Rationale and Objectives
We sought to investigate the value of a MRI scoring system including dynamic motility evaluation in the assessment of small bowel Crohn’s disease activity.
Materials and Methods
From March 2005 to December 2006, 52 patients with suspected Crohn’s disease onset or relapse underwent MRI on a 1.5-T magnet. Bowel distention was achieved orally assuming a mean of 1.6 L of a polyethyleneglycol (PEG) preparation. Per-patient assessment of disease activity was based on a scoring system including evaluation of morphology and motility of the small bowel and perivisceral structures (true-FISP, cine-true-FISP, and HASTE T2W sequences) and dynamic assessment of parietal contrast enhancement (FLASH T1W sequence). Patients were included in three categories, using endoscopic biopsy as the standard reference: no activity/quiescent disease, mild activity, or moderate-to-severe activity. Patients without terminal ileum involvement were excluded from data analysis.
Results
MRI allowed a detailed and panoramic evaluation of the small bowel in all subjects examined. MRI properly assessed 14 of 16 (87.5%) cases of no activity/quiescent disease, 12 of 14 (85.7%) cases of mild activity, and 15 of 15 (100%) cases of severe activity. Overall, activity score led to a per-patient misdiagnosis of disease activity in a nonsignificant proportion of subjects (4 of 45; 8.8%) ( P > .05), determining two false-positive and two false-negative results of mild disease activity. Sensitivity, specificity, PPV, NPV, and overall accuracy in assessing disease activity were 93.1%, 87.5%, 93.1%, 87.5%, and 91.1%, respectively.
Conclusion
Accurate assessment of Crohn’s disease activity is achieved by using an activity score providing an overall interpretation of MRI findings.
Crohn’s disease is a major inflammatory bowel disorder characterized by a chronic and relapsing course ( ). Assessment of inflammatory activity plays a crucial role in planning the patient’s management and in monitoring the effects of therapy ( ). To date, there are no standardized methods for the assessment of intestinal disease activity in Crohn’s disease ( ). Crohn’s Disease Activity Index (CDAI) ( ), the most widely used clinical scoring, is not universally accepted as it is based predominantly on subjective evaluation of clinical symptoms ( ). In clinical practice, biologic indexes (such as WBC, erythrrocyte sedimentation rate, C-reactive protein, or orosomucoids) have been found to be accurate predictors of disease activity, especially when supported by endoscopy and imaging results ( ). Therefore, clinical activity is currently assessed using a combination of clinical and physical findings, laboratory tests, endoscopy, and imaging procedures, including CT ( ), small bowel enteroclysis or follow-through ( ), sonography ( ), MRI ( ), and leukocyte scintigraphy or positron emission tomography ( ).
Over the past years, technical developments allowed MRI to provide panoramic and detailed representation of the small bowel, becoming one of the most promising imaging tools in evaluating Crohn’s disease. Accuracy in diagnosing Crohn’s disease has been proven to be comparable ( ) or superior ( ) to conventional radiographic methods, such as enteroclysis or follow-through techniques, with the advantage of the lack of ionizing radiation exposure and the added value of evaluating extraluminal structures. Moreover, small bowel MRI has been shown to be useful in assessing disease activity ( ) and monitoring the effects of therapy ( ).
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Subjects and methods
Patient Population and Standard Reference
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MRI and Radiological Examinations
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Image Analysis
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Table 1
Ranking of Small Bowel MRI Follow-Through Findings Evaluated in Assessing Crohn’s Disease Activity
MRI Findings MRI Scoring 0 1 2 Wall thickness (mm) <3 3.1−4 >4 WCE ⁎ (%) <70 70−100 >100 Luminal stenosis (%) <50 (not significant) 50−80 (mild) >80 (severe) Mucosal abnormalities ⁎⁎ Absent Present Layered wall enhancement Absent Present Peristalsis Present Absent Distensibility Present Absent Mesenteric involvement ⁎⁎⁎ Absent Present Pathologic lymph nodes (n > 3) ⁎⁎⁎⁎ Absent Present Sinus tracts-fistulas Absent Present Inflammatory masses Absent Present
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Table 2
MRI Activity Score for Crohn’s Disease
Activity Disease 0–1 No activity 2–6 Mild activity >7 Moderate-to-severe activity
Scoring, which corresponds to histological categories of disease (endoscopic biopsy of the terminal ileum), is based on MRI findings as ranked in Table 1 .
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Data Analysis
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Results
Imaging Results and Scoring System Application
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Table 3
MRI Findings in Patients With Suspected Crohn’s Disease Onset or Relapse According to Three Categories of Disease Activity, as Established by the Application of the Activity Score Illustrated in Table 1 (On a Per-Patient Basis)
MRI Findings MRI Scoring No Activity (n = 16) Mild Activity (n = 14) Moderate-to-severe Activity (n = 15) Wall thickness (>3 mm) — 12 15 WCE ⁎ (>70%) 2 12 15 Luminal stenosis (>70%) — 5 10 Mucosal abnormalities ⁎⁎ — 7 12 Layered wall enhancement — 4 12 Absent peristalsis — 10 13 Absent distensibility — 12 15 Mesenteric involvement ⁎⁎⁎ — 9 11 Pathological lymph nodes ⁎⁎⁎⁎ — 11 7 Sinus tracts – fistulas — — 1 Inflammatory masses — — 1 No pathological findings 14 — —
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Disease Activity Evaluation
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Table 4
Per-Patient Comparison Between MRI Score and Standard Reference (Histological Examination on Terminal Ileum After Endoscopic Biopsy) in Assessing Crohn’s Disease Activity
Disease Activity MRI Histology TP TN FP FN No activity — 14 2 — 16 Mild activity 12 — — 2 14 Moderate-to-severe activity 15 — — — 15
TP, true-positive cases; TN, true-negative cases; FP, false-positive cases; FN, false-positive cases.
MRI determined a nonsignificant proportion of activity misdiagnoses ( P > .05). Numbers refer to patients.
Table 5
Comparison of the Accuracy in Assessing Crohn’s Disease Activity on a Per-Patient Basis Among the Whole Activity Score, WCE, and Wall Thickness
Activity Score WCE ⁎ Wall Thickness Sensitivity, % 93.1 (78; 98.1) 87.1 (71.1; 94.9) 86.2 (69.4; 94.5) Specificity, % 87.5 (64; 96.5) 85.7 (60.1; 96) 93.8 (71,7; 99.7) PPV, % 93.1 (78; 98.1) 93.1 (78; 98.1) 96.2 (81.1; 99.8) NPV, % 87.5 (64; 96.5) 75 (50.5; 89.8) 78.9 (56.7; 91.5) Accuracy, % 91.1 (82.8; 99.4) 86.6 (76.7; 96.5) 88.8 (79.7; 97.9)
PPV, positive predictive value; NPV, negative value (95% confidence interval).
Overall, the activity score resulted more accurate than single, more-reliable parameters of disease activity.
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Discussion
Role of Small-Bowel MRI in Crohn’s Disease
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MRI Assessment of Disease Activity
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Evaluation of the Activity Score System
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Limitations and Conclusion
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