Inflammatory Bowel Disease in Children and Adolescents

Rationale and Objectives

The purpose of this study was to determine the accuracy of magnetic resonance enterography (MRE) compared to histopathology in the evaluation of pediatric inflammatory bowel disease and to assess interreader reliability for image interpretation.

Materials and Methods

All magnetic resonance enterography studies performed for known or suspected inflammatory bowel disease between July 2009 and July 2010 were retrospectively reviewed by two pediatric radiologists. Exams were evaluated for signs of enteric inflammation and extraenteric disease. A five-point, Likert-type scale was used to assess the overall likelihood of active inflammation, with scores ≥ 3 considered positive. Cohen’s κ coefficient was calculated to assess interreader agreement. A subset of patients who had undergone ileocolonoscopy or surgery with confirmed histopathology within 45 days of MRE were used to assess the accuracy of MRE for detecting active inflammation in the terminal ileum and large bowel.

Results

A total of 91 magnetic resonance enterography studies were reviewed. Of these, 45 had comparison histopathology within 45 days. The overall sensitivity of MRE for detecting active inflammation compared to ileocolonoscopy was 92% for both readers, while specificity was 100% for reader 1 and 75% for reader 2. Of the individual parameters evaluated, mucosal hyperenhancement and bowel wall thickening were the most sensitive indicators of active inflammation, each having sensitivity of 86% and specificity of 88%. Cohen’s κ coefficient was 0.59, indicating moderate agreement between the readers.

Conclusions

MRE has high overall diagnostic accuracy for detecting active bowel inflammation in pediatric patients compared to ileocolonoscopy and demonstrates moderate interreader reliability.

The preferred modality for evaluating potential small bowel inflammation in patients with known or suspected inflammatory bowel disease (IBD) varies greatly on the basis of provider or patient preference, hospital or regional standard, and the availability of different modalities. Ileocolonoscopy is a first-line investigation in the diagnostic workup . Visualization of the colonic mucosa as well as the terminal ileum with histologic sampling in combination with clinical findings usually provides a definitive diagnosis. Most guidelines also call for evaluation of the entire small bowel when the diagnosis is uncertain, because Crohn disease (CD) in particular frequently affects areas not reached by standard ileocolonoscopy . Additionally, the absence of abnormal findings on ileocolonoscopy in the colon and terminal ileum does not exclude IBD, because a minority of patients with CD will have isolated disease in the more proximal gastrointestinal tract .

In the past, imaging methods for assessment of small bowel inflammation have included enteroclysis or small bowel follow-through. Although these methods are still widely used and remain the preferred imaging study at many institutions, their low sensitivity and specificity and relatively low interreader reliability have led to an increased use of more advanced techniques with higher diagnostic yield . More recently, computed tomographic enterography, magnetic resonance enterography (MRE), ultrasound, and capsule endoscopy each have been advocated as the ideal method of evaluating the small bowel in patients with known or suspected IBD. Although each of these modalities has advantages and disadvantages, MRE may be the most promising modality because of its ability to provide excellent soft tissue contrast, cine and multiplanar capabilities, evaluation of enhancement patterns, and detection of extraintestinal complications without the use of ionizing radiation.

Get Radiology Tree app to read full this article<

Materials and methods

Study

Get Radiology Tree app to read full this article<

Magnetic Resonance Imaging Protocol

Get Radiology Tree app to read full this article<

Table 1

Protocol for Magnetic Resonance Imaging Parameters

FIESTA Cine (FB) SSFSE (FB, RT) SSFSE (BH) FIESTA (BH, with and without FS) LAVA Precontrast (BH, FS) FSPGR Postcontrast (BH, FS) LAVA Postcontrast (BH, FS) Plane Coronal Axial Coronal Coronal, axial Coronal, axial Coronal Coronal, axial Slice thickness (mm) 8 6 5 5, 6 4, 6 5 4, 6 Gap (mm) 8 7 6 6, 7 2, 3 6 2, 3 TR (ms) 3 1235 812 3.3 3.4 210 3.4 TE (ms) 1.3 140 140 1.4 1.6 1.5 1.6 Matrix size 256 × 256 320 × 224 288 × 192 256 × 256 320 × 192 352 × 192 320 × 192 Flip angle (°) 45 90 90 45 12 80 12 Delay (seconds) 20 60, 120, 180

BH, breath-hold; FIESTA, fast imaging employing steady-state acquisition; FB, free breathing; FS, fat saturation; FSPGR, fast spoiled gradient-echo; LAVA, liver acquisition with volume acceleration; RT, respiratory trigger; SSFSE, single-shot fast spin-echo; TE, echo time; TR, repetition time.

