Use and Misuse of CT
and MR Imaging in IBD
David H. Bruining, MD
Mayo Clinic, Rochester, MN
bruining.david@mayo.edu
Division of
GASTROENTEROLOGY
& HEPATOLOGY
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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
Hs-CRP
IL-6
Calprotectin
Lactoferrin
IL-6
Calprotectin
Lactoferrin
CDAI
SES-CD
0.65
0.47
0.52
0.16
0.46
0.45
0.55
0.15
0.43
0.76
0.23
0.45
0.19
0.48
CDAI
0.15
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
Jones et al: Clin Gastroenterol Hepatol, 2008
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CT and MR Enterography
Similar Performance to CTE for Identifying Active Disease
CTE
MRE
Siddiki et al: Am J Roentgenol, 2009
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CT and MR Enterography
Advantages – CTE
Advantages – MRE
• Less interobserver
variability
• No radiation
• Higher image quality
• Shorter image
acquisition times
• Cost
• Access
• Bone assessments
• Multiple phases
• Detection of fibrosis
• MRI superior for
perianal disease
• Pregnancy
• Renal insufficiency
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Appropriate Use
Right Test for the Right Patient
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Use of CT and MR
Enterography in Crohn’s Disease
Suspected Crohn’s disease
Established Crohn’s disease
• Establish disease
• Response to treatment
• Determine optimal strategy
for endoscopic confirmation
(BAE)
• Surgical planning
• Define extent and severity
• Penetrating and stricturing
complications
• Exclude alternate etiologies
• Penetrating and stricturing
complications
• Extra-intestinal disease
manifestation
• Exclude alternate etiologies
• Extraintestinal disease
manifestation
• Bone health interrogations
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Lesion Remodeling on CTE
6/7/2004*
9/26/2005
6/18/2007
*Infliximab initiated in 2004 after examination
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CTE Generated Finite Element Model
Bone Strength
Density
distribution
Regions of
failure
Weber et al: DDW, 2013
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When and How to Image
Established disease
•
•
•
•
•
•
Suspected disease
• Establish diagnosis
• Exclude alternate or additional
etiologies for patient symptoms
Postoperative
MRE
• SBFT (complex)
Occult stricture
• Enteroclysis
Other
• VCE and ultrasound
Disease activity
Disease extent
Disease severity
Evaluate for penetrating disease
Surgical planning
Assess response to therapy
CTE
•
•
•
•
•
•
Age <35 years
Serial examinations
Renal disease
Pregnancy
Stricture
Perianal disease
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Misuse of CT and MR Enterography
Wrong test
Wrong patient
• Multiple CTEs in young
patient (MRE)
• Chronic abdominal pain with
multiple negative CT or MR
examinations
• 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)
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Emergency Medicine and IBD
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
Kerner et al: Clin Gastroenterol Hepatoll, 2012
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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
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