Bowel Ultrasound Scan Predicts Corticosteroid Failure in Children With Acute Severe Colitis

Abstract

Background and objective: Acute severe colitis (ASC) is a potentially life-threatening event. Optimal timing for second-line treatment in children is mainly based on the clinical score Pediatric Ulcerative Colitis Activity Index. The aim of our study was to evaluate the potential role of bowel ultrasound scan (BUS) in predicting the need of second-line therapy in ASC. Methods: Patients younger than 18 years admitted to a single tertiary referral center with ASC were included. We retrospectively reviewed medical records collecting clinical and BUS data. Colonic wall thickness (CWT), loss of colonic wall stratification (CWS), presence of hyperechoic lymph nodes, and colonic wall flow evaluated at power Doppler were assessed at BUS performed within the third day of hospitalization. Results: Sixty-nine ASC episodes from 52 different patients were identified. CWT showed significantly higher values in patients who required second-line therapy (5.14 vs 3.69 mm; P < 0.001). Loss of CWS was present in 17 of 36 (47.2%) of steroid-resistant ASC versus only 1 of 33 of those responding to intravenous corticosteroids (P < 0.001, sensitivity = 47%, specificity = 97%). Using a receiver operating characteristic curve, a cut-off of 3.4 mm was individuated for CWT to predict steroid treatment failure, showing a sensitivity of 92% and a specificity of 52%. The multivariable binary logistic regression analysis identified thickened colonic wall (CWT >3.4 mm) and loss of CWS as independent predictors of steroid resistance. Conclusions: BUS is a noninvasive, easily accessible, and cost-effective resource that may identify at an early stage first-line therapy failure in pediatric ASC.

Defining Transabdominal Intestinal Ultrasound Treatment Response and Remission in Inflammatory Bowel Disease: Systematic Review and Expert Consensus Statement

“… 22 In UC, IUS response can be detected after 10–14 days, 40 , 45 possibly even earlier. 55 Such rapid rates of improvement have not been reported for biologics or immunomodulators. Two years after treatment initiation with either anti-tumour necrosis factor [TNF] or azathioprine, Castiglione et al .…”

Diagnostic accuracy of multimodal noninvasive follow‐up for pediatric ulcerative colitis: A single‐center prospective study

“…Nonetheless, US has proven to be a valuable tool, particularly as a first line choice, during severe disease even at the patient's bedside. 10,12,19 In contrast, CCE has demonstrated excellent accuracy in assessing the extent of disease and distinguishing between mild and moderate-severe disease. However, it has shown a lower accuracy in identifying moderate disease activity.…”

“…However, it has been previously reported that US may be less accurate in detecting mild disease, as it may not identify superficial mucosal lesions such as erythema and mild friability. Nonetheless, US has proven to be a valuable tool, particularly as a first line choice, during severe disease even at the patient's bedside 10,12,19 …”

“…FCP has emerged as a biomarker that correlates closely with mucosal inflammation; however, it does not provide information about disease extent, 6 even if combined with the PUCAI score. Recently, colonic ultrasonography (US) and colon capsule endoscopy (CCE) have shown high accuracy in evaluating mucosal changes, disease extent, and activity, especially in children with UC 7–12 . These noninvasive tools are well tolerated, radiation‐free, and not require anesthesia, while providing an accurate evaluation of the entire colonic mucosa 7,10 …”

Intestinal Ultrasound in Inflammatory Bowel Disease: A Valuable and Increasingly Important Tool

“…Similarly, in a retrospective study including 69 ASUC episodes in 52 paediatric patients, salvage therapy was more frequently needed in patients with higher BWT, higher vascularisation, and loss of BWS at admission. A thickened wall (>3.4 mm) and loss of BWS were independent predictors of steroid resistance [ 67 ]. Thus, if IUS parameters prove to be independent predictors of response to systemic steroids in the ASUC setting, early IUS could enable a timelier introduction of salvage therapy.…”