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Division of GASTROENTEROLOGY& HEPATOLOGY

Use and Misuse of CT and MR Imaging in IBD

David H. Bruining, MDMayo Clinic, Rochester, MN

bruining.david@mayo.edu

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Disclosures

Consulting

• Bracco

• Avantis

Research Support

• Janssen Biotech

• Given

• Genentech

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Discussion Points

What is known/standard of care

• Benefits of Imaging

• CTE and MRE performance

Appropriation / inappropriate applications

• How are we doing?

• New developments

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Symptoms Aren’t Enough

Jones et al: Clin Gastroenterol Hepatol, 2008

Correlation coefficients (bolded) were significant; P<0.05; n=164CDAI; Crohn’s disease activity index: SES-CD; simple endoscopic core for Crohn's disease

IL-6 Calprotectin Lactoferrin CDAI SES-CD

Hs-CRP 0.65 0.47 0.52 0.16 0.46

IL-6 0.45 0.55 0.15 0.43

Calprotectin 0.76 0.23 0.45

Lactoferrin 0.19 0.48

CDAI 0.15

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CT and MR EnterographySimilar Performance to CTE for Identifying Active Disease

Siddiki et al: Am J Roentgenol, 2009

CTE MRE

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CT and MR Enterography

Advantages – CTE

• Less interobserver variability

• Higher image quality

• Shorter image acquisition times

• Cost

• Access

• Bone assessments

Advantages – MRE

• No radiation

• Multiple phases

• Detection of fibrosis

• MRI superior for perianal disease

• Pregnancy

• Renal insufficiency

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Appropriate UseRight Test for the Right Patient

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Use of CT and MR Enterography in Crohn’s Disease

Suspected Crohn’s disease

• Establish disease

• Determine optimal strategy for endoscopic confirmation (BAE)

• Define extent and severity

• Exclude alternate etiologies

• Penetrating and stricturing complications

• Extra-intestinal disease manifestation

Established Crohn’s disease

• Response to treatment

• Surgical planning

• Exclude alternate etiologies

• Penetrating and stricturing complications

• Extraintestinal disease manifestation

• Bone health interrogations

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Lesion Remodeling on CTE

*Infliximab initiated in 2004 after examination

6/7/2004* 9/26/2005 6/18/2007

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CTE Generated Finite Element ModelBone Strength

Weber et al: DDW, 2013

Densitydistribution

Regions of failure

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When and How to Image

Suspected disease• Establish diagnosis• Exclude alternate or additional

etiologies for patient symptoms

Established disease• Disease activity• Disease extent• Disease severity• Evaluate for penetrating disease• Surgical planning• Assess response to therapy

MRE• Age <35 years• Serial examinations• Renal disease• Pregnancy• Stricture• Perianal disease

CTE

Postoperative• SBFT (complex)

Occult stricture• Enteroclysis

Other• VCE and ultrasound

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Misuse of CT and MR Enterography

Wrong test

• Multiple CTEs in young patient (MRE)

• MRE in elderly (CTE)

• CTE or MRE for dysplasia (colonoscopy)

• MRE for inpatient with sepsis/SIRS, tremor, obese, diabetics (CTE)

• CTE in patient with renal insufficiency or pregnancy (MRE)

Wrong patient

• Chronic abdominal pain with multiple negative CT or MR examinations

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Emergency Medicine and IBD

Kerner et al: Clin Gastroenterol Hepatoll, 2012

2001-2003 (%)n=169

2007-2009 (%)n=482 P

Inflammation or bowel wall thickening

65 (38.5) 257 (53.3) 0.003

Obstruction 35 (20.7) 95 (19.7) 0.90

Abscess or perforation 17 (10.1) 50 (10.4) 0.12

Non-CD urgent findings 11 (6.5) 34 (7.0) 0.99

POA 51 (30.2) 138 (28.6) 0.92

POANCD 61 (36.1) 166 (34.4) 0.91

POA; perforation, obstruction, abscess: POANCD; POA + non-CD urgent

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Can We Do Better?

• Several models in development for ED triage

• APON Risk Score• APON: Abscess, perforation, obstruction, new or

worsening non-CD urgent findings• Final model variables: History of obstruction, history

of intra-abdominal abscess, current hematochezia and WBC >12,000/µL

• Score subtracts 1 for hematochezia and adds 1 point for others

• APON risk score -1 is associated with low risk

Kerner et al: Inflamm Bowel Dis, 2013

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Summary

• Cross-sectional imaging • Objective measure of disease activity• Detects penetrating disease and extraintestinal

manifestations• Alters management plans

• Appropriate use• Applications continue to expand• Key is to match right patient with right exam

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Future Research

• Fine-tuned predictive models – acute presentations• Widely available ED tool• Simple

• Role of ultrasound

• Standardized imaging algorithms, guidelines and reporting lexicon