Consensus Recommendations for Evaluation, Interpretation, and Utilization of Computed Tomography and Magnetic Resonance Enterography in Patients With Small Bowel Crohn’s Disease
2018; Elsevier BV; Volume: 154; Issue: 4 Linguagem: Inglês
10.1053/j.gastro.2017.11.274
ISSN1528-0012
AutoresDavid H. Bruining, Ellen M. Zimmermann, Edward V. Loftus, William J. Sandborn, Cary G. Sauer, Scott A. Strong, Mahmoud M. Al-Hawary, Sudha A. Anupindi, Mark E. Baker, David H. Bruining, Kassa Darge, Jonathan R. Dillman, David M. Einstein, Jeff L. Fidler, Joel G. Fletcher, Michael S. Gee, David Grand, Flavius F. Guglielmo, Amy K. Hara, Tracy A. Jaffe, Dean D. T. Maglinte, Alec J. Megibow, Seong Ho Park, Joel F. Platt, Daniel J. Podberesky, Jordi Rimola, Dushyant V. Sahani, Jorge A. Soto, Stuart A. Taylor,
Tópico(s)Diverticular Disease and Complications
ResumoComputed tomography and magnetic resonance enterography have become routine small bowel imaging tests to evaluate patients with established or suspected Crohn’s disease, but the interpretation and use of these imaging modalities can vary widely. A shared understanding of imaging findings, nomenclature, and utilization will improve the utility of these imaging techniques to guide treatment options, as well as assess for treatment response and complications. Representatives from the Society of Abdominal Radiology Crohn’s Disease-Focused Panel, the Society of Pediatric Radiology, the American Gastroenterological Association, and other experts, systematically evaluated evidence for imaging findings associated with small bowel Crohn’s disease enteric inflammation and established recommendations for the evaluation, interpretation, and use of computed tomography and magnetic resonance enterography in small bowel Crohn’s disease. This work makes recommendations for imaging findings that indicate small bowel Crohn’s disease, how inflammatory small bowel Crohn’s disease and its complications should be described, elucidates potential extra-enteric findings that may be seen at imaging, and recommends that cross-sectional enterography should be performed at diagnosis of Crohn’s disease and considered for small bowel Crohn’s disease monitoring paradigms. A useful morphologic construct describing how imaging findings evolve with disease progression and response is described, and standard impressions for radiologic reports that convey meaningful information to gastroenterologists and surgeons are presented. Computed tomography and magnetic resonance enterography have become routine small bowel imaging tests to evaluate patients with established or suspected Crohn’s disease, but the interpretation and use of these imaging modalities can vary widely. A shared understanding of imaging findings, nomenclature, and utilization will improve the utility of these imaging techniques to guide treatment options, as well as assess for treatment response and complications. Representatives from the Society of Abdominal Radiology Crohn’s Disease-Focused Panel, the Society of Pediatric Radiology, the American Gastroenterological Association, and other experts, systematically evaluated evidence for imaging findings associated with small bowel Crohn’s disease enteric inflammation and established recommendations for the evaluation, interpretation, and use of computed tomography and magnetic resonance enterography in small bowel Crohn’s disease. This work makes recommendations for imaging findings that indicate small bowel Crohn’s disease, how inflammatory small bowel Crohn’s disease and its complications should be described, elucidates potential extra-enteric findings that may be seen at imaging, and recommends that cross-sectional enterography should be performed at diagnosis of Crohn’s disease and considered for small bowel Crohn’s disease monitoring paradigms. A useful morphologic construct describing how imaging findings evolve with disease progression and response is described, and standard impressions for radiologic reports that convey meaningful information to gastroenterologists and surgeons are presented. Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) have emerged as the most effective methods for imaging the small bowel in patients with Crohn’s disease.1Fletcher J.G. Fidler J.L. Bruining D.H. Huprich J.E. New concepts in intestinal imaging for inflammatory bowel diseases.Gastroenterology. 