Hands-On MRI 2017 Abdomino-pelvic MRI. February 1-3, 2017 Paris/FR ESMRMB

Transcription

1 Hands-On MRI 2017 Abdomino-pelvic MRI February 1-3, 2017 Paris/FR

2 MR Enterography Pr C.Hoeffel CHU Reims

3 Disposition Technique and Protocol Crohn s disease Other diseases

4 MR Enteroclysis or Enterography? Torkzad M et al. Insights in imaging 2015

5 Technique and Protocol Eur Radiol 2016

6 Technique and Protocol-Patient preparation Little evidence-recommandations based on expert opinion Fast for solid food and drink except non sparkling water for 4-6 hours No laxative bowel preparation No rectal water enema unless dedicated colonic exam needed

7 Technique and Protocol-Contrast agent No single preferred contrast agent- Recommended: hyperosmolar properties(biphasic- diarrhea) Mannitol PEG Sorbitol Lactulose, etc ml-20 to 25 ml/kg in peds- split in two or continuous? minutes beforeexamination, or 30 min advisablein patients with significant bowel resection Plug stoma in case of colostomy

8 Technique and Protocol-Positioning Prone or supine, prone Compresses abdomen=> reducesnumberor coronal section and limits peristalsis Uncomfortable=> avoid when stoma or wall disease Should include at least small boweland colon extendedto the pelvis- Perineum, liver? From back to front, cover only whatisnecessarynot to increase breathhold duration. Total acquisition time 30 min

9 Both1.5 and 3 T are adequate Use of phasedarraycoilsis mandatory Spasmolytic agents Recommended Apply before gado ± diffusion First line: IV hyoscine butylbromide20 mg (0.5 mg/kg in peds) Second line: IV Glucagon (0.5 mg if < 25 kg and 1 mg if > 25 kg) Optional in peds Technique and Protocol 1.5 T 3 T

10 Technique and Protocol-Sequences What basic sequences should the protocol be including( recommended)? Axial and coronal fat spin echot2 W sequenceswithoutfat saturation Axial and coronal steadystate free precessiongradient echo( SSFP GE, TRUFFI Siemens) without Fat Saturation An axial or coronal Fat saturatedfse T2W Maximal thickness5 mm, 2D or 3D but 2 D ispreferred FS Non- enhanced coronal T1 followed by Gado

11 Technique and Protocol-Sequences TRUFI /FFE/FIESTA- balanced steady-state free procession Pros= Fast, lackof motion artefacts. No needfor breathhold Mesenteric vessels and lymph nodes well identified +/- dynamic sequences: motility studies (decreased motility in inflamed boweldifferentiationbetweenfibroticand inflammatory involvement) Cons= No information on diseaseactivity(edemaor fibrosis) Susceptibility artefacts and mild chemical shift effect

12 Technique and Protocol-Sequences

13 Technique and Protocol-Sequences T2 HASTE/RARE/ single-shot half-fourier -withfat suppression Pros = Lack of motion artefacts Eitherbreathholdor breath-holdfree acquisition- very short Satisfactoryspatial resolution-usedfor oedema. Optionaluse of fat saton one of the T2 weighted sequences for differentiation betweensubmucosalfat and oedema. Cons = Flow-voidartefacts due to intestinal peristalsis Low spatial resolution=> limited analysis of mesentery

14 Technique and Protocol-Sequences

15 Technique and Protocol-Sequences FS Non-enhancedcoronal T1 followed by Gado If IBD, Enteric(45 sec) or portal venous(70 sec) phase If suspectedchronicgi bleeding, arterial(30 sec), enteric, portal Pump-injectedwithrate of 2 ml/sec and mmol/kg in adultsand peds(0.1 ) Maximal slice thickness3 mm, 3 D Coronal and axial, best if 2D in axial Wall, mesentery Amzallag-Bellenger