Background and Aims: Bowel ultrasound (BU) is a non-invasive, inexpensive, widely available tool, valuable for inflammatory bowel disease (IBD) assessment. The aim of the present study was to investigate the clinical utility of BU to predict the need to intensify therapy in IBD patients. Methods: One hundred seventeen IBD patients (89 Crohn’s disease, and 28 ulcerative colitis) diagnosis established at least 6 months before enrolment, undergoing maintenance therapy were prospectively included in the study. Bowel ultrasound investigated the following parameters: the bowel wall thickness (BWT), loss of wall stratification, the presence of the bowel wall Doppler signal, the visible lymph nodes, the mucosal hyperechoic spots, and the irregular external bowel wall. The patients were followed-up for 6 months, registering the need to escalate the treatment regimen. Subgroup analyses were conducted for patients requiring immediate treatment intensification (37 subjects), due to active disease at baseline and patients with subsequent treatment intensification, in the 6 months follow-up period (21 cases) in comparison to patients that required no therapeutic optimization (59). Results: During the follow-up, 49.6% of patients needed treatment escalation. All the investigated BU variables were significantly associated with the main outcome. In the multivariate analysis, the mean BWT (p<0.0001), and the presence of the bowel wall Doppler signal (p=0.007) were independent predictors of the main outcome. For the subgroup analyses: mean BWT (p=0.0001) and the presence of the bowel wall Doppler signal (p=0.01) were independent predictors for immediate treatment intensification (active disease at baseline) and mean BWT (p=0.0003) and the lack of bowel wall stratification (p=0.05) were independent predictors for the need of subsequent therapeutic optimization. Logistic regression prediction models and prediction scores (BU score) had the best AUROC values (>0.91) when compared to traditional biomarkers of active inflammation, such as C reactive protein or fecal calprotectin. Conclusion: Bowel ultrasound could be used as a non-invasive, easy to use diagnostic tool to predict the need to intensify therapy in patients with IBD.
Acute diverticulitis is a frequent complication in patients with colonic diverticulosis. The diagnosis is based on the clinical presentation, biological markers and imaging. Abdominal ultrasonography is, in many centers, the first examination in patients presenting with abdominal pain. Bowel ultrasonography has the advantage of being an inexpensive, nonionizing, readily available and repeatable examining method, but needs an experienced operator, and it is, thus, not widely used in clinical practice. We present a case series of acute diverticulitis, using bowel ultrasonography to establish the diagnosis in three different clinical settings: uncomplicated diverticulitis, abscess complicated diverticulitis and neoplasia associated diverticulitis. The patients were examined at admission, abdominal pain being the main symptom. The ultrasound examination started with a 3-5 MHz probe as in the case of classic ultrasound, followed by a 5-11 MHz probe examination that allowed adequate investigation of the bowel loops and establishing a diagnosis of acute diverticulitis based on ultrasonographic criteria. All patients had the diagnosis confirmed by a computer tomography scan and subsequently underwent antibiotic treatment. All patients had ultrasonographic characteristics suggesting parietal inflammation, overlapping with the lesions observed at CT scan which were indicative of acute diverticulitis. Both imaging techniques were able to show complications and extraintestinal alterations. Abdominal ultrasound is the imaging method most frequently used in patients presenting with abdominal pain. By using the appropriate transducer, acute diverticulitis and complications could be accurately diagnosed.
Background In spite of prolonged disease remission of IBD patients, induced by the new biological molecules, a significant number of them suffer from persistent debilitating symptoms with major impact on the quality of life. Frequently, these symptoms are due to post-inflammatory motility changes and misinterpreted as functional disorders. Our aim is to identify and characterize the anorectal motility dysfunction in IBD patients. Methods We are conducting an ongoing prospective study started in August 2019, which includes the IBD patients admitted in a Tertiary Gastroenterology Centre in Bucharest, with specific symptoms (anorectal pain, incontinence, difficult defecation). We perform high resolution anorectal manometry using Sandhill Scientific systems, the parameters being analysed using InSIGHT software. The manometric testing comprise measurements of anorectal pressure at rest, during squeeze, simulated evacuation, rectoanal inhibitory reflex (RAIR) and rectal sensory testing, in compliance with International Anorectal Physiology Working Group protocol. Results We studied 21 patients (12 patients with Ulcerative Colitis and 9 patients with Crohn’s Disease, 15 females and 6 males, mean age 40 (±11.43) years. Only 23.1% (5 patients) had rectal active involvement. Symptoms were reported by 81.0% (17) patients: pain (57.1%), anal incontinence (94.1%), difficult evacuation (29.4%), urgency (64.7%) and intolerance of rectal therapies (35.3%); rectal inflammation was not correlated with the presence of symptoms in our study group (p= 0.53). Modified manometric parameters were found in 81.0% patients and were associated with previous pelvic surgical interventions (p<0.05); although, the latter does not seem to increase the risk of incontinence (p=0.33). In 61.9% cases the manometric measurements correlated with the symptoms. 85% of the patients with passive incontinence presented lower resting pressure and 57.1% of those with active incontinence were found with lower squeeze pressures. Changes compatible with dyssynergia were detected in 61.9% of the cases. Sensory testing revealed alterations in 46.2% of patients, and RAIR was negative in 33.3% of the cases. Conclusion There is a considerable number of patients with anorectal motility changes. Therefore, pelvic floor investigation is an essential tool in the management of IBD patients with anorectal symptoms.