2011; 140: 1795-1806Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 2Panes J. Bouhnik Y. Reinisch W. et al.Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines.J Crohns Colitis. 2013; 7: 556-585Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar Cross-sectional enterography techniques complement ileocolonoscopy and can visualize intramural or proximal small bowel inflammation in approximately 50% of Crohn’s disease patients who have endoscopically normal examinations.3Faubion Jr., W.A. Fletcher J.G. O'Byrne S. et al.EMerging BiomARKers in Inflammatory Bowel Disease (EMBARK) study identifies fecal calprotectin, serum MMP9, and serum IL-22 as a novel combination of biomarkers for Crohn's disease activity: role of cross-sectional imaging.Am J Gastroenterol. 2013; 108: 1891-1900Crossref PubMed Scopus (37) Google Scholar, 4Rimola J. Rodriguez S. Garcia-Bosch O. et al.Magnetic resonance for assessment of disease activity and severity in ileocolonic Crohn's disease.Gut. 2009; 58: 1113-1120Crossref PubMed Scopus (304) Google Scholar, 5Samuel S. Bruining D.H. Loftus Jr., E.V. et al.Endoscopic skipping of the distal terminal ileum in Crohn's disease can lead to negative results from ileocolonoscopy.Clin Gastroenterol Hepatol. 2012; 10: 1253-1259Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar CTE and MRE are useful tools for Crohn’s disease diagnosis, determining distribution of disease involvement, and detecting complications of the disease.1Fletcher J.G. Fidler J.L. Bruining D.H. Huprich J.E. New concepts in intestinal imaging for inflammatory bowel diseases.Gastroenterology. 2011; 140: 1795-1806Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 2Panes J. Bouhnik Y. Reinisch W. et al.Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines.J Crohns Colitis. 2013; 7: 556-585Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar Recent data suggest that cross-sectional imaging may be useful in determining response to therapy, assessing bowel healing, and monitoring disease progression.6Deepak P. Fletcher J.G. Fidler J.L. et al.Radiological response is associated with better long-term outcomes and is a potential treatment target in patients with small bowel Crohn's disease.Am J Gastroenterol. 2016; 111: 997-1006Crossref PubMed Google Scholar The Society of Abdominal Radiology (SAR) formed a Crohn’s Disease-Focused Panel, which has established standards for the technical performance of these examinations7Baker M.E. Hara A.K. Platt J.F. et al.CT enterography for Crohn's disease: optimal technique and imaging issues.Abdom Imaging. 2015; 40: 938-952Crossref PubMed Google Scholar, 8Grand D.J. Guglielmo F.F. Al-Hawary M.M. MR enterography in Crohn's disease: current consensus on optimal imaging technique and future advances from the SAR Crohn's disease-focused panel.Abdom Imaging. 2015; 40: 953-964Crossref PubMed Scopus (0) Google Scholar, 9American College of Radiology. ACR-SAR-SPR Practice parameter for the performance of CT enterography. https://www.acr.org/∼/media/99D260410DF44A3BA01F1AB716DE8F2F.pdf. Published 2015. Accessed March 2, 2017.Google Scholar (Appendix 1). CTE and MRE are now performed across a range of institutions, with the radiologic literature focusing on the technical aspects of diagnosis and identification of mural inflammation or penetrating complications, such as fistula and abscess, using various acquisition methods and imaging findings. Important prior consensus statements, including those of the European Crohn’s and Colitis Organization and European Society of Gastrointestinal and Abdominal Radiology and SAR recommendations for the performance of CTE and MRE establish critical and necessary rationale for when and how imaging of inflammatory bowel disease patients should be performed, respectively.2Panes J. Bouhnik Y. Reinisch W. et al.Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines.J Crohns Colitis. 2013; 7: 556-585Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar, 7Baker M.E. Hara A.K. Platt J.F. et al.CT enterography for Crohn's disease: optimal technique and imaging issues.Abdom Imaging. 