MR enterography to evaluate sub-clinical intestinal inflammation in children with spondyloarthritis

Abstract

BackgroundMagnetic resonance enterography (MRE) is an established tool to evaluate for changes associated with inflammatory bowel disease (IBD), but has not been studied in sub-clinical IBD. We sought to evaluate the use of MRE in children with spondyloarthritis (SpA), who are at risk of having sub-clinical gut inflammation.MethodsChildren with juvenile idiopathic arthritis (JIA) with evidence of intestinal inflammation as evidence by an abnormal fecal calprotectin assay were offered MRE of their intestines. Flavored sports drink containing polyethylene glycol 3350 was used as oral contrast. Glucagon was used to arrest peristalsis. Patients were imaged in the prone position on a 1.5 T scanner. Heavily T2-weighted fat-suppressed coronal and axial images using breath-hold technique were obtained, followed by post-gadolinium fat-suppressed T1-weighted gradient echo images.ResultsWe recruited five children with juvenile idiopathic arthritis (JIA); four had SpA, and one had poly-articular JIA. All five had evidence of intestinal inflammation based upon a positive fecal calprotectin assay and successfully completed the MRE. Three of the studies showed findings suggestive of IBD, including thickening and contrast uptake at the terminal ileum (TI) in one child, contrast uptake of the distal ileum in another, and prominent vasa recta and mesenteric lymph nodes in the third. The child with evidence of inflammatory changes at the TI underwent colonoscopy, which revealed inflammatory bowel disease limited to the TI.ConclusionsMRE can be used to evaluate for subclinical IBD in children with JIA. This protocol was safe and well-tolerated, and identified mild changes in three of the subjects.

Update on Juvenile Spondyloarthritis

“…Interestingly, elevated levels of fecal calprotectin, a marker of intestinal inflammation, were seen in a small series of ERA patients compared to healthy, other JIA, and other connective tissue disease controls 37 . In a follow-up study, MR enterography performed on 5 patients with JIA and elevated fecal calprotectin, including 4 with jSpA, showed evidence of intestinal inflammation 38 .…”

The microbiota in pediatric rheumatic disease: epiphenomenon or therapeutic target?

“…Specifically, Picco et al (2000) used the urinary lactulose/mannitol test to demonstrate altered intestinal permeability in children with JIA (28); they found it was higher in children with juvenile spondyloarthritis (SpA) compared to those with other forms of JIA, who themselves had higher levels than healthy control subjects. Several additional studies have identified evidence of sub-clinical intestinal inflammation in children with spondyloarthritis using colonoscopy (29), fecal calprotectin (30), or MRI (31); all of these studies suggest children with at least the SpA variant of JIA may have qualitatively similar, while quantitatively less, intestinal abnormalities as patients with inflammatory bowel disease (IBD). Conversely, it is well-established that up to one quarter of patients with IBD has arthritis, typically SpA (32).…”

Enthesitis-related arthritis

“…Elevated fecal calprotectin, a marker of gut inflammation, has been found in patients with ERA as compared to other JIA subtypes, healthy, or other connective tissue diseases in childhood, and such patients have been demonstrated to have a MRI evidence of gut inflammation [24].…”