Background and Aims To improve management of patients with Crohn’s disease, objective measurements of disease activity are needed. Ileocolonoscopy is the current reference standard but has limitations that restrict repeated use. Ultrasonography is potentially useful for activity monitoring, but no validated sonographic activity index is currently in widespread use. Thus, we aimed to construct and validate a simple ultrasound score for Crohn’s disease. Methods Forty patients were prospectively examined with ultrasound and endoscopy in the development phase. The Simple Endoscopic Score for Crohn’s Disease [SES-CD] was used as a reference standard. Seven ultrasound variables [bowel wall thickness, length, colour Doppler, stenosis, fistula, stratification and fatty wrapping] were initially included, and multiple linear regression was used to select the variables that should be included in the final score. Second, the ultrasound data from each patient were re-examined for interobserver assessment using weighted kappa and intraclass correlation. Finally, the activity index was validated in a new cohort of 124 patients. Results Length, fistula and stenosis were excluded. The combination of the remaining variables provided a multiple correlation coefficient of r = 0.78. Interobserver analysis revealed poor agreement for stratification and fatty wrapping and these were thus excluded. There was excellent interobserver agreement for the remaining score consisting of wall thickness and colour Doppler. In both patient cohorts, the ultrasound score correlated well with SES-CD [Development cohort: rho = 0.83, p < 0.001, Validation cohort: rho = 0.78, p < 0.001]. A receiver operating characteristic curve analysis revealed an area under the curve of 0.92 and 0.88 for detecting endoscopic activity and moderate endoscopic activity, respectively. Conclusions A simple ultrasound activity index for Crohn’s disease consisting of bowel wall thickness and colour Doppler was constructed and validated and correlated well with endoscopic disease activity. ClinicalTrials. gov ID: NCT03481751

Article first published online 2 September 2014.

Purpose To explore the ability of gastrointestinal ultrasound (GIUS) to separate patients in endoscopic remission from patients with active disease in a heterogeneous hospital cohort with Crohn’s disease (CD). Materials and Methods 145 CD patients scheduled for ileocolonoscopy were prospectively included. The endoscopic disease activity was quantified using the Simple Endoscopic Score for Crohn’s disease (SES-CD), and mucosal healing was strictly defined as SES-CD = 0. Ultrasound remission was defined as wall thickness < 3 mm (< 4 mm in the rectum). Additionally, SES-CD was compared to color Doppler, Harvey Bradshaw’s index (HBI), C-reactive protein (CRP) and calprotectin. 23 patients were examined by two investigators for interobserver assessment. Results 102 had active disease and 43 patients were in remission. GIUS yielded a sensitivity of 92.2 % and a specificity of 86 % for wall thickness and a sensitivity of 66.7 % and a specificity of 97.7 % for color Doppler. The sensitivity and specificity were 34.3 % and 88.4 %, respectively, for HBI, 35.7 % and 82.9 %, respectively, for CRP and 55.9 % and 82.1 %, respectively, for calprotectin. The interobserver analysis revealed excellent agreement for wall thickness (k = 0.90) and color Doppler (k = 0.91) measurements. Conclusion GIUS has a high sensitivity for detecting endoscopic activity. Accordingly, bowel ultrasound has the potential to reduce the number of routine ileocolonoscopies in patients with CD.

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The amplitude-based parameters PE, WiAUC and WoR could potentially be used to separate fibrotic and inflammatory lesions in patients suffering from CD due to significant differences and low interobserver variability.

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Background Treatment goals for Crohn’s disease (CD) have changed from symptom control to objective endpoints, preferably endoscopic remission. However, as the relative invasiveness of ileocolonoscopy limits repeated examinations, a surrogate marker of endoscopic remission is needed. Gastrointestinal ultrasound (GIUS) is accurate in detecting CD, and we aimed to explore its ability to distinguish between patients with active disease from patients in remission. Methods One hundred and forty-five CD patients scheduled for ileocolonoscopy were prospectively included. The endoscopic disease activity was quantified using the Simple Endoscopic Score for Crohn’s disease (SES-CD), and endoscopic remission was strictly defined as SES-CD=0. Ultrasound remission was defined as wall thickness &lt;3 mm (&lt;4 mm in the rectum). Additionally, SES-CD was compared with colour Doppler, Harvey Bradshaw’s index (HBI), C-reactive protein (CRP) and calprotectin. Twenty-three patients were examined by two investigators for interobserver assessment. Results 102 had active disease and 43 patients were in remission. GIUS yielded a sensitivity of 92.2% and specificity of 86% for wall thickness and sensitivity 66.7% and specificity 97.7% for colour Doppler. For HBI sensitivity was 34.3% and specificity 88.4%, CRP sensitivity 35.7% and specificity 82.9% and calprotectin sensitivity 55.9 % and specificity 82.1%. The interobserver analysis revealed excellent agreement (k=0.90). Conclusion GIUS has a high sensitivity for detecting endoscopic activity, but poorer specificity. In a hospital cohort of patients with Crohn’s disease, the number of invasive procedures could be reduced by reserving ileocolonoscopy for patients with a normal ultrasound for identification of patients in remission.

Background Gastrointestinal ultrasound (GIUS) can be used to measure bowel wall thickness (BWT). If the bowel wall is less than 3 mm in all bowel segments in a patient with Crohn’s disease(CD) this predicts endoscopic remission with a high degree of accuracy, but still some CD patients with disease located to the terminal ileum and colon will have a thickened bowel wall even if they are in endoscopic remission. Could BWT be an independent predictor of disease activity in CD? The aim of the study was to investigate if a normalisation of bowel wall thickness in CD patients affects risk for important negative clinical endpoints such as need for corticosteroids, failure in maintenance treatment, hospital admissions and surgery. Methods Patients with CD referred to the Haukeland University Hospital for ileocolonoscopy were examined with GIUS and followed for at least 12 months. The clinical endpoints examined were defined as the need for short- or long-time treatment with corticosteroids, changes in the maintenance treatment including drug switch and dose adjustments, hospital admissions and any surgical procedure that could be related to Crohn’s disease. Patients were categorized into 3 groups according to their findings on endoscopy and GIUS: The activity group (1) consisted of patients with activity on GIUS defined as any bowel wall segment ≥3mm and Simple Endoscopic score of Crohn’s disease (SES-CD) &gt;2. The group in transmural remission (2) was defined as all patients with BWT &lt;3mm independent of findings on endoscopy. The final group (3) consisted of the patients with isolated endoscopic remission defined as SES-CD ≤2 and BWT ≥3mm in one or more bowel segment. Results 155 CD patients were included in the study. In total 61/155 patients experienced one or more negative, clinical endpoint during the one year follow up period. 9/155 received treatment with corticosteroids, 50/155 had adjustments in their medical therapy, 32/155 were admitted to the hospital at least once and 18/155 had surgery. In group 1, 44/92 experienced one or more endpoints while the corresponding numbers were 9/40 in group 2 and 8/23 in group 3. The frequency of clinical endpoints were significantly different between the different groups (p=0,020, Fischer’s exact test). Only patients in group 1 were operated. Conclusion The group with transmural remission had fewer patients with negative, clinical endpoints which suggests that GIUS is well suited for distinguishing between CD patients with high or low risk for negative clinical endpoints.