S. Greco

Oral contrast enhanced bowel ultrasonography in the assessment of small intestine Crohn’s disease. A prospective comparison with conventional ultrasound, x ray studies, and ileocolonoscopy

Background/Aim: Although ultrasound (US) has proved to be useful in intestinal diseases, barium enteroclysis (BE) remains the gold standard technique for assessing patients with small bowel Crohn’s disease (CD). The ingestion of anechoic non-absorbable solutions has been recently proposed in order to distend intestinal loops and improve small bowel visualisation. The authors’ aim was to evaluate the accuracy of oral contrast US in finding CD lesions, assessing their extent within the bowel, and detecting luminal complications, compared with BE and ileocolonoscopy. Methods: 102 consecutive patients with proven CD, having undergone complete x ray and endoscopic evaluation, were enrolled in the study. Each US examination, before and after the ingestion of a polyethylene glycol (PEG) solution (500–800 ml), was performed independently by two sonographers unaware of the results of other diagnostic procedures. The accuracy of conventional and contrast enhanced US in detecting CD lesions and luminal complications, as well as the extent of bowel involvement, were determined. Interobserver agreement between sonographers with both US techniques was also estimated. Results: After oral contrast, satisfactory distension of the intestinal lumen was obtained in all patients, with a mean time to reach the terminal ileum of 31.4 (SD 10.9) minutes. Overall sensitivity of conventional and oral contrast US in detecting CD lesions were 91.4% and 96.1%, respectively. The correlation coefficient between US and x ray extent of ileal disease was r1 = 0.83 (p<0.001) before and r2 = 0.94 (p<0.001) after PEG ingestion; r1 versus r2 p<0.01. Sensitivity in detecting strictures was 74% for conventional US and 89% for contrast US. Overall interobserver agreement for bowel wall thickness and disease location within the small bowel was already good before but significantly improved after PEG ingestion. Conclusions: Oral contrast bowel US is comparable with BE in defining anatomic location and extension of CD and superior to conventional US in detecting luminal complications, as well as reducing interobserver variability between sonographers. It may be therefore regarded as the first imaging procedure in the diagnostic work up and follow up of small intestine CD.

Autologous haematopoietic stem cell transplantation without CD34 + cell selection in refractory Crohn’s disease

Objectives: Autologous haematopoietic stem cell transplantation (HSCT) with CD34+ cell selection has recently been used in the treatment of refractory Crohn’s disease, showing good safety and promising efficacy. We investigated the safety and efficacy of HSCT with unselected peripheral blood stem cells (PBSCs) in moderate–severe refractory Crohn’s disease. Patients: Four patients (three male, one female; age range 26–45 years) with active moderate–severe Crohn’s disease (median Crohn’s Disease Activity Index (CDAI) 319, range 272–345), refractory or intolerant to multiple drugs including infliximab, were enrolled. Interventions: Unselected PBSCs were collected after mobilisation with cyclophosphamide (CTX) 1.5 g/m2 and granulocyte-colony stimulating factor (G-CSF) 10 μg/kg. The conditioning regimen included CTX 50 mg/kg on days −5 to −2 and rabbit anti-thymocyte globulin (ATG) 2.5 mg/kg on days −4 to −2. Main outcome measures: Primary endpoints were toxicity and clinical remission (CDAI<150) at 3 months. Secondary endpoints were clinical and endoscopic response at 3 months and toxicity, clinical and endoscopic remission at 12 months. Results: No improvement or slight deterioration was observed following mobilisation (median CDAI 339, range 258–404). At the third month, the primary endpoint of clinical remission was achieved in all patients, with a median CDAI of 91 (range 56–102), and complete endoscopic remission was achieved in 2/3 patients. After a median follow-up of 16.5 months, 3/4 patients maintained both clinical and endoscopic remission, despite withdrawal of all drugs, and complete fistula closure was observed in all affected patients. No deaths or life-threatening infection occurred. Unexpected adverse events included a perianal abscess after mobilisation in one patient, pleural and pericardial effusions in another and BK virus-related macrohaematuria in another, all rapidly resolved with conservative treatment. Conclusion: Autologous HSCT with unselected PBSC appears to be safe and can induce and maintain remission in previously refractory Crohn’s disease patients.