Get Radiology Tree app to read full this article<

Image Interpretation

Get Radiology Tree app to read full this article<

Reference Standard

Get Radiology Tree app to read full this article<

Statistical Analysis

Get Radiology Tree app to read full this article<

Results

Patients

Get Radiology Tree app to read full this article<

Magnetic Resonance Findings

Get Radiology Tree app to read full this article<

Table 2

Values for Detection of Inflammatory Bowel Disease by Each Reader Overall and by Region

Variable Reader 1 Reader 2 % 95% CI % 95% CI Overall ( n = 45) Sensitivity 92 78–98 92 78–98 Specificity 100 63–100 75 35–97 PPV 100 90–100 94 81–99 NPV 73 39–94 67 30–93 Terminal ileum ( n = 33) Sensitivity 81 58–95 81 58–95 Specificity 100 74–100 75 43–95 PPV 100 80–100 85 62–97 NPV 75 48–93 69 39–91 Colon ( n = 44) Sensitivity 45 27–64 32 17–51 Specificity 92 64–100 100 75–100 PPV 93 68–100 100 69–100 NPV 41 24–61 38 22–56

CI, confidence interval; NPV, negative predictive value; PPV, positive predictive value.

Get Radiology Tree app to read full this article<

Table 3

Prevalence of Inflammation on Magnetic Resonance Enterography by Bowel Segment ( n = 91)

Location of Inflammation Reader 1 Reader 2 Stomach/duodenum 2 (2%) 3 (3%) Jejunum 10 (11%) 7 (8%) Proximal ileum 13 (14%) 6 (7%) Jejunum and/or proximal ileum 17 (19%) 9 (10%) Terminal ileum 47 (52%) 50 (55%) Colon 29 (32%) 26 (29%)

Get Radiology Tree app to read full this article<

Table 4

Prevalence of Individual Inflammatory Parameters for Total Patient Population ( n = 91) and Pathology-proven Subgroup ( n = 45) for Reader 1 and Statistical Measures for Subgroup

Finding Prevalence ( n = 91) Prevalence ( n = 45) Sensitivity ( n = 45) Specificity ( n = 45)n (%)n (%) % 95% CI % 95% CI Mucosal hyperenhancement 65 (71) 33 (73) 86 71–95 88 47–100 Mural stratification 24 (26) 10 (22) 27 14–44 100 63–100 Bowel wall thickening 62 (68) 33 (73) 86 71–95 88 47–100 Diminished peristalsis 27 (30) 15 (33) 41 25–58 100 63–100 Luminal narrowing 58 (64) 30 (67) 78 62–90 88 47–100 Engorged vasa recta 38 (42) 20 (44) 54 37–71 100 63–100 Mesenteric inflammation 37 (41) 19 (42) 51 34–68 100 63–100 Free fluid 18 (20) 10 (22) 22 10–28 75 35–97 Skip lesions 22 (24) 10 (22) 27 14–44 100 63–100 Prominent lymph nodes 23 (25) 13 (29) 35 20–53 100 63–100

CI, confidence interval.