2015; 40: 938-952Crossref PubMed Google Scholar, 8Grand D.J. Guglielmo F.F. Al-Hawary M.M. MR enterography in Crohn's disease: current consensus on optimal imaging technique and future advances from the SAR Crohn's disease-focused panel.Abdom Imaging. 2015; 40: 953-964Crossref PubMed Scopus (0) Google Scholar To date, however, there are no agreed-upon expectations for structures that should be evaluated at cross-sectional enterography, no standardized nomenclature for describing imaging findings in Crohn’s disease, no guidance for how to describe severity and burden of different Crohn’s disease imaging findings to best guide medical and surgical management, and no consensus between US gastroenterology and radiology societies on when these tests should be performed. The purpose of this work is to establish a common system for mapping specific imaging findings to clinically useful impressions and for description of Crohn’s disease phenotypes that can guide gastroenterologists and surgeons in making important treatment decisions for Crohn’s disease patients. The standardization will both advance patient care through improved understanding of the communicated imaging findings and improve comparison of reported research in the field. Because CTE and MRE findings change patient management in a substantial proportion of symptomatic patients,10Bruining D.H. Siddiki H.A. Fletcher J.G. et al.Benefit of computed tomography enterography in Crohn's disease: effects on patient management and physician level of confidence.Inflamm Bowel Dis. 2012; 18: 219-225Crossref PubMed Scopus (37) Google Scholar, 11Higgins P.D. Caoili E. Zimmermann M. et al.Computed tomographic enterography adds information to clinical management in small bowel Crohn's disease.Inflamm Bowel Dis. 2007; 13: 262-268Crossref PubMed Scopus (0) Google Scholar systematic review of CTE and MRE images is essential to maximize patient benefit. A motivating example for how a systematic review of imaging findings and standard nomenclature might improve patient care can be found in the standard reporting template for pancreatic cancer: an interdisciplinary group of radiologists, medical oncologists, pancreatologists, and pancreatic surgeons recommended a systematized reporting template for pancreatic carcinoma, designed to capture objective imaging findings to guide and improve therapeutic decisions.12Al-Hawary M.M. Francis I.R. Chari S.T. et al.Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the society of abdominal radiology and the American Pancreatic Association.Gastroenterology. 2014; 146: 291-304. e291Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar In Crohn’s disease, the use of imaging is evolving over time. Cross-sectional imaging was initially used to detect and stage Crohn’s disease,5Samuel S. Bruining D.H. Loftus Jr., E.V. et al.Endoscopic skipping of the distal terminal ileum in Crohn's disease can lead to negative results from ileocolonoscopy.Clin Gastroenterol Hepatol. 2012; 10: 1253-1259Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar but it is increasingly being used to gauge therapeutic response,4Rimola J. Rodriguez S. Garcia-Bosch O. et al.Magnetic resonance for assessment of disease activity and severity in ileocolonic Crohn's disease.Gut. 2009; 58: 1113-1120Crossref PubMed Scopus (304) Google Scholar, 13Bruining D.H. Loftus Jr., E.V. Ehman E.C. et al.Computed tomography enterography detects intestinal wall changes and effects of treatment in patients with Crohn's disease.Clin Gastroenterol Hepatol. 2011; 9: 679-683. e671Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar providing objective measures to guide treatment decisions that can potentially alter the natural history of the disease.14Bruining D.H. Bhatnagar G. Rimola J. et al.CT and MR enterography in Crohn's disease: current and future applications.Abdom Imaging. 2015; 40: 965-974Crossref PubMed Scopus (0) Google Scholar Mucosal healing as detected by colonoscopy in Crohn’s disease results in improved outcome15Baert F. Moortgat L. Van Assche G. et al.Mucosal healing predicts sustained clinical remission in patients with early-stage Crohn's disease.Gastroenterology. 2010; 138 (quiz e410−e461): 463-468Abstract Full Text Full Text PDF PubMed Scopus (445) Google Scholar, 16Beppu T. Ono Y. Matsui T. et al.Mucosal healing of ileal lesions is associated with long-term clinical remission after infliimab maintenance treatment in patients with Crohn's disease.Dig Endosc. 