Transmural healing and MRI healing are associated with lower risk of bowel damage progression than endoscopic mucosal healing in Crohn’s disease

Abstract

SummaryBackgroundEndoscopic mucosal healing is the current therapeutic target in Crohn's disease. However, transmural healing could lead to better outcomes.AimsTo assess whether transmural healing or magnetic resonance imaging (MRI) healing are better therapeutic targets than endoscopic mucosal healing to predict long‐term improved outcome in Crohn's diseaseMethodsFrom our MRI database, we retrospectively identified all Crohn's disease patients who had MRI and colonoscopy within a 3‐month interval (median interval = 17.5 days). Four groups were considered: endoscopic mucosal healing (no ulceration or aphthoid erosion), MRI healing (no MRI signs of inflammation and no complication), transmural healing (combination of endoscopic and MRI healing) or no healing. Outcomes were time to surgery, bowel damage progression, hospitalisation, major outcomes (one of the three previous endpoints) and Crohn's disease‐related drug discontinuation. Results were expressed in multivariable analyses adjusted on potential confounders (hazard ratio (HR) [95% confidence interval]).ResultsAmong 154 patients with Crohn's disease, 51.9% (80/154), 10.4% (16/154), 19.5% (30/154) and 18.2% (28/154) achieved no healing, endoscopic mucosal healing, MRI healing and transmural healing, respectively. Transmural healing (HR = 0.05 [0.00‐0.40], P = 0.002) and MRI healing (HR = 0.09 [0.00‐0.47], P = 0.005) were associated with lower risk of bowel damage progression than endoscopic mucosal healing. In addition, achieving transmural healing or MRI healing reduced the risk of experiencing major outcomes compared to endoscopic mucosal healing (HR = 0.28 [0.00‐0.74], P = 0.01). Patients with transmural healing also had a decreased risk of relapse‐related drug discontinuation (HR = 0.35 [0.13‐0.95], P = 0.039) compared to those with endoscopic mucosal healing.ConclusionTransmural healing and MRI healing are associated with lower risk of bowel damage progression than endoscopic mucosal healing and could be considered as better therapeutic targets in Crohn's disease.

Magnetic resonance enterography findings 46 weeks after initiation of biological therapy predict long‐term adverse outcomes in Crohn's disease

“…Another option is to define healing as the absence of inflammatory lesions except wall thickening on MRE. Using this approach, Lafeuille et al 13 found that patients who achieved healing had a lower risk of intestinal damage progression including bowel resection, and that MRE predicted these outcomes better than endoscopy. Although our study supports the idea that normalisation of wall thickness should not be included as a therapeutic target, our results suggest that the definition of healing should be further adjusted to allow residual findings or sequels such as mild hyperperfusion, mild mural thickening and/or enteric fat deposition that result from multiple cycles of inflammation followed by healing process.…”

“…Several studies have found that post-treatment MRE findings are more accurate than endoscopy in predicting the need for surgery and hospitalization in CD. [12][13][14][15][16][17] However, differences in the definition of transmural healing on intestinal ultrasound or MRE in these studies hinder efforts to define the optimal goal for medical treatment. 1,18 The lack of a validated definition of transmural healing and of a formal analysis of the associations between individual MRE findings and clinical outcomes preclude the definition of the MREbased therapeutic targets for optimising medical treatment in CD patients.…”

“…Transmural healing is a potential therapeutic target of interest in CD. Several studies have found that post‐treatment MRE findings are more accurate than endoscopy in predicting the need for surgery and hospitalization in CD 12–17 . However, differences in the definition of transmural healing on intestinal ultrasound or MRE in these studies hinder efforts to define the optimal goal for medical treatment 1,18 .…”

Postoperative small bowel Crohn's disease: how to diagnose, manage and treat

“…Based on such data, an international panel has judged IUS to be a valuable tool for evaluating POR [25]. Studies have demonstrated that transmural activity, as assessed by IUS, is associated with worse outcomes even in the absence of endoscopic recurrence [26 ▪ ,27]. More advanced techniques, such as contrast-enhanced ultrasonography and ultrasound elastography may hold promise but they are currently not widely available [28 ▪▪ ].…”

Early transmural healing and its predictors assessed by magnetic resonance enterography in patients with Crohn’s disease receiving ustekinumab

“…5,6 Recent studies demonstrated that transmural healing (TH), assessed by intestinal ultrasonography (IUS) or magnetic resonance enterography (MRE), might be a more appropriate therapeutic goal of CD than MH. 7–9…”