Get Radiology Tree app to read full this article<

Discussion

Get Radiology Tree app to read full this article<

Conclusions

Get Radiology Tree app to read full this article<

References

1. Petritsch W., Tillinger W., Vogelsang H., et. al.: Endoscopy in IBD. A Consensus Report of the IBD Working of the Austrian Association of Gastroenterology and Hepatology. [article in German] Z Gastroenterol 2006; 44: pp. 1183-1192.
2. Inflammatory bowel disease in children and adolescents: recommendations for diagnosis—the Porto criteria. J Pediatr Gastroenterol Nutr 2005; 41: pp. 1-7.
3. Bernstein C.N., Fried M., Krabshuis J.H., et. al.: World Gastroenterology Organization practice guidelines for the diagnosis and management of IBD in 2010. Inflamm Bowel Dis 2010; 16: pp. 112-124.
4. Baumgart D.C.: The diagnosis and treatment of Crohn’s disease and ulcerative colitis. Dtsch Arztebl Int 2009; 106: pp. 123-133.
5. Sandhu BK, Fell JM, Beattie RM, et al., Guidelines for the management of inflammatory bowel disease in children in the United Kingdom. J Pediatr Gastroenterol Nutr. In press.
6. Halligan S., Nicholls S., Bartram C.I., et. al.: The distribution of small bowel Crohn’s disease in children compared to adults. Clin Radiol 1994; 49: pp. 314-316.
7. Halligan S., Nicholls S., Beattie R.M., et. al.: The role of small bowel radiology in the diagnosis and management of Crohn’s disease. Acta Paediatr 1995; 84: pp. 1375-1378.
8. Lipson A., Bartram C.I., Williams C.B., et. al.: Barium studies and ileoscopy compared in children with suspected Crohn’s disease. Clin Radiol 1990; 41: pp. 5-8.
9. Solem C.A., Loftus E.V., Fletcher J.G., et. al.: Small-bowel imaging in Crohn’s disease: a prospective, blinded, 4-way comparison trial. Gastrointest Endosc 2008; 68: pp. 255-266.
10. Hafeez R., Greenhalgh R., Rajan J., et. al.: Use of small bowel imaging for the diagnosis and staging of Crohn’s disease—a survey of current UK practice. Br J Radiol 2011; 84: pp. 508-517.
11. Chalian M., Ozturk A., Oliva-Hemker M., et. al.: MR enterography findings of inflammatory bowel disease in pediatric patients. AJR Am J Roentgenol 2011; 196: pp. W810-W816.
12. de Bie CI, Buderus S, Sandhu BK, et al. Diagnostic workup of paediatric inflammatory bowel disease patients in Europe: results of a 5-year audit of the EUROKIDS registry. J Pediatr Gastroenterol Nutr. In press.
13. Siddiki H.A., Fidler J.L., Fletcher J.G., et. al.: Prospective comparison of state-of-the-art MR enterography and CT enterography in small-bowel Crohn’s disease. AJR Am J Roentgenol 2009; 193: pp. 113-121.
14. Lee S.S., Kim A.Y., Yanget S.-K., et. al.: Crohn disease of the small bowel: comparison of CT enterography, MR enterography, and small-bowel follow-through as diagnostic techniques. Radiology 2009; 251: pp. 751-761.
15. Fiorino G., Bonifacio C., Peyrin-Biroulet L., et. al.: Prospective comparison of computed tomography enterography and magnetic resonance enterography for assessment of disease activity and complications in ileocolonic Crohn’s disease. Inflamm Bowel Dis 2011; 17: pp. 1073-1080.
16. Albert J.G., Martiny F., Krummenerl A., et. al.: Diagnosis of small bowel Crohn’s disease: a prospective comparison of capsule endoscopy with magnetic resonance imaging and fluoroscopic enteroclysis. Gut 2005; 54: pp. 1721-1727.
17. Gallego J.C., Echarri A.I., Porta A., et. al.: Ileal Crohn’s disease: MRI with endoscopic correlation. Eur J Radiol 2011; 80: pp. e8-e12.
18. Choi D., Jin Lee S., Ah Cho Y., et. al.: Bowel wall thickening in patients with Crohn’s disease: CT patterns and correlation with inflammatory activity. Clin Radiol 2003; 58: pp. 68-74.
19. Abramson O., Durant M., Mow W., et. al.: Incidence, prevalence, and time trends of pediatric inflammatory bowel disease in northern California 1996 to 2006. J Pediatr 2010; 157: pp. 233-239.
20. Lehtinen P., Ashorn M., Iltanen S., et. al.: Incidence trends of pediatric inflammatory bowel disease in Finland 1987-2003, a nationwide study. Inflamm Bowel Dis 2011; 17: pp. 1778-1783.
21. Wilson J., Hair C., Knight R., et. al.: High incidence of inflammatory bowel disease in Australia: a prospective population-based Australian incidence study. Inflamm Bowel Dis 2010; 16: pp. 1550-1556.
22. Jussila A., Virta L.J., Kautiainen H., et. al.: Increasing incidence of inflammatory bowel diseases between 2000 and 2007: a nationwide register study in Finland. Inflamm Bowel Dis 2012; 18: pp. 555-561.