2015; 27: 73-81Crossref PubMed Scopus (7) Google Scholar, 17Sakuraba A. Annunziata M.L. Cohen R.D. et al.Mucosal healing is associated with improved long-term outcome of maintenance therapy with natalizumab in Crohn's disease.Inflamm Bowel Dis. 2013; 19: 2577-2583Crossref PubMed Scopus (18) Google Scholar, 18Schnitzler F. Fidder H. Ferrante M. et al.Mucosal healing predicts long-term outcome of maintenance therapy with infliximab in Crohn's disease.Inflamm Bowel Dis. 2009; 15: 1295-1301Crossref PubMed Scopus (393) Google Scholar; however, more recently, cross-sectional imaging, primarily MRE, has demonstrated a high correlation between mucosal healing at endoscopy and transmural healing at cross-sectional imaging, with improved outcomes when detected.19Hashimoto S. Shimizu K. Shibata H. et al.Utility of computed tomographic enteroclysis/enterography for the assessment of mucosal healing in Crohn's disease.Gastroenterol Res Pract. 2013; 2013: 984916Crossref PubMed Google Scholar, 20Ordas I. Rimola J. Rodriguez S. et al.Accuracy of magnetic resonance enterography in assessing response to therapy and mucosal healing in patients with Crohn's disease.Gastroenterology. 2014; 146: 374-382. e371Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 21Sauer C.G. Middleton J.P. McCracken C. et al.Magnetic resonance enterography healing and magnetic resonance enterography remission predicts improved outcome in pediatric Crohn disease.J Pediatr Gastroenterol Nutr. 2016; 62: 378-383Crossref PubMed Scopus (8) Google Scholar Thus, there needs to be a shared understanding of the goals of imaging between referring clinicians and radiologists: while numerous investigators have consequently examined the relationship between objective and subjective imaging findings and the severity of endoscopic and histologic inflammation,4Rimola J. Rodriguez S. Garcia-Bosch O. et al.Magnetic resonance for assessment of disease activity and severity in ileocolonic Crohn's disease.Gut. 2009; 58: 1113-1120Crossref PubMed Scopus (304) Google Scholar, 22Zappa M. Stefanescu C. Cazals-Hatem D. et al.Which magnetic resonance imaging findings accurately evaluate inflammation in small bowel Crohn's disease? A retrospective comparison with surgical pathologic analysis.Inflamm Bowel Dis. 2011; 17: 984-993Crossref PubMed Scopus (0) Google Scholar, 23Rimola J. Ordas I. Rodriguez S. et al.Magnetic resonance imaging for evaluation of Crohn's disease: validation of parameters of severity and quantitative index of activity.Inflamm Bowel Dis. 2011; 17: 1759-1768Crossref PubMed Scopus (204) Google Scholar, 24Steward M.J. Punwani S. Proctor I. et al.Non-perforating small bowel Crohn's disease assessed by MRI enterography: derivation and histopathological validation of an MR-based activity index.Eur J Radiol. 2012; 81: 2080-2088Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 25Kim K.J. Lee Y. Park S.H. et al.Diffusion-weighted MR enterography for evaluating Crohn's disease: how does it add diagnostically to conventional MR enterography?.Inflamm Bowel Dis. 2015; 21: 101-109Crossref PubMed Scopus (29) Google Scholar others have described the extent of intestinal damage using cross-sectional findings.26Pariente B. Cosnes J. Danese S. et al.Development of the Crohn's disease digestive damage score, the Lemann score.Inflamm Bowel Dis. 2011; 17: 1415-1422Crossref PubMed Scopus (0) Google Scholar Information conveying length of involvement, severity of inflammation or bowel dilation, and surgical resections are required when assessing for therapeutic response. While the existing Montreal classification (and pediatric Paris classification) sub-classify phenotypes of Crohn’s disease, including nonstricturing and nonpenetrating inflammatory disease; stricturing disease; penetrating complications; and perianal fistula,27Levine A. Griffiths A. Markowitz J. et al.Pediatric modification of the Montreal classification for inflammatory bowel disease: the Paris classification.Inflamm Bowel Dis. 2011; 17: 1314-1321Crossref PubMed Scopus (419) Google Scholar, 28Silverberg M.S. Satsangi J. Ahmad T. et al.Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology.Can J Gastroenterol. 