Background IBD are chronic diseases that require multiple endoscopic and imaging assessments, being diseases that not only involve a multitude of medical resources but patient compliance too. Bowel ultrasound (BUS) is a useful imaging tool in monitoring inflammatory bowel diseases (IBD) patients. Current guidelines recommend BUS altogether with other cross-sectional imaging methods to diagnose, monitor IBD patients and also for detecting complications and post-surgery recurrence. A multitude of ultrasonographic features are used to describe pathologic findings related to IBD but not all of them are easy to integrate in clinical practice, especially in unexperienced hands. Methods Our study included 117 IBD patients of which 28 were diagnosed with ulcerative colitis and 89 with Crohn’s disease. Diagnosis was established endoscopically and histologically and both patients with active and inactive disease were included. Exclusion criteria consisted in patients with other causes of inflammatory syndrome, patients with solely rectal localization of the disease or a surgical history. Subjects were prospectively evaluated using BUS and several sonographic aspects of the bowel wall were monitored: bowel wall thickness, bowel echo pattern, Doppler signal (DS) presence, hypertrophic mesenteric fat, and the presence of lymph nodes. Biological markers of inflammation were obtained including faecal calprotectin. Patients were followed up for the next 6 months and data regarding treatment intensification was noted. All patients signed an informed consent, and the study was approved by the Ethics Committee of the Fundeni Clinical Institute. Results Significantly higher values of clinical and biological markers were associated with the presence of parietal DS (p<0.0001) suggesting that this BUS feature is an important bowel wall inflammation surrogate. Higher Limberg scores (a subjective Doppler signal score used in BUS) correlated with increased values of biological markers of inflammation (p=0.002). A multivariate analysis showed that DS and a thicker than 5 mm bowel wall were independent predictors of step-up therapy. The presence of parietal DS raised the patient risk of switching therapy 7.6 times, while bowel wall thickness only 2.4 times, making DS the most useful BUS feature in evaluating inflammatory activity and predicting the need for step-up therapy. Conclusion DS is one of the most important BUS features to use in evaluating and monitoring IBD patients and could have a role in disease decision making. This finding should advocate for this imaging method in clinical practice, and even low BUS-experience practitioners are encouraged to use it.
Background Bowel ultrasonography (BUS) is an accurate imaging method for detecting and monitoring inflammatory bowel disease (IBD) patients. This technique is recommended by current guidelines besides gold standard endoscopic assessment in managing IBD patients. Several BUS characteristics strongly correlate with biological markers of inflammation suggesting that these tests could be used in monitoring IBD patients but is yet unknown how these features predict the patient’s evolution. Methods Our study included 95 consecutive IBD patients (24 diagnosed with ulcerative colitis, 71 with Crohn’s disease) with both active and inactive disease at presentation. IBD diagnosis was established endoscopically and histologically. Patients with superimposed infection (viral or bacterial) and patients that had solely rectal involvement of the disease were excluded. BUS was conducted at baseline by one skilled examiner blinded to biological data. Biological markers were evaluated at baseline and all cases were prospectively followed-up for the need of therapy escalation during the next 6 months. The following BUS characteristics were registered in every patient: bowel wall thickness, alteration of wall structure, thickened mucosa or submucosa, presence of hyperechoic spots in the mucosal wall, irregularity of the external wall, Doppler signal, presence of mesenteric hypertrophy, presence of lymph nodes, and an overall assessment of the examination. No special preparation was needed before BUS. Results Of all the monitored sonographic features, the following characteristics correlated with the need of increasing treatment in the following 6 months: bowel wall thickness, altered structure of the wall, hypertrophic mucosa, Doppler signal, and the overall assessment of the examination (p < 0.001). The presence of the lymph nodes, hyperechoic spots in the mucosa, thickened submucosa and the irregularity of the external wall were not statistically significant correlated with the need for treatment escalation. The strongest correlation with the need for increasing treatment was documented for a mean bowel wall thickness > 5 mm and for Doppler signal presence in the bowel wall (p < 0.00001). In the multivariate analysis, Doppler signal presence was the only independent predictor for the need treatment escalation during a 6-month follow-up. Conclusion The most important sonographic features with an impact on therapeutic decision making in IBD patients are: bowel wall thickness, Doppler signal, altered stratification of the wall and mesenteric hypertrophy. In our analysis, the Doppler signal was the only independent predictor for the need for step-up therapy.
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