Role of early ultrasound in detecting inflammatory intestinal disorders and identifying their anatomical location within the bowel

Background : Although bowel ultrasound is a widely accepted diagnostic tool in bowel diseases, its value as the primary imaging procedure in patients with symptoms/signs suggestive of inflammatory bowel disorders is still unclear.

Hospital use of acid-suppressive medications and its fall-out on prescribing in general practice: a 1-month survey

Background: Acid‐suppressive medications are commonly used in hospitalized patients, but, to date, little is known about the overall use of these drugs in the hospital setting.

Sonographic prevalence of liver steatosis and biliary tract stones in patients with inflammatory bowel disease: study of 511 subjects at a single center.

Goals: Inflammatory bowel diseases (IBDs) are associated with pathologic findings in the liver and biliary tract. Ultrasonography (US) represents a noninvasive means to study hepatobiliary abnormalities. This study evaluated the prevalence of US hepatobiliary changes and their relationship to clinical variables in a large IBD patient population followed in a single center. Study: Five hundred eighty‐three consecutive IBD patients were studied with US. After excluding patients with preexisting acute or chronic hepatitis, metabolic disorders, or obesity, 511 patients were investigated for age, duration, site, and severity of the disease, history of surgery, and present medical treatment. At US, liver size, echogenicity (graded as mild‐to‐moderate or severe indicating a corresponding degree of hepatic steatosis), focal lesions of the liver and gallbladder, and biliary tract abnormalities were recorded. Results: Three hundred eleven patients with Crohn disease (CD) and 200 patients with ulcerative colitis (UC) were recruited for the study. Hepatobiliary abnormalities were found at US in 54.2% and 55.9% of CD and UC patients, respectively. Liver enlargement and mild‐to‐moderate to severe liver steatosis were found in 25.7% and 39.5% of CD patients and in 25.5% and 35.5% of UC patients, respectively, a higher prevalence than among healthy controls (P < 0.001). The prevalence of gallstones among CD patients was 11%, higher than that among UC patients (7.5%) and controls (5.5%) (P = 0.016). The higher risk of gallbladder stones in CD was related to age, female sex, and previous surgery. Conclusion: The prevalence of liver enlargement and liver steatosis was higher among IBD patients. The prevalence of gallstones was increased in CD patients only. This risk was related to age, female sex, and previous surgery.

Incidence and risk factors for gallstones in patients with inflammatory bowel disease: A large case‐control study

The risk for gallstones (GD) in inflammatory bowel diseases and the factors responsible for this complication have not been well established. We studied the incidence of GD in a cohort of Crohns disease (CD) and ulcerative colitis (UC) patients and investigated the related risk factors. A case‐controlled study was carried out. The study population included 634 inflammatory bowel disease (IBD) patients (429 CD, 205 UC) and 634 age‐matched, sex‐matched, and body mass index (BMI)‐matched controls free of GD at enrollment, who were followed for a mean of 7.2 years (range, 5‐11 years).The incidence of GD was calculated by dividing the number of events per person‐years of follow‐up. Multivariate analysis was used to discriminate among the impact of different variables on the risk of developing GD. The incidence rates of GD were 14.35/1,000 persons/year in CD as compared with 7.75 in matched controls (P = 0.012) and 7.48/1000 persons/year in UC patients as compared with 6.06 in matched‐controls (P = 0.38). Ileo‐colonic CD location (OR, 2.14), disease duration >15years (OR, 4.26), >3 clinical recurrences (OR, 8.07), ileal resection >30 cm (OR, 7.03), >3 hospitalizations (OR, 20.7), multiple TPN treatments (OR, 8.07), and long hospital stay (OR, 24.8) were significantly related to GD in CD patients. Conclusion: Only CD patients have a significantly higher risk of developing GD than well‐matched hospital controls. Site of disease at diagnosis, lifetime surgery, extent of ileal resections, number of clinical recurrences, TPN, and the frequency and duration of hospitalizations are independently associated with GD. (HEPATOLOGY 2007;45:1267–1274.)