2005; 19: 5A-36ACrossref PubMed Google Scholar they do not describe the length and severity of inflammatory involvement or the anatomic relationship of coexisting phenotypes that are necessary to make important surgical and medical management decisions. More specifically, the Montreal/Paris classifications do not take into account the dynamic continuum of the disease, the overlap or co-existence of stricturing and penetrating disease (2 separate types of disease complications occurring from disease progression),29Oberhuber G. Stangl P.C. Vogelsang H. et al.Significant association of strictures and internal fistula formation in Crohn's disease.Virchows Arch. 2000; 437: 293-297Crossref PubMed Scopus (0) Google Scholar, 30Kelly J.K. Preshaw R.M. Origin of fistulas in Crohn's disease.J Clin Gastroenterol. 1989; 11: 193-196Crossref PubMed Scopus (0) Google Scholar or the fact that active inflammation is most often present in stricturing complications.22Zappa M. Stefanescu C. Cazals-Hatem D. et al.Which magnetic resonance imaging findings accurately evaluate inflammation in small bowel Crohn's disease? A retrospective comparison with surgical pathologic analysis.Inflamm Bowel Dis. 2011; 17: 984-993Crossref PubMed Scopus (0) Google Scholar, 29Oberhuber G. Stangl P.C. Vogelsang H. et al.Significant association of strictures and internal fistula formation in Crohn's disease.Virchows Arch. 2000; 437: 293-297Crossref PubMed Scopus (0) Google Scholar, 31Adler J. Punglia D.R. Dillman J.R. et al.Computed tomography enterography findings correlate with tissue inflammation, not fibrosis in resected small bowel Crohn's disease.Inflamm Bowel Dis. 2012; 18: 849-856Crossref PubMed Scopus (0) Google Scholar Both CTE and MRE can detect the morphologic continuum and co-existing “complications” with regularity, thus prompting the need for radiologists to reliably define and reproducibly describe the anatomic burden of inflammation and Crohn’s disease complications. These recommendations define imaging findings that should be evaluated, how disease burden should be described, and pathophysiologic conclusions that will improve the ability of gastroenterologists and intestinal surgeons to best make management decisions. For example, radiologists should examine for Crohn’s disease strictures, which are defined in this guideline as small bowel segments with luminal narrowing and unequivocal proximal (upstream) dilation. Moreover, these recommendations emphasize that when strictures are found, the length of the stricture and radiologic findings of concurrent inflammation and obstruction should be described. These elements provide much of the critical information a gastroenterologist will need to consider in determining options for medical, surgical, or endoscopic therapy. The benefits of a shared understanding and improved communication of cross-sectional enterography examinations will facilitate:•Improved use of imaging to guide treatment options, and assess for therapeutic response.•Improved understanding for how to compare and assess Crohn’s inflammatory burden.•Improved systematic assessment of important complications.•Improved ability to track and understand the natural history of Crohn’s disease. The SAR Crohn’s Disease-Focused Panel was established in March 2014 to disseminate knowledge and improve the quality and availability of small bowel and Crohn’s disease imaging techniques, with an overall aim to improve the care of patients with Crohn’s disease. After approval from the SAR Board of Directors and the American Gastroenterological Association’s (AGA) Institute Council, this panel met with representatives from the AGA’s Imaging and Advanced Technology section in person, via e-mail, and through conference calls, to develop a shared understanding of imaging findings across enterography techniques and their physiologic substrates. Representatives with expertise in Crohn’s disease were also sought and included from the Society of Pediatric Radiology, the European Society of Gastrointestinal and Abdominal Radiology, the Society for Surgery of the Alimentary Tract, the American Society of Colon and Rectal Surgeons, and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Through electronic communications and conference calls, consensus recommendations were reached and submitted to the SAR Board and AGA Council for approval. A primary