Jaap Stoker

Magnetic resonance imaging for evaluation of disease activity in Crohn’s disease: a systematic review

To systematically review the evidence on the accuracy of MRI for grading disease activity in Crohn’s disease (CD). The MEDLINE, EMBASE, CINAHL and Cochrane databases were searched for studies on the accuracy of MRI in grading CD compared to a predefined reference standard. Two independent observers scored all relevant data. Three disease stages were defined: remission, mild and frank disease. The accuracy rates of MRI per disease stage were calculated by means of a random-effects model. Seven studies were included from a search resulting in 253 articles. In total 140 patients (16 patients in remission, 29 with mild disease and 95 with frank disease) were used for data analysis. MRI correctly graded 91% (95% CI: 84–96%) of patients with frank disease, 62% (95% CI: 44–79) of patients with mild disease and 62% (95% CI: 38–84) of patients in remission. MRI more often overstaged than understaged disease activity; MRI overstaged disease activity in 38% of patients in remission, mostly as mild disease. Overstaging of mild disease was observed in 21%, understaging in 17%. MRI correctly grades disease activity in a large proportion of patients with frank disease. For patients in remission or with mild disease, MRI correctly stages disease activity in many patients (62%).

Detection of inflammatory bowel disease: diagnostic performance of cross-sectional imaging modalities

Different cross-sectional imaging techniques can be used as a diagnostic tool for the evaluation of inflammatory bowel disease (IBD). In this report the diagnostic performances of ultrasonography, magnetic resonance imaging and computed tomography in the detection of IBD and the evaluation of known IBD are described, together with a short update on patient preparation and imaging technique of the respective modalities discussed.

Non-invasive evaluation of liver fibrosis: a comparison of ultrasound-based transient elastography and MR elastography in patients with viral hepatitis B and C

AbstractObjectiveTo compare the diagnostic accuracy of TE and MRE and establish cutoff levels and diagnostic strategies for both techniques, enabling selection of patients for liver biopsy.MethodsOne hundred three patients with chronic hepatitis B or C and liver biopsy were prospectively included. Areas under curves (AUROC) were compared for TE and MRE for METAVIR fibrosis gradeu2009≥u2009F2 and ≥F3. We defined cutoff values for selection of patients with F0–F1 (sensitivity >95xa0%) and for significant fibrosis F2–F4 (specificity >95xa0%).ResultsFollowing exclusions, 85 patients were analysed (65 CHB, 19 CHC, 1 co-infected). Fibrosis stages were F0 (nu2009=u20093), F1 (nu2009=u200953), F2 (nu2009=u200915), F3 (nu2009=u20098) and F4 (nu2009=u20096). TE and MRE accuracy were comparable [AUROCTEu2009≥u2009F2: 0.914 (95xa0% CI: 0.857–0.972) vs. AUROCMREu2009≥u2009F2: 0.909 (0.840–0.977), Pu2009=u20090.89; AUROCTEu2009≥u2009F3: 0.895 (0.816–0.974) vs. AUROCMREu2009≥u2009F3: 0.928 (0.874–0.982), Pu2009=u20090.42]. Cutoff values of <5.2 and ≥8.9xa0kPa (TE) and <1.66 and ≥2.18xa0kPa (MRE) diagnosed 64xa0% and 66xa0% of patients correctly as F0–F1 or F2–F4. A conditional strategy in inconclusive test results increased diagnostic yield to 80xa0%.ConclusionTE and MRE have comparable accuracy for detecting significant fibrosis, which was reliably detected or excluded in two-thirds of patients. A conditional strategy further increased diagnostic yield to 80xa0%.Key Points• Both ultrasound-based transient elastography and magnetic resonance elastography can assess hepatic fibrosis.n • Both have comparable accuracy for detecting liver fibrosis in viral hepatitis.n • The individual techniques reliably detect or exclude significant liver fibrosis in 66xa0%.n • A conditional strategy for inconclusive findings increases the number of correct diagnoses.

