom Imaging 2000 May-Jun
25(3)219-28 bull Knuesel PR et al Assessment of dynamic contrast enhancement of the small bowel in active Crohnrsquos disease using 3D MR
enterography Eur J Radiol 2009 Jan 6 bull Jensen MD Nathan T Rafaelsen SR Kjeldsen J Clin Gastroenterol Hepatol Diagnostic accuracy of capsule endoscopy for
small bowel Crohns disease is superior to that of MR enterography or CT enterography 2011 Feb9(2)124-9 bull Solem CA Loftus EV Jr Fletcher JG Baron TH Gostout CJ Petersen BT Tremaine WJ Egan LJ Faubion WA Schroeder KW
Pardi DS Hanson KA Jewell DA Barlow JM Fidler JL Huprich JE Johnson CD Harmsen WS Zinsmeister AR Sandborn WJ Small-bowel imaging in Crohns disease a prospective blinded 4-way comparison trial Gastrointest Endosc 2008 Aug68(2)255-66 Triester SL Leighton JA Leontiadis GI Gurudu SR Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohns disease Am J Gastroenterol 2006 May101(5)954-64
bull Dionisio PM Gurudu SR Leighton JA Leontiadis GI Fleischer DE Hara AK Heigh RI Shiff AD Sharma VK Am J Gastroenterol Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohns disease a meta-analysis 2010 Jun105(6)1240-8 quiz 1249