Home MRI Scoring System Including Dynamic Motility Evaluation in Assessing the Activity of Crohn’s Disease of the Terminal Ileum
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MRI Scoring System Including Dynamic Motility Evaluation in Assessing the Activity of Crohn’s Disease of the Terminal Ileum

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.

Figure 1, A 40-year-old female patient with suspected clinical onset of Crohn’s disease showing mild abdominal pain and equivocal clinical assessment of disease activity (CDAI > 150). Histology demonstrated mild disease activity. ( a ) Intermediate weighted true-FISP sequence acquired on coronal plane showed a diffuse thickening of terminal ileum (maximum thickness of 4.2 mm, 2 points) with a focal luminal narrowing of 50% to 80% (1 point). Neither mucosal abnormalities nor significant reduction in peristaltic activity and distensibility at kinematic examination (not shown) was seen. By positioning five sequential punctual regions of interest (ROIs; white encircled points) along the thickened wall on a coronal T1-weighted FLASH sequence, a homogeneous contrast enhancement of 95% (1 point) was found before ( b ) and after ( c ) gadolinium administration. The patient was a true-positive case of mild disease activity with a MRI score of 4.

Figure 2, A 45-year-old female subject with known Crohn’s disease, showing a terminolateral ileocolic anastomosis after previous right hemicolectomy and terminal ileum resection. Patient was referred for MRI due to recent onset of intense abdominal pain, fever, and acute phase reactant elevation. Moderate disease activity was found at histological examination. ( a ) Intermediate weighted true-FISP sequence acquired on coronal plane showed a 5-cm-long tract of marked wall thickening (2 points) and luminal narrowing with prestenotic dilatation (2 points) at the level of ileal anastamotic loop. The presence of comb sign ( white arrow ) indicated mesenteric involvement (1 point). Sparse small lymph nodes were visible in the mesenteric fat. This tract was rigid and not distensible at kinematic examination (2 points). ( b ) T2-weighted coronal HASTE sequence showed the high degree of luminal stenosis and the absence of fistulas and sinus tracts. Pre- ( c ) and post-contrast ( d ) coronal T1-weighted FLASH sequences (white encircled points indicate five sequential punctual regions of interest along the thickened wall) showed a homogeneous wall contrast enhancement of 276% (2 points) and enhancement of mesenteric vessels. The patient was a true-positive case of moderate-to-severe disease activity with an MRI score of 9.

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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