23. Shin D.H., Sinn D.H., Kim Y.H., et. al.: Increasing incidence of inflammatory bowel disease among young men in Korea between 2003 and 2008. Dig Dis Sci 2011; 56: pp. 1154-1159.
24. Messaris E., Chandolias N., Grand D., et. al.: Role of magnetic resonance enterography in the management of Crohn disease. Arch Surg 2010; 145: pp. 471-475.
25. Lichtenstein G.R.: Emerging prognostic markers to determine Crohn’s disease natural history and improve management strategies: a review of recent literature. Gastroenterol Hepatol (N Y) 2010; 6: pp. 99-107.
26. Buchner A.M., Blonski W., Lichtenstein G.R.: Update on the management of Crohn’s disease. Curr Gastroenterol Rep 2011; 13: pp. 465-474.
27. Florie J., Horsthuis K., Hommes D.W., et. al.: Magnetic resonance imaging compared with ileocolonoscopy in evaluating disease severity in Crohn’s disease. Clin Gastroenterol Hepatol 2005; 3: pp. 1221-1228.
28. Jensen M.D., Ormstrup T., Vagn-Hansen C., et. al.: Interobserver and intermodality agreement for detection of small bowel Crohn’s disease with MR enterography and CT enterography. Inflamm Bowel Dis 2011; 17: pp. 1081-1088.
29. Rimola J., Rodriguez S., García-Bosch O., et. al.: Magnetic resonance for assessment of disease activity and severity in ileocolonic Crohn’s disease. Gut 2009; 58: pp. 1113-1120.
30. Horsthuis K., de Ridder L., Smets A.M., et. al.: Magnetic resonance enterography for suspected inflammatory bowel disease in a pediatric population. J Pediatr Gastroenterol Nutr 2010; 51: pp. 603-609.
31. Alexopoulou E., Roma E., Loggitsi D., et. al.: Magnetic resonance imaging of the small bowel in children with idiopathic inflammatory bowel disease: evaluation of disease activity. Pediatr Radiol 2009; 39: pp. 791-797.
32. Casciani E., Masselli G., Di Nardo G., et. al.: MR enterography versus capsule endoscopy in paediatric patients with suspected Crohn’s disease. Eur Radiol 2011; 21: pp. 823-831.
33. Magnano G., Granata C., Barabino A., et. al.: Polyethylene glycol and contrast-enhanced MRI of Crohn’s disease in children: preliminary experience. Pediatr Radiol 2003; 33: pp. 385-391.
34. Borthne A.S., Abdelnoor M., Rugtveit J., et. al.: Bowel magnetic resonance imaging of pediatric patients with oral mannitol MRI compared to endoscopy and intestinal ultrasound. Eur Radiol 2006; 16: pp. 207-214.
35. Pilleul F., Godefroy C., Yzebe-Beziat D., et. al.: Magnetic resonance imaging in Crohn’s disease. Gastroenterol Clin Biol 2005; 29: pp. 803-808.
36. Dillman J.R., Ladino-Torres M.F., Adler J., et. al.: Comparison of MR enterography and histopathology in the evaluation of pediatric Crohn disease. Pediatr Radiol 2011; 41: pp. 1552-1558.
37. Gee M.S., Nimkin K., Hsu M., et. al.: Prospective evaluation of MR enterography as the primary imaging modality for pediatric Crohn disease assessment. AJR Am J Roentgenol 2011; 197: pp. 224-231.
38. Maccioni F., Colaiacomo M.C., Parlanti S.: Ulcerative colitis: value of MR imaging. Abdom Imaging 2005; 30: pp. 584-592.
39. Bender G., Kende A., McLarney J.: Intestinal mural stratification: etiopathology, etiology, and the extreme. Appl Radiol 2001; 30: pp. 33-45.
40. Maccioni F., Viscido A., Broglia L., et. al.: Evaluation of Crohn disease activity with magnetic resonance imaging. Abdom Imaging 2000; 25: pp. 219-228.
41. Groshar D., Bernstine H., Stern D., et. al.: PET/CT enterography in Crohn disease: correlation of disease activity on CT enterography with 18F-FDG uptake. J Nucl Med 2010; 51: pp. 1009-1014.
42. Johnson K.T., Hara A.K., Johnson C.D.: Evaluation of colitis: usefulness of CT enterography technique. Emerg Radiol 2009; 16: pp. 277-282.
43. Zimmermann E.M., Al-Hawary M.M.: MRI of the small bowel in patients with Crohn’s disease. Curr Opin Gastroenterol 2011; 27: pp. 132-138.

Inflammatory Bowel Disease in Children and Adolescents

Rationale and Objectives

Materials and Methods

Results

Conclusions

Materials and methods

Study

Magnetic Resonance Imaging Protocol

Image Interpretation

Reference Standard

Statistical Analysis

Results

Patients

Magnetic Resonance Findings

Discussion

Conclusions

References

Further Reading

A Comparative Study of HRCT Image Metrics and PFT Values for Characterization of ILD and COPD

Awareness and Level of Knowledge of Interventional Radiology among Medical Students at a Canadian Institution

CAD-associated Reader Error in CT Colonography