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Evaluation of Diffusion-weighted MR Imaging for Detection of Bowel Inflammation in Patients with Crohn's Disease

Posted Apr 30, 2009 Updated Apr 7, 2023
By Aytekin Oto MD , Fang Zhu MD PhD , Kirti Kulkarni MD , Gregory S. Karczmar PhD , Jerrold R. Turner MD PhD , David Rubin MD
7 min read

Rationale and Objectives

The aims of this study were to determine the feasibility of diffusion-weighted magnetic resonance imaging (DWI) in the detection of bowel inflammation and to investigate the changes in apparent diffusion coefficient (ADC) values in the inflamed bowel in patients with Crohn’s disease.

Materials and Methods

Eleven patients who underwent magnetic resonance enterography (including DWI) for Crohn’s disease and colonoscopy or surgery within 4 weeks of examination were recruited. Two radiologists reviewed diffusion-weighted images and ADC maps to evaluate for inflammation in each bowel segment (terminal ileum, cecum, ascending colon, transverse colon, descending colon, and rectosigmoid colon) and measured the ADC values of each bowel segment. Endoscopic and pathologic results were correlated with DWI findings.

Results

Fifty-three segments (19 with inflammation, 34 normal) were included. DWI detected inflammation in 18 of 19 segments (94.7%) and showed normal results in 28 of 34 segments (82.4%). On diffusion-weighted images, bowel segments with inflammation revealed higher signal compared to normal segments. Artifact levels were none or minimal in 10 of 11 patients (90.9%) and moderate in one patient. On quantitative analysis, ADC values of inflamed and normal bowel were measured as 0.47 − 2.60 × 10 −3 and 1.39 − 4.03 × 10 −3 mm 2 /s, respectively ( P < .05).

Conclusion

DWI with parallel imaging is a feasible technique for the detection of inflammation in patients with Crohn’s disease. ADC values are decreased in inflamed bowel segments, indicating restricted diffusion.

Magnetic resonance (MR) imaging has been increasingly used for the diagnosis and follow-up of patients with inflammatory bowel disease. Its lack of ionizing radiation, excellent soft-tissue contrast resolution, and potential to perform real-time and functional imaging are the important advantages of MR imaging that make it well suited for imaging the gastrointestinal tract . Currently, evaluation of the bowel wall by MR imaging is based on its signal on T2-weighted images, thickness, and the degree of contrast enhancement . Although the results of MR imaging using these criteria are promising, several clinically important issues, such as the accurate estimation of the extent of disease, reliable differentiation between chronic and active inflammation, and monitoring response to treatment, remain as diagnostic challenges.

A new possibility to expand the capability of MR imaging is to apply new MR applications that can give additional information about the structural organization of tissues on bowel imaging. Diffusion-weighted imaging (DWI) reflects the changes in the water mobility caused by interactions with cell membranes, macromolecules, and alterations of the tissue environment. DWI has been widely used for intracranial diseases but has only recently been applied to the abdomen. Initial results suggest that it can be useful for the evaluation of various hepatic, renal, and pancreatic diseases . The available published descriptions of DWI for the evaluation of the bowel are focused on the detection of colorectal cancer . To our knowledge, the use of DWI for the detection of bowel wall inflammation and its associated features has not been previously described.

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Materials and methods

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MR Imaging Protocol

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Image Analysis

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Qualitative Analysis

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Quantitative Analysis

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Endoscopic and Surgical Findings

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Statistical Analysis

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Results

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Table 1

Disease Activity by Endoscopy or Surgery, Inflammation Grading Score on a per Segment Basis, and Artifact Level

Patient Terminal Ileum Cecum Ascending Colon Transverse Colon Descending Colon Rectosigmoid Colon 1 N/A N/A N/A N/A Inf (3) Inf (1) 2 N/A N/A N/A N/A N/A N (1) 3 N (1) Inf (2) Inf (2) N (2) Inf (3) Inf (2) 4 N (1) Inf (3) Inf (3) Inf (2) Inf (3) Inf (2) 5 N (1) N (1) N (1) Inf (3) Inf (3) Inf (2) 6 Inf (2) X X N (2) N (2) N (2) 7 N N N N N N 8 Inf N N N N N 9 N N N N N N 10 Inf X N N N N 11 N/A Inf Inf N N N

Inf, inflamed segment; N, normal segment; N/A, segment could not be evaluated by colonoscopy; X, segment was previously excised.

Numbers in parenthesis are artifact level grading scores: 0 = no artifacts, 1 = minimal artifacts (no significant impact on evaluation), 2 = moderate artifacts (significant impact on evaluation), and 3 = severe artifacts (nondiagnostic).

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Qualitative Evaluation

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Figure 1, Patient 7: axial diffusion-weighted images at b = 0 s/mm 2 (a) and b = 600 s/mm 2 (b) through the midabdomen in a 54-year-old man with suspected Crohn's disease. No increased signal in the walls of the ascending (A), transverse (T), and descending (D) colon segments is seen in the diffusion-weighted image at b = 600 s/mm 2 (b) . Colonoscopy confirmed the normal findings.

Figure 2, Patient 11: a 21-year-old man with known Crohn's disease. Axial diffusion-weighted image through the lower abdomen ( b = 600 s/mm 2 ) (a) shows increased signal and thickening of the cecal wall (arrow) with associated high-signal pericecal lymph nodes (arrowheads) . Note the normal dark signal of the other bowel segments. The cecal wall (arrow) and the lymph nodes demonstrate low signal on the apparent diffusion coefficient map (b) , consistent with restricted diffusion. (c) Diffusion-weighted image at b = 0 s/mm 2 for comparison. Colonoscopy showed patchy active colitis with ulceration in the cecum.

Figure 3, Patient 10: a 34-year-old woman with known Crohn's disease and history of ileal resection and right hemicolectomy. Axial diffusion-weighted image through the pelvis ( b = 600 s/mm 2 ) (a) and corresponding apparent diffusion coefficient map (b) showed multiple small-bowel loops in the pelvis demonstrating restricted diffusion in their walls (arrowheads) , including the most distal ileum anastomosed to the colon. (c) Diffusion-weighted image at b = 0 s/mm 2 for comparison. Colonoscopic biopsy of the distal small-bowel loops showed active inflammation with ulcers.

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Quantitative Analysis

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Figure 4, Bland-Altman 95% limits of agreement in apparent diffusion coefficient (ADC): interobserver agreement.

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Figure 5, Receiver-operating characteristic (ROC) curve for apparent diffusion coefficient.

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Discussion

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Academic Radiology, Volume 16, Issue 5
Journals General Radiology
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