aim of this work was to define and describe key imaging findings that relate to the diagnosis, severity, and type of Crohn’s disease involvement in the small bowel. To this end, the evidence of Crohn’s disease inflammation for specific imaging findings at CTE and MRE was evaluated according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system for evaluation of diagnostic tests.32Schunemann H.J. Oxman A.D. Brozek J. et al.Grading quality of evidence and strength of recommendations for diagnostic tests and strategies.BMJ. 2008; 336: 1106-1110Crossref PubMed Google Scholar, 33Guyatt G.H. Oxman A.D. Kunz R. et al.What is “quality of evidence” and why is it important to clinicians?.BMJ. 2008; 336: 995-998Crossref PubMed Google Scholar, 34Guyatt G.H. Oxman A.D. Vist G.E. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar For this purpose, CTE and MRE were not considered as stand-alone tests, but as part of an imaging strategy combined with clinical assessment and ileocolonoscopy.32Schunemann H.J. Oxman A.D. Brozek J. et al.Grading quality of evidence and strength of recommendations for diagnostic tests and strategies.BMJ. 2008; 336: 1106-1110Crossref PubMed Google Scholar In developing these recommendations, authors from the SAR Crohn’s Disease-Focused Panel and the AGA’s Imaging and Advanced Technology section reviewed original investigations and meta-analyses from the medical literature relating to each imaging finding. Practical conclusions were reached relating to each imaging finding reviewed, with the quality of the evidence for each conclusion graded along a 4-point scale (ie, very low, low, moderate, high) based on formalized, agreed-upon evaluation criteria: high-quality studies were those that enrolled consecutive patients in a clinically relevant cohort, with universal application of an endoscopic or histologic reference standard, clear blinding of readers, and site-specific correlation between reference and reader findings. Quality was downgraded if these criteria were not met, if there was substantial variation between studies without a clear explanation, or if there was major uncertainty about the effect of false positives and negatives. Conclusions for the level of evidence relating to each imaging finding were proposed by each pair of reviewers along with their assessment of the formalized criteria for evaluating the scientific evidence, with final agreement by consensus of panel and section members, respectively. Based on these conclusions, recommendations for use of CTE or MRE or incorporation of each imaging finding into a clinical report were created by the entire author group, with strong recommendations indicating confidence that incorporation will have desirable effects on patient outcomes and outweigh undesirable effects or alternatives.35Guyatt G.H. Oxman A.D. Kunz R. et al.Going from evidence to recommendations.BMJ. 2008; 336: 1049-1051Crossref PubMed Google Scholar The strength of the recommendation also takes into account alternative management strategies. All authors then approved the final document by consensus. Subsequently, this document was submitted to the AGA Institute Council, the Board of Directors for SAR, and the Society of Pediatric Radiology, all of which approved the document. Table 1 defines and describes imaging findings of mural inflammation at CTE and MRE, along with important diagnostic considerations and practical conclusions. Figure 1 pictorially illustrates an imaging-based morphologic construct that demonstrates the role of mural inflammation in driving Crohn’s disease exacerbations and response as seen at cross-sectional enterography, and which will be explained in greater depth after individual imaging findings have been reviewed. The pictorial representation of a single bowel loop is used to facilitate a unified understanding of how mural inflammation can change independent of signal properties of cross-sectional imaging modalities. Multiple studies have shown that in patients with Crohn’s disease, imaging findings of inflammation are strongly associated with the presence of histologic inflammation.36Bodily K.D. Fletcher J.G. Solem C.A. et al.Crohn Disease: mural attenuation and thickness at contrast-enhanced CT enterography—correlation with endoscopic and histologic findings of inflammation.Radiology. 