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