Background and aims Intestinal ultrasound (IUS) is an accurate, patient-centered monitoring tool that objectively evaluates Crohn’s disease (CD) activity. However, no current, widely accepted, reproducible activity index exists to facilitate consistent IUS identification of inflammatory activity. The aim of this study is to identify key parameters of CD inflammation on IUS, evaluate their reliability and develop an IUS index reflecting segmental activity. Methods There were 3 phases: 1) expert consensus Delphi method to derive measures of IUS activity; 2) an initial, multi-expert case acquisition and expert-interpretation of 20 blinded cases to measure inter-rater reliability for individual measures; 3) refinement of case acquisition and interpretation by 12 international experts, with 30 blinded case reads with reliability assessment and development of a segmental activity score. Results Delphi Consensus: Eleven experts representing 7 countries identified four key parameters including (1) bowel wall thickness (BWT) (2) bowel wall stratification (3) hyperemia of the wall [color Doppler imaging] and (4) inflammatory mesenteric fat. Blind Read: Each variable exhibited moderate to substantial reliability. Optimal, standardized image and cineloop acquisition were established. Second Blind Read and score development: intra-class correlation coefficient (ICC) for BWT was almost perfect 0.96 (0.94-0.98). All 4 parameters correlated with the global disease activity assessment and were included in the final International Bowel Ultrasound Segmental Activity Score with almost perfect ICC [0.97 (0.95-0.99, p<0.001)]. Conclusions Using expert consensus and standardized approaches, identification of key activity measurements on IUS has been achieved and a segmental activity score has been proposed, demonstrating excellent reliability.

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Background and Aims Transmural healing has emerged as a treatment target in Crohn’s disease (CD). We investigated whether transmural healing assessed with intestinal ultrasound (IUS) is associated with improved clinical outcomes in patients with CD in clinical remission. Methods Patients with CD in clinical remission at baseline (HBI <4) having IUS between August 2017 and June 2020 with at least 6‐months’ follow‐up were retrospectively studied. Time to medication escalation, corticosteroid use and CD‐related hospitalisation or surgery were compared by the presence or absence of sonographic healing, defined as bowel wall thickness ≤3 mm without hyperemia on color Doppler, inflammatory fat, or disrupted bowel wall stratification. Factors associated with survival were analyzed by Kaplan–Meier analysis using Cox proportional‐hazard model. Results Of 202 consecutive patients (50% male), sonographic inflammation was present in 61%. During median follow‐up of 19 (IQR 13–27) months, medication escalation occurred in 52%, corticosteroid use in 23%, hospitalisation in 21%, and CD‐related surgery in 13%. Sonographic healing was significantly associated with a reduced risk of medication escalation (p = 0.0018), corticosteroid use (p = 0.0247), hospitalisation (p = 0.0102), and surgery (p = 0.083). On multivariable analysis, sonographic healing was significantly associated with an increased odds of medication escalation‐free survival (hazard ratio [HR]:1.94; 95% CI 1.23–3.06; p = 0.004) and corticosteroid‐free survival (HR:2.41; 95% CI 1.24–4.67; p = 0.009), but not with hospitalisation or surgery. Conclusion In patients with CD in clinical remission, sonographic healing is associated with improved clinical outcomes. Further studies are needed to determine whether sonographic healing should be a treatment target.

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SummaryBackgroundCrohn’s disease is an inflammatory, penetrating intestinal disease associated with fistula formation. Fistulae in Crohn’s disease can be classified into external and internal fistulae. Internal fistulae form between the gastrointestinal tract and another internal organ and include enteroenteric, enterocolic, enterovesical and rectovaginal fistulae. They are associated with significant morbidity and a decreased quality of life.AimTo review the classification, diagnosis, medical and surgical management of internal fistulae in Crohn’s disease, and propose a treatment algorithm.MethodsA literature review on internal fistulae in Crohn’s disease in the adult population was undertaken, synthesised and summarised.ResultsInternal fistulae occur in up to 15% of patients with Crohn’s disease. Multi‐modal assessment including a combination of endoscopy and cross‐sectional imaging, usually magnetic resonance, is required to diagnose fistulae and determine extent of disease. Determining optimal treatment strategies for these complex fistulae remains a challenge due to limited and generally low‐quality data. Most studies to date have focussed on luminal disease, with (usually post hoc) outcomes more often reported for external fistulae, particularly perianal fistulae, than internal fistulae. Anti‐tumour necrosis factor therapies have emerged as the mainstay of medical therapy, with particularly promising data for enterovesical fistulae, but many patients will still require surgical intervention. The indications and optimal timing of surgery vs medical therapy remains uncertain; thus multi‐disciplinary input when making such decisions is important.ConclusionsInternal fistulae result in significantly increased morbidity in Crohn’s disease, and further studies to determine optimal multi‐modality management strategies incorporating medical and surgical therapy are required.