Are Colonoscopy and Bowel Ultrasound Useful for Assessing Response to Short-Term Therapy and Predicting Disease Outcome of Moderate-to-Severe Forms of Ulcerative Colitis?: A Prospective Study

OBJECTIVES:Mucosal healing has been proposed as an important sign of the efficacy of medical treatment of inflammatory bowel disease; however, direct evidence in ulcerative colitis (UC) is scarce. We evaluated the usefulness of colonoscopy and bowel ultrasound (US) as indexes of response to short-term therapy and as predictors of subsequent outcome in UC.METHODS:A total of 83 patients with moderate-to-severe UC were recruited; endoscopic and US severity was graded 0–3 at entry according to validated scores. Of the recruited patients, 74, who were clinically responsive to steroids, were followed up with repeated colonoscopy and bowel US at 3, 9, and 15 months from recruitment. Concordance between clinical, endoscopic, and US scores at various visits was determined by kappa statistics. Multiple unconditional logistic regression models were used to assess the predictivity of clinical, endoscopic, and US scores measured at 3 and 9 months on the development of endoscopic UC relapse within 15 months.RESULTS:A variable concordance was found over time between endoscopic and clinical score (weighted κ between 0.38 and 0.95), with high and consistent concordance between endoscopic and US scores (weighted κ between 0.76 and 0.90). On logistic regression analysis, moderate-to-severe endoscopic and US scores at 3 months were associated with a high risk of endoscopic activity at 15 months (odds ratio (OR): 5.2; 95% confidence interval (CI): 1.6–17.6 and OR: 9.1; 95% CI: 2.5–33.5, respectively).CONCLUSIONS:Bowel US may be used as a surrogate of colonoscopy in assessing the short-term response of severe forms of UC to therapy. Both US score and endoscopic score after 3 months of steroid therapy predict outcome of disease at 15 months.

Modern imaging of Crohn's disease using bowel ultrasound.

Technological advancement of ultrasound (US) equipments and understanding of bowel appearances with high resolution US during the last decade has led to consideration of this imaging procedure as an important tool for inflammatory bowel diseases assessment. In particular, Crohns disease (CD) for its pathologic characteristics (that is, inflammatory infiltration of the entire bowel wall with possible extension to the surrounding mesentery) is the disease entity which has mainly taken advantage from this non-invasive, radiation-free technique. Beside correctly defining anatomic location and extension of CD lesions within the bowel in the majority of cases, US also shows perigut abnormalities and may demonstrate complications such as fistulas and abscesses. With the help of Power Doppler function, some additional information may be obtained about the local activity of the disease which is particularly useful in the presence of strictures.New US technologies (such as those using intravenous bolus contrast agents or oral nonabsorbable anechoic solutions) may further improve diagnostic capability of US in this context, thus probably revolutioning the diagnostic approach to this disease in the near future, particularly during follow-up in CD of the small bowel.

Imaging inflammatory bowel disease using bowel ultrasound

During the last two decades the general availability of high resolution ultrasound has greatly improved the diagnostic potential of ultrasound in the assessment of inflammatory bowel disease (IBD). This technique has proved to be useful as a screening imaging modality in patients with symptoms or clinical signs that strongly indicate an inflammatory bowel disorder as well as for assessing the anatomical extension of Crohns disease (CD) lesions at primary diagnosis. Another important indication is the follow-up of patients who are already known to have CD. Here, the technique may play a key role in the detection of luminal and mesentery complications or for the evaluation of disease extension during a clinical flare-up of both CD and ulcerative colitis. By contrast, the role of bowel ultrasound in the assessment of disease activity is limited so far, even though colour Doppler flow imaging may, perhaps, help to differentiate inflammatory from fibrotic intestinal strictures. New ultrasound technologies, such as those using oral and intravenous contrast agents, will probably further increase the diagnostic capability of ultrasound in this context, thus radically changing the diagnostic approach to IBD in the near future.

Behaviour of the bowel wall during the first year after surgery is a strong predictor of symptomatic recurrence of Crohn's disease: a prospective study

Background : Recurrences after surgery for Crohns disease are frequent and unpredictable. To date, there is little agreement as to which factors increase a patient risk of early recurrence.