©2013 MFMER | Division of GASTROENTEROLOGY & HEPATOLOGY Use and Misuse of CT and MR Imaging in IBD David H. Bruining, MD Mayo Clinic, Rochester, MN
©2013 MFMER | Disclosures Consulting Bracco Avantis Research Support Janssen Biotech Given Genentech
©2013 MFMER | Discussion Points What is known/standard of care Benefits of Imaging CTE and MRE performance Appropriation / inappropriate applications How are we doing? New developments
©2013 MFMER | Symptoms Aren’t Enough Jones et al: Clin Gastroenterol Hepatol, 2008 Correlation coefficients (bolded) were significant; P<0.05; n=164 CDAI; Crohn’s disease activity index: SES-CD; simple endoscopic core for Crohn's disease IL-6CalprotectinLactoferrinCDAISES-CD Hs-CRP IL Calprotectin Lactoferrin CDAI0.15
©2013 MFMER | CT and MR Enterography Similar Performance to CTE for Identifying Active Disease Siddiki et al: Am J Roentgenol, 2009 CTE MRE
©2013 MFMER | 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
©2013 MFMER | Appropriate Use Right Test for the Right Patient
©2013 MFMER |
©2013 MFMER | 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
©2013 MFMER | Lesion Remodeling on CTE *Infliximab initiated in 2004 after examination 6/7/2004* 9/26/2005 6/18/2007
©2013 MFMER | CTE Generated Finite Element Model Bone Strength Weber et al: DDW, 2013 Density distribution Regions of failure
©2013 MFMER | When and How to Image Suspected disease Establish diagnosis Exclude alternate or additional etiologies for patient symptoms 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 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 MRE Age <35 years Serial examinations Renal disease Pregnancy Stricture Perianal disease CTE Postoperative SBFT (complex) Occult stricture Enteroclysis Other VCE and ultrasound Postoperative SBFT (complex) Occult stricture Enteroclysis Other VCE and ultrasound
©2013 MFMER | 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
©2013 MFMER | Emergency Medicine and IBD Kerner et al: Clin Gastroenterol Hepatoll, (%) n= (%) n=482P Inflammation or bowel wall thickening 65 (38.5)257 (53.3) Obstruction 35 (20.7) 95 (19.7)0.90 Abscess or perforation 17 (10.1) 50 (10.4)0.12 Non-CD urgent findings11 (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
©2013 MFMER | 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
©2013 MFMER | 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
©2013 MFMER | Future Research Fine-tuned predictive models – acute presentations Widely available ED tool Simple Role of ultrasound Standardized imaging algorithms, guidelines and reporting lexicon