2006; 238: 505-516Crossref PubMed Scopus (234) Google Scholar, 37Church P.C. Turner D. Feldman B.M. et al.Systematic review with meta-analysis: magnetic resonance enterography signs for the detection of inflammation and intestinal damage in Crohn's disease.Aliment Pharmacol Ther. 2015; 41: 153-166Crossref PubMed Scopus (0) Google Scholar, 38Horsthuis K. Bipat S. Bennink R.J. et al.Inflammatory bowel disease diagnosed with US, MR, scintigraphy, and CT: meta-analysis of prospective studies.Radiology. 2008; 247: 64-79Crossref PubMed Scopus (322) Google Scholar, 39Qiu Y. Mao R. Chen B.L. et al.Systematic review with meta-analysis: magnetic resonance enterography vs. computed tomography enterography for evaluating disease activity in small bowel Crohn's disease.Aliment Pharmacol Ther. 2014; 40: 134-146Crossref PubMed Scopus (34) Google Scholar, 40Siddiki H. Fletcher J.G. Hara A.K. et al.Validation of a lower radiation computed tomography enterography imaging protocol to detect Crohn's disease in the small bowel.Inflamm Bowel Dis. 2011; 17: 778-786Crossref PubMed Scopus (38) Google Scholar Evidence describing and supporting the use of these imaging findings for small bowel inflammation is provided in references within Table 1. By extension and inference, similar findings can reflect enteric inflammation in the stomach and colon.Table 1Imaging Findings Associated With Small Bowel Crohn’s Disease InflammationImaging findingsDescription/definitionDDX considerations/commentsConclusions (level of evidence)Segmental mural hyperenhancementIncreased attenuation/signal intensity on contrast-enhanced scan in noncontracted segment in comparison to nearby normal small bowel segmentsPredictive but nonspecific sign36Bodily K.D. Fletcher J.G. Solem C.A. et al.Crohn Disease: mural attenuation and thickness at contrast-enhanced CT enterography—correlation with endoscopic and histologic findings of inflammation.Radiology. 2006; 238: 505-516Crossref PubMed Scopus (234) Google Scholar, 41Baker M.E. Walter J. Obuchowski N.A. et al.Mural attenuation in normal small bowel and active inflammatory Crohn's disease on CT enterography: location, absolute attenuation, relative attenuation, and the effect of wall thickness.AJR Am J Roentgenol. 2009; 192: 417-423Crossref PubMed Scopus (0) Google ScholarCauses include Crohn’s disease-related mural inflammation, backwash ileitis, infectious enteritis, mucositis, graft-vs-host disease, contraction or underdistension, radiation enteritis, NSAID enteropathy, angioedema, vasculitis, and ischemiaAltered enhancement in Crohn’s disease can also reflect processes other than inflammation, such as fibrosis or chronic mesenteric venous occlusionMore likely indicates Crohn’s disease when asymmetric and combined with other mural and mesenteric findings belowContrast-enhanced imaging is performed in enteric to portal phases of enhancement7Baker M.E. Hara A.K. Platt J.F. et al.CT enterography for Crohn's disease: optimal technique and imaging issues.Abdom Imaging. 2015; 40: 938-952Crossref PubMed Google Scholar, 8Grand D.J. Guglielmo F.F. Al-Hawary M.M. MR enterography in Crohn's disease: current consensus on optimal imaging technique and future advances from the SAR Crohn's disease-focused panel.Abdom Imaging. 2015; 40: 953-964Crossref PubMed Scopus (0) Google Scholar1.Segmental mural hyperenhancement and wall thickening have a moderately high sensitivity and specificity for small bowel Crohn’s disease at CTE or MRE.37Church P.C. Turner D. Feldman B.M. et al.Systematic review with meta-analysis: magnetic resonance enterography signs for the detection of inflammation and intestinal damage in Crohn's disease.Aliment Pharmacol Ther. 2015; 41: 153-166Crossref PubMed Scopus (0) Google Scholar, 38Horsthuis K. Bipat S. Bennink R.J. et al.Inflammatory bowel disease diagnosed with US, MR, scintigraphy, and CT: meta-analysis of prospective studies.Radiology. 2008; 247: 64-79Crossref PubMed Scopus (322) Google Scholar, 39Qiu Y. Mao R. Chen B.L. et al.Systematic review with meta-analysis: magnetic resonance enterography vs. computed tomography enterography for evaluating disease activity in small bowel Crohn's disease.Aliment Pharmacol Ther. 2014; 40: 134-146Crossref P
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