Stefania Orlando

The role of ultrasound elasticity imaging in predicting ileal fibrosis in Crohn's disease patients

Backgound:Bowel wall fibrosis is associated with a complicated disease behavior in patients with Crohns disease (CD). The quantitative assessment of fibrosis severity in CD-affected bowel can help clinical decision making. Our aim was to evaluate the feasibility, reliability, and reproducibility of ultrasound elasticity imaging (UEI) toward the assessment of ileal fibrosis in CD patients. Methods:Twenty-three consecutive patients with ileal or ileocolonic CD, elected for surgical resection of the terminal ileum, underwent bowel ultrasound and UEI. Twenty inflammatory CD patients without complications were enrolled as controls. Bowel wall stiffness was evaluated with UEI by means of color scale and quantitative strain ratio measurement. The severity of bowel wall fibrosis and inflammation were evaluated on histological sections by semiquantitative and quantitative image analysis and used as a reference standard. Results:The UEI strain ratio measurement was significantly correlated with the severity of bowel fibrosis at both semiquantitative and quantitative histological image analysis: it was characterized by an excellent discriminatory ability for severe bowel fibrosis (area under the receiver operating characteristic curve: 0.917; 95% confidence interval, 0.788–1.000). UEI strain ratio measurements were characterized by an excellent interrater agreement. At multivariate analysis, bowel wall fibrosis proved the only independent determinant of the strain ratio. The ileal strain ratio of inflammatory CD patients was significantly lower than in operated CD patients with severe fibrosis. Conclusions:UEI can be used to assess ileal fibrosis in CD patients.

Ultrasound Elasticity Imaging Predicts Therapeutic Outcomes of Patients With Crohn’s Disease Treated With Anti-Tumour Necrosis Factor Antibodies

Background and Aims Ultrasound elasticity imaging is a non-invasive technique developed to evaluate fibrosis. Measuring tissue strain by ultrasound elasticity imaging can reliably detect severe ileal fibrosis in patients with Crohns disease [CD]. We have hypothesised that a more severe range of fibrosis might influence the therapeutic response to anti-tumour necrosis factor [TNF] treatment. The aim of this study was to assess the ability of ultrasound elasticity imaging to predict the therapeutic outcome for CD patients. Methods Consecutive patients with ileal/ileocolonic CD, starting anti-TNF treatment, were enrolled for the study. These patients underwent bowel ultrasound and ultrasound elasticity imaging at baseline and at 14 and 52 weeks after anti-TNF treatment. Bowel wall stiffness was quantified by calculating the strain ratio between the mesenteric tissue and the bowel wall. Strain ratio ≥ 2 was used to identify severe ileal fibrosis. Transmural healing at 14 and 52 weeks was defined as bowel wall thickness ≤ 3 mm. Results Thirty patients with CD were enrolled. Five patients underwent surgery for bowel obstruction. The frequency of surgeries was significantly greater in patients with a strain ratio ≥ 2 at baseline [p = 0.003]. A significant reduction of the bowel thickness was observed after 14 and 52 weeks of anti-TNF treatment [p < 0.005]. A significant inverse correlation was observed between the strain ratio values at baseline and the thickness variations following anti-TNF therapy [p = 0.007]; 27% of patients achieved transmural healing at 14 weeks. The baseline strain ratio was significantly lower in patients with transmural healing [p < 0.05]. Conclusions This study shows that ultrasound elasticity imaging predicts therapeutic outcomes for CD patients treated with anti-TNF.

Rifaximin plus fibre versus fibre alone in preventing diverticulitis recurrence: a (problematic) trial to tackle an epidemiologically relevant problem.

Diverticular disease is a common clinical condition, with ageelated increasing incidence and very high frequency in the elderly. he disease may be asymptomatic, but recurrent diverticulitis is a ommon complication, often requiring hospitalization. Therefore revention of recurrent diverticulitis in patients at risk is a relevant linical objective, to reduce disease-related morbidity, mortality nd costs. In the present issue of Digestive and Liver Disease, Lanas et al. nvestigate the possible effect of rifaximin plus fibre versus fibre lone in preventing a recurrence of colonic diverticular disease i.e. diverticulitis) [1]. This topic has already been considered in ifferent series mainly involving participants with uncomplicated olonic diverticular disease for whom an appropriate therapeutic egimen remains to be defined [2–5]. The study was ambitious with a solid primary composite endoint (i.e. diverticulitis recurrence, with/without complications) nd a detailed estimate of participants to be included (228 per rm, assuming a 20% incidence of events in those receiving antibitic plus fibre versus 10% in those on fibre alone, and accepting a wo-tailed alpha error of 0.05 and 80% power). When compared to he study plan, however, the actual study conduction was deeply ifferent. During an 18-month period, a total number of only 167 patients ere enrolled in 23 different Spanish centres, the number of particpants varying from one to 29 per centre. This remarkable difference n recruitment was considered in the multi-variable analysis, but nfortunately no details were given concerning the pre-enrolment efinition of clinical criteria for each centre, including imaging esults. Again, out of the calculated 556 participants, 167 were actually andomized during the study period (two however did not attend he first visit), thus representing only 30% of the planned number. he authors bypassed the problem of the missed sample size by

Evolving roles of cross-sectional imaging in Crohn's disease

The implementation of cross-sectional imaging techniques for the clinical management of Crohns disease patients has steadily grown over the recent years, thanks to a series of technological advances, including the evolution of contrast media for magnetic resonance, computed tomography and bowel ultrasound. This has resulted in a continuous improvement of diagnostic accuracy and capability to detect Crohns disease-related complications. Additionally, a progressive widening of indications for cross-sectional imaging in Crohns disease has been put forward, thus leading to hypothesize that in the near future imaging techniques can increasingly complement endoscopy in most clinical settings, including the grading of disease activity and the assessment of mucosal healing or Crohns disease post-surgical recurrence.

Non-invasive evaluation of intestinal disorders: The role of elastographic techniques

Over the recent years the non-invasive techniques for the evaluation of the small bowel have been playing a major role in the management of chronic intestinal diseases, such as inflammatory bowel diseases (IBD). The diagnostic performances of magnetic resonance imaging, computed tomography and ultrasound in the field of small bowel disorders, have been assessed and established for more than two decades. Newer sonographic techniques, such as strain elastography and shear wave elastography, have been put forward for the assessment of disease activity and characterization of IBD-related damage in the setting of Crohn’s disease and other gastrointestinal disorders. The data from the preliminary research and clinical studies have shown promising results as regards the ability of elastographic techniques to differentiate inflammatory from fibrotic tissue. The distinction between IBD activity (inflammation) and IBD-related damage (fibrosis) is currently considered crucial for the assessment and management of patients. Moreover, all the elastographic techniques are currently being considered in the setting of other intestinal disorders (e.g., rectal tumors, appendicitis). The aim of this paper is to offer both a comprehensive narrative review of the non-invasive techniques available for the assessment of small-bowel disorders, with particular emphasis on inflammatory bowel diseases, and a summary of the current evidence on the use of elastographic techniques in this setting.

ERCP or NO ERCP: the case report of a frail patient

A 70-year-old man was admitted to the emergency department (ED) for a severe, continuous epigastric pain with back radiation and fever with chills, lasting 24 h. His recent medical history was characterized by a longterm hospital stay (3.5 months) because of a severe acute necrotizing biliary pancreatitis (AP) complicated by acute respiratory distress syndrome (ARDS), which required invasive ventilation in the intensive care unit (ICU), and led to a septic shock secondary to the infection of two abdominal necrotic collections, dealt by an aggressive long-term antibiotic regimen that included levofloxacin (750 mg once a day, i.v.), piperacillin–tazobactam (4.5 g t.i.d, i.v.) and imipenem/cilastatin (500 q.i.d., i.v.) for a total of 1 month with concomitant placement of percutaneous drainages. A CT scan carried out before the patient’s referral to a rehabilitation unit showed two residual fluid collections (66 and 55 mm in diameter, respectively) adjacent to the pancreatic tail and head, respectively. There was no evidence of any concomitant intraor extra-hepatic bile duct dilatation, with signs of sludge and multiple small radioopaque stones in the gallbladder. The patient’s past history revealed a long-life substantial consumption of tobacco (i.e., two packets of cigarettes daily over 50 years, corresponding to a total of 100 packs/ year), which was responsible for a GOLD stage D chronic obstructive pulmonary disease (COPD) requiring nocturnal and on exercise oxygen therapy (2L/min) in addition to inhalatory fluticasone and salmeterol. Besides COPD, other co-morbidities were chronic post-ischemic cardiomyopathy with reduced ejection fraction (44%), treated by PTCA with DES shunt placement in the patient’s left coronary artery 7 years before, long-standing arterial hypertension, hypothyroidism needing replacement therapy, and previous hepatitis B infection (positive anti-HBc). The severity of both the clinical status and co-morbidities was considered as an absolute contraindication to cholecystectomy. On account of the lack of common bile duct stones (CBDS), no endoscopic retrograde cholangiopancreatography (ERCP) was performed. Following 105 days from hospital admission, the patient was referred to a post-acute rehabilitation unit (RU) where he experienced a further episode of mild AP, conservatively treated with oral fasting, parenteral nutrition, and broadspectrum antibiotic therapy (ceftriaxone and metronidazole). One month later, the patient was discharged. Overall, in 4.5 months this patient reported a weight loss of 25 kilos (from 75 to 50 kg, and BMI from 23 to 18.5). Soon after returning home, the patient experienced a further episode of severe abdominal pain, which required further admission to the ED. When readmitted to our unit, the patient’s ongoing therapy included: levothyroxine 100 mcg once a day, pantoprazole 20 mg twice a day, acetylsalicylic acid 100 mg once a day, furosemide 25 mg once a day, & Dario Conte dario.conte@unimi.it