Feasibility study of computed tomography colonography using limited bowel preparation at normal and low-dose levels study

The purpose was to evaluate low-dose CT colonography without cathartic cleansing in terms of image quality, polyp visualization and patient acceptance. Sixty-one patients scheduled for colonoscopy started a low-fiber diet, lactulose and amidotrizoic-acid for fecal tagging 2xa0days prior to the CT scan (standard dose, 5.8–8.2xa0mSv). The original raw data of 51 patients were modified and reconstructed at simulated 2.3 and 0.7xa0mSv levels. Two observers evaluated the standard dose scan regarding image quality and polyps. A third evaluated the presence of polyps at all three mSv levels in a blinded prospective way. All observers were blinded to the reference standard: colonoscopy. At three times patients were given questionnaires relating to their experiences and preference. Image quality was sufficient in all patients, but significantly lower in the cecum, sigmoid and rectum. The two observers correctly identified respectively 10/15 (67%) and 9/15 (60%) polyps ≥10xa0mm, with 5 and 8 false-positive lesions (standard dose scan). Dose reduction down to 0.7xa0mSv was not associated with significant changes in diagnostic value (polyps ≥10xa0mm). Eighty percent of patients preferred CT colonography and 13% preferred colonoscopy (P<0.001). CT colonography without cleansing is preferred to colonoscopy and shows sufficient image quality and moderate sensitivity, without impaired diagnostic value at dose-levels as low as 0.7xa0mSv.

Comparison of MRI (including SS SE-EPI and SPIO-enhanced MRI) and FDG-PET/CT for the detection of colorectal liver metastases

Fluoro-18-deoxyglucose positron emission tomography computed tomography (FDG-PET/CT) and magnetic resonance imaging (MRI), including unenhanced single-shot spin-echo echo planar imaging (SS SE-EPI) and small paramagnetic iron oxide (SPIO) enhancement, were compared prospectively for detecting colorectal liver metastases. Twenty-four consecutive patients suspected for metastases underwent MRI and FDG-PET/CT. Fourteen patients (58%) had previously received chemotherapy, including seven patients whose chemotherapy was still continuing to within 1 month of the PET/CT study. The mean interval between PET/CT and MRI was 10.2u2009±u20095.2xa0days. Histopathology (nu2009=u200918) or follow-up imaging (nu2009=u20096) were used as reference. Seventy-seven metastases were detected. In nine patients, MRI and PET/CT gave concordant results. Sensitivities for unenhanced SS SE-EPI, MRI without SS SE-EPI and FDG-PET/CT were, respectively, 100% (pu2009=u20099u2009×u200910−10 vs PET, pu2009=u20098u2009×u200910−3 vs MRI without SS SE-EPI), 90% (pu2009=u20092u2009×u200910−7 vs PET) and 60%. PET/CT sensitivity dropped significantly with decreasing size, from 100% in lesions larger than 20xa0mm (identical to MRI), over 54% in lesions between 10 and 20xa0mm (pu2009=u20093u2009×u2009105 versus unenhanced SS SE-EPI), to 32% in lesions under 10xa0mm (pu2009=u20096u2009×u200910−5 versus unenhanced SS SE-EPI). Positive predictive value of PET was 100% (identical to MRI). MRI, particularly unenhanced SS SE-EPI, has good sensitivity and positive predictive value for detecting liver metastases from colorectal carcinoma. Its sensitivity is better than that of FDG-PET/CT, especially for small lesions.

Electrical stimulation and pelvic floor muscle training with biofeedback in patients with fecal incontinence: a cohort study of 281 patients

PurposePelvic floor rehabilitation is an appealing treatment for patients with fecal incontinence but reported results vary. This study was designed to assess the outcome of pelvic floor rehabilitation in a large series of consecutive patients with fecal incontinence caused by different etiologies.MethodsA total of 281 patients (252 females) were included. Data about medical history, anal manometry, rectal capacity measurement, and endoanal sonography were collected. Subgroups of patients were defined by anal sphincter complex integrity, and nature and possible underlying causes of fecal incontinence. Subsequently patients were referred for pelvic floor rehabilitation, comprising nine sessions of electric stimulation and pelvic floor muscle training with biofeedback. Pelvic floor rehabilitation outcome was documented with Vaizey score, anal manometry, and rectal capacity measurement findings.ResultsVaizey score improved from baseline in 143 of 239 patients (60 percent), remained unchanged in 56 patients (23 percent), and deteriorated in 40 patients (17 percent). Mean Vaizey score reduced with 3.2 points (P < 0.001). A Vaizey score reduction of ≥ 50 percent was observed in 32 patients (13 percent). Mean squeeze pressure (+5.1xa0mmHg; P = 0.04) and maximal tolerated volume (+11xa0ml; P = 0.01) improved from baseline. Resting pressure (P = 0.22), sensory threshold (P = 0.52), and urge sensation (P = 0.06) remained unchanged. Subgroup analyses did not show substantial differences in effects of pelvic floor rehabilitation between subgroups.ConclusionsPelvic floor rehabilitation leads overall to a modest improvement in severity of fecal incontinence, squeeze pressure, and maximal tolerated volume. Only in a few patients, a substantial improvement of the baseline Vaizey score was observed. Further studies are needed to identify patients who most likely will benefit from pelvic floor rehabilitation.

Selecting an outcome measure for evaluating treatment in fecal incontinence

PURPOSEVarious outcome measures exist to evaluate treatment in fecal incontinence, including descriptive, severity (fecal incontinence scoring systems), and impact (quality-of-life questionnaires) and diagnostic measures. We studied associations between changes after treatment for a number of outcome measures and compared them to patients’ subjective perception of relief.METHODSWe analyzed data of 66 patients (92 percent female; mean age, 62 years) (Vaizey score, Wexner score, two impact scales, utility, resting pressure, and maximal incremental squeeze pressure) at baseline and after physiotherapy. In a standardized interview by phone, we asked patients to compare their situation before and after treatment. Correlations between changes in outcome measures were calculated. These changes were compared with patients’ subjective perception.RESULTSThere was a high correlation between the changes in the Vaizey and the Wexner scores (r = 0.94, P < 0.01). Changes in Vaizey and Wexner scores correlated moderately with changes in maximum incremental squeeze pressure (r = −0.29, −0.30, both P < 0.05). Changes in utility and resting pressure were not correlated with changes in any of the other measurements (all r values between −0.086 and 0.18). Average severity scores (Vaizey and Wexner) were 1 point lower for patients who rated their situation as worse or equal (62 percent), 4 points lower for patients who reported their situation to be better (21 percent), and 9 points lower in patients who rated their situation much better (17 percent) (P < .05).CONCLUSIONSeverity measures are best related to patients’ subjective perception of relief.

Whole-body MRI for the detection of bone marrow involvement in lymphoma: prospective study in 116 patients and comparison with FDG-PET

AbstractObjectiveTo assess and compare the value of whole-body MRI with FDG-PET for detecting bone marrow involvement in lymphoma.MethodsA total of 116 patients with newly diagnosed lymphoma prospectively underwent whole-body MRI and blind bone marrow biopsy (BMB) of the posterior iliac crest. Of 116 patients, 80 also underwent FDG-PET. Patient-based sensitivities of whole-body MRI for detecting bone marrow involvement were calculated using BMB as reference standard and compared with FDG-PET in aggressive and indolent lymphomas separately.ResultsSensitivity of whole-body MRI in all lymphomas was 45.5xa0% [95xa0% confidence interval (CI): 29.8–62.0xa0%]. Sensitivity of whole-body MRI in aggressive lymphoma [88.9xa0% (95xa0% CI: 54.3–100xa0%)] was significantly higher (Pu2009=u20090.0029) than that in indolent lymphoma [23.5xa0% (95xa0% CI: 9.1–47.8xa0%)]. Sensitivity of FDG-PET in aggressive lymphoma [83.3xa0% (95xa0% CI: 41.8–98.9xa0%)] was also significantly higher (Pu2009=u20090.026) than that in indolent lymphoma [12.5xa0% (95xa0% CI: 0–49.2xa0%)]. There were no significant differences in sensitivity between whole-body MRI and FDG-PET (Pu2009=u20091.00)ConclusionSensitivity of whole-body MRI for detecting lymphomatous bone marrow involvement is too low to (partially) replace BMB. Sensitivity of whole-body MRI is significantly higher in aggressive lymphoma than in indolent lymphoma and is equal to FDG-PET in both entities.Key Points• Bone marrow involvement in lymphoma has prognostic and therapeutic implications.n • Blind bone marrow biopsy (BMB) is standard for bone marrow assessment.n • Neither whole-body MRI nor FDG-PET can yet replace BMB.n • Both techniques have higher sensitivity in aggressive than in indolent lymphoma.n • Both imaging techniques are complementary to BMB.

Can the outcome of pelvic-floor rehabilitation in patients with fecal incontinence be predicted?

PurposePelvic-floor rehabilitation does not provide the same degree of relief in all fecal incontinent patients. We aimed at studying prospectively the ability of tests to predict the outcome of pelvic-floor rehabilitation in patients with fecal incontinence.Materials and methodsTwo hundred fifty consecutive patients (228 women) underwent medical history and a standardized series of tests, including physical examination, anal manometry, pudendal nerve latency testing, anal sensitivity testing, rectal capacity measurement, defecography, endoanal sonography, and endoanal magnetic resonance imaging. Subsequently, patients were referred for pelvic-floor rehabilitation. Outcome of pelvic-floor rehabilitation was quantified by the Vaizey incontinence score. Linear regression analyses were used to identify candidate predictors and to construct a multivariable prediction model for the posttreatment Vaizey score.ResultsAfter pelvic-floor rehabilitation, the mean baseline Vaizey score (18, SDu2009±u20093) was reduced with 3.2 points (pu2009<u20090.001). In addition to the baseline Vaizey score, three elements from medical history were significantly associated with the posttreatment Vaizey score (presence of passive incontinence, thin stool consistency, primary repair of a rupture after vaginal delivery at childbed) (R2, 0.18). The predictive value was significantly but marginally improved by adding the following test results: perineal and/or perianal scar tissue (physical examination), and maximal squeeze pressure (anal manometry; R2, 0.20; pu2009=u20090.05).ConclusionAdditional tests have a limited role in predicting success of pelvic-floor rehabilitation in patients with fecal incontinence.

Functional changes after physiotherapy in fecal incontinence

BackgroundPhysiotherapy is a common treatment option in patients with fecal incontinence. Although physiotherapy may result in relief of symptoms, to what extent improvement is associated with changes in anorectal function is still unclear.AimThe aim of the present study was to investigate prospectively how anorectal function changes with physiotherapy and whether these changes are related to changes in fecal incontinence score.MethodsConsenting consecutive patients (n=266) with fecal incontinence (91% women; mean age, 59 years) underwent anorectal manometry, anal and rectal mucosal sensitivity measurements, and rectal capacity measurement at baseline and after nine sessions of standardized pelvic floor physiotherapy. These findings were compared with changes in Vaizey incontinence score.ResultsOn follow-up 3 months after physiotherapy, squeeze pressure (p=0.028), as well as urge sensation threshold (p=0.046) and maximum tolerable volume (p=0.018), had increased significantly. The extent of improvement was not related to age, duration of fecal incontinence, menopause, and endosonography findings. All other anorectal functions did not change. An improvement in the Vaizey score was moderately correlated with an increase in incremental squeeze pressure (r=0.14, p=0.04) and a decrease in anal mucosal sensitivity threshold (r=0.20, p=0.01).ConclusionsPhysiotherapy improves squeeze pressure, urge sensation, and maximum tolerable volume. However, improved anorectal function does not always result in a decrease in fecal incontinence complaints.