Impact of Intestinal Ultrasound on Classification and Management of Crohn’s Disease Patients with Inconclusive Colonoscopy

Abstract

Background and Aims. We aim to evaluate the benefit of ultrasound in the assessment of Crohn's disease and to demonstrate its potential contribution to disease management. Methods. We conduct a retrospective review of adult patients with Crohn's disease examined with sonography and colonoscopy within 30 days. Study patients were identified in whom colonoscopy did not access a pathological segment, detected and evaluated by ultrasonography. Changes in management were predominantly attributed to ultrasound in those cases where the diseased segment was not assessed on endoscopy. Results. From 115 patients with temporally related ileocolonoscopy and ultrasound, 41 had disease fully assessed on ultrasound only, with complications in 26/41. Twenty-nine of 41 had mild or no endoscopic inflammation with moderate or severe disease on ultrasound at the same segment or at a segment proximal to the reach of the endoscope. Changes in management were significantly attributed to ultrasound in 22 of these 29 patients. Conclusion. The benefit of cross-sectional imaging is invaluable for the comprehensive assessment of bowel not shown on ileocolonoscopy. Ultrasound may make a significant contribution to correct classification of disease extent and severity of Crohn's disease. Prospective studies are needed to further understand the contribution of US in patient management.

Point of Care Ultrasound Accurately Distinguishes Inflammatory from Non Inflammatory Disease in Patients Presenting with Abdominal Pain and Diarrhea

“…There were no cases where the distal terminal ileum was normal on endoscopy and disease was isolated to the proximal small bowel, as has been reported in up to 30% of cases with small bowel involvement [30]; however, in 2 patients with both US and endoscopic activity (true positives), there was an estimation between 25 and 30 cm of active disease proximal to that region examined endoscopically. Thus, US also provided insight into the length or burden of the disease [31]. One case exhibited negative US and negative endoscopy, yet mild inflammatory activity on pathology.…”

The importance of intestinal ultrasound and elastographic techniques in inflammatory bowel diseases

“…The actual research data suggests that intestinal US has a pivotal role in monitoring CD and response to therapy [31,39,40,[66][67][68]. There are yet few studies concerning this subject, but the results are promising.…”

Utility of MR enterography and ultrasound for the investigation of small bowel Crohn's disease

“…Few would disagree that radiologists require specific training when evaluating the small bowel for CD, although it is unclear whether this is greater for US than for MRI, as is commonly supposed. There is in fact few data evaluating training requirements for competency in SBUS, although learned bodies (for example, European gastroenterologists) have produced detailed curriculums and advice on learning strategies . With respect to MRE, one study investigating formal training with direct case‐by‐case feedback in 31 inexperienced readers concluded that experience of at least 100 cases was required to achieve the acceptable MRE activity grading accuracy of 75% …”

“…111 Interestingly, SBUS disclosed active disease in up to 52% of patients asymptomatic on follow up. 111,112 Wilkens et al 113 retrospectively reviewed 115 CD patients having comprehensive ultrasound and colonoscopy within 30 days of each other. Seventy-four patients (64%) had disease matched on the two tests but 41 (36%) patients demonstrated abnormal bowel on US alone, proximal to the reach of ileocolonoscopy (although of these only eight had disease confirmed by subsequent surgery: the remainder had no corroborative test).…”

“…In 29 (71%) of these patients, ultrasound demonstrated moderate or severe inflammation despite an endoscopic diagnosis of mild or no inflammation. 113 This changed management in 22 (76%) of these patients (13 changes in medical therapy, eight surgical referrals, one hospital admission), attributed to the SBUS. 113 The emerging literature therefore supports a role for treatment monitoring using SBUS and also for follow-up of asymptomatic patients given the high prevalence of asymptomatic (and thus untreated) inflammation.…”