Rationale and Objectives
This study aimed to evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) and computed tomography (CT) in assessing small bowel (SB) Crohn disease (CD).
Materials and Methods
We systematically searched PubMed, Elsevier, ScienceDirect, Karger, Web of Science, Wiley Online Library, and Springer for studies in which CT or MRI were evaluated to assess SB CD. Bivariate random effect meta-analytic methods were used to estimate pooled sensitivity, specificity, and receiver operating characteristic curves. Diagnostic odds ratios (DORs) in a per-patient–based analysis were estimated. The area under the receiver operating characteristic curve was also calculated to measure the diagnostic accuracy.
Results
Twenty-one studies involving 913 patients were included in this meta-analysis. There was no significant difference observed between modalities. The diagnostic performances (lnDOR) for CT and MRI also showed no significant difference. Subgroup analysis was performed for MR imaging (MR enteroclysis, MR enterography, and CT enterography). The diagnostic performances (lnDOR) for MR enteroclysis, MR enterography, and CT enterography did not show a significant difference among them. No significant difference was found between these techniques. Deeks funnel plot asymmetry test for publication bias showed that no significant publication bias was observed in this analysis.
Conclusions
This meta-analysis suggests that both MRI and CT have high diagnostic accuracy in detecting SB CD. MRI has the potential to be the first-line radiation-free modality for SB CD imaging.
Introduction
Crohn disease (CD) is a chronic inflammatory bowel disease of great diagnostic challenges, with an incidence of approximately 100–200 per 100,000 in North America and Europe, and a total of 400,000–600,000 patients in North America . The small bowel (SB) is the most commonly affected site, and it is the only affected site in around 30% of cases . Many new imaging tools are available in clinical practices for the evaluation of SB disorders. Among those, magnetic resonance imaging (MRI) and computed tomographic (CT) techniques are playing an important role for SB imaging. The previously established SB barium enteroclysis and barium follow-through are gradually being shifted toward MR enteroclysis and enterography, and CT enteroclysis and enterography.
One of the major differences between MRI and CT is in radiation dose for detection. MR enterography and MR enteroclysis require no or only a trivial dose, whereas CT enteroclysis and CT enterography require a large radiation dose around 10–15 mSv , although studies showed a lower dose (under 9 mSv) used in patients with CD . Some research estimated that the lifetime risk for an adult patient to acquire a fatal cancer from radiation is 1 in 20,000 per mSv , whereas a study showed that in 15% of patients with CD, the cumulative effective radiation dose was more than 75 mSv, which could increase the cancer mortality by as much as 7.3% . Some studies have compared CT and MRI in patients with CD, but the results were variable and controversial. This meta-analysis from published data aims to provide an up-to-date overview of the diagnostic accuracy of these imaging modalities for SB CD.
Materials and Methods
Search Strategy
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Data Extraction and Methodological Assessment
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Statistical Methods
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Publication Bias
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Results
Literature Search
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TABLE 1
Patient and Design Characteristics of the 21 Studies Included
Study Technique Design Age (y) (Average) No. of Patients Gender (Female Proportion) Patient Spectrum ( n ) Time Interval Between Reference Test and Index Test Lee et al. 2009 CT enterography Prospective 8–44 (29) 23 43% Endoscopic grade of CD was grade 0 in 5 patients, grade 1 in 2 patients, grade 3 in 4 patients, grade 4 in 9 patients, and grade 5 in 3 patients NA Lee et al. 2009 MR Enterography Prospective 8–44 (29) 23 43% Endoscopic grade of CD was grade 0 in 5 patients, grade 1 in 2 patients, grade 3 in 4 patients, grade 4 in 9 patients, and grade 5 in 3 patients NA Albert et al. 2005 MRI Prospective 18–72 (36.6) 24 75% 14 CD, 1 irritable bowel syndrome, 2 infectious colitis, 2 normal, 1 indeterminate colitis, 1 ulcerative colitis, 1 intolerance to lactulose, 1 symptoms due to adhesions NA Crook et al. 2009 MR Enterography Prospective 25–83 (56) 19 58% 5 CD, 4 non-Hodgkin lymphoma, 1 jejunal adenocarcinoma, 6 postradiotherapy enteritis, 1 jejunal lymphangioma, jejunal angiodysplasia, 1 NSAID-induced enteropathy, 1 small bowel obstruction due to adhesions NA Laghi et al. 2003 MRI Prospective 8–17 (13.6) 46 NA 18 active ulcerative colitis, 11 spondyloarthropathy and indeterminate ileocolitis 0 d Negaard et al. 2006 MR Enteroclysis Prospective 18–73 (39) 35 88% Suspected CD ≤3 mo Negaard et al. 2007 MR Enteroclysis Prospective 16–65 (33) 41 45% 40 suspected CD ≤3 mo Siddiki et al. 2009 MR Enterography Prospective 20–60 (40) 30 45% 22 active disease, 2 inactive disease NA Siddiki et al. 2009 CT Enterography Prospective 20–60 (40) 30 45% 22 active disease, 2 inactive disease NA Pilleul et al. 2005 MRI Prospective 8–18 (12.6) 15 88% Suspected CD 24.9 d Jensen et al. 2011 MR Enterography Prospective 15–74 (30) 72 70% Clinically suspected CD median 13 d Jensen et al. 2011 CT Enterography Prospective 15–74 (30) 73 70% Clinically suspected CD median 13 d Bodily et al. 2006 CT Enterography Retrospective male 24–72 (46), female 17–72 (43) 96 68% 16 bowel wall thickness ≤30 d Minordi et al. 2009 CT Prospective 25–75 (43) 34 41% 7 mucosal hyperdensity without wall thickening, 3 mucosal hyperdensity with wall thickening NA Mazzeo et al. 2001 Spiral CT Prospective 18–71 33 55% Certain or suspected CD of the small bowel NA Ochsenkuhn et al. 2004 MR Enteroclysis Prospective 19–57 (34) 25 48% CD known SBE on same day, 10 wk (range, 3–13 wk) for CS and HA Hassan et al. 2003 CT Enteroclysis Prospective 21–73 (44) 39 50% CD known or suspected NA Wold et al. 2003 CT Enterography Prospective 22–55 23 52% CD known or suspected Mean, 5.3 d (range, 0–34 d) Minordi et al. 2011 CT Enteroclysis Prospective 18–85 (48) 57 55% Small bowel, bleeding pertinent to small bowel, or suspected or positive CD Mean, 25 d Siddiki et al. 2011 CT Enterography Prospective NA 137 NA Known or suspected CD ≤30 d Wiarda et al. 2012 MR Enteroclysis Prospective 20–74 (36) 38 62% Known or suspected CD Median, 22 d (range, 4–112 d)
CD, Crohn disease; CS, colonoscopy; CT, computed tomography; HA, histopathologic analysis; MR, magnetic resonance; MRI, magnetic resonance imaging; NA, not available; NSAID, non-steroidal anti-inflammatory drug; SBE, small bowel barium enteroclysis; SBFT, small bowel follow-through.
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Study Quality Assessment
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Meta-analysis
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TABLE 2
Summary of Per-patient Sensitivity and Specificity
Study TP FP FN TN Sensitivity Specificity Lee et al. 2009 16 1 2 4 0.89 (0.65, 0.99) 0.8 (0.28, 0.99) Lee et al. 2009 15 0 3 5 0.83 (0.59, 0.96) 1 (0.48, 1) Albert et al. 2005 10 2 4 8 0.71 (0.42, 0.92) 0.8 (0.44, 0.97) Crook et al. 2009 5 0 0 14 1 (0.48, 1) 1 (0.77, 1) Laghi et al. 2003 26 0 0 20 1 (0.87, 1) 1 (0.83, 1) Negaard et al. 2006 14 2 2 17 0.88 (0.62, 0.98) 0.89 (0.67, 0.99) Negaard et al. 2007 15 0 3 23 0.83 (0.59, 0.96) 1 (0.85, 1) Siddiki et al. 2009 19 3 2 6 0.9 (0.7, 0.99) 0.67 (0.3, 0.93) Siddiki et al. 2009 20 1 1 8 0.95 (0.76, 1) 0.89 (0.52, 1) Pilleul et al. 2005 5 0 1 9 0.83 (0.36, 1) 1 (0.66, 1) Jensen et al. 2011 17 7 4 44 0.81 (0.58, 0.95) 0.86 (0.74, 0.94) Jensen et al. 2011 16 8 5 44 0.76 (0.53, 0.92) 0.85 (0.72, 0.93) Bodily et al. 2006 28 7 19 42 0.6 (0.44, 0.74) 0.86 (0.73, 0.94) Minordi et al. 2009 31 0 1 2 0.97 (0.84, 1) 1 (0.16, 1) Mazzeo et al. 2001 12 0 2 19 0.86 (0.57, 0.98) 1 (0.82, 1) Ochsenkuhn et al. 2004 16 1 2 6 0.89 (0.65, 0.99) 0.86 (0.42, 1) Hassan et al. 2003 26 0 4 9 0.87 (0.69, 0.96) 1 (0.66, 1) Wold et al. 2003 10 1 3 9 0.77 (0.46, 0.95) 0.9 (0.55, 1) Minordi et al. 2011 34 0 3 20 0.92 (0.78, 0.98) 1 (0.83, 1) Siddiki et al. 2011 74 5 9 49 0.89 (0.8, 0.95) 0.91 (0.8, 0.97) Wiarda et al. 2012 14 2 5 17 0.74 (0.49, 0.91) 0.89 (0.67, 0.99)
CI, confidence interval; FN, false negative; FP, false positive; TN, true negative; TP, true positive.
Note: Numbers in parentheses are 95% CIs.
TABLE 3
Summary of Sensitivity and Specificity Comparison
Z (Sensitivity)P Value Z (Specificity)P Value CT vs MRI −0.7718 .4402 0 1 1 vs 2 1.4418 .1493 −6.3906 <.0001 2 vs 3 −1.2305 .2185 2.9998 .0027 3 vs 4 −0.6973 .4856 1.6945 .0902 1 vs 4 −0.8641 .3876 0.3069 .7589 2 vs 4 8.00E+03 <.0001 4.4289 <.0001 1 vs 3 0 1 −1.8321 .0669
1, CT enterography; 2, CT enteroclysis; 3, MR enteroclysis; 4, MR enterography; CT, computed tomography; MR, magnetic resonance; MRI, magnetic resonance imaging.
TABLE 4
Summary of Diagnostic Performances
Z (lnDOR)P Value 1 vs 2 2.281 .0566 2 vs 3 −0.865 .4122 3 vs 4 0.1886 .8566 1 vs 4 1.3904 .2231 2 vs 4 −0.5597 .591 1 vs 3 1.5541 .1809 CT vs MRI 0.0744 .9417
1, CT enterography; 2, CT enteroclysis; 3, MR enteroclysis; 4, MR enterography; CT, computed tomography; MR, magnetic resonance; MRI, magnetic resonance imaging.
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Publication Bias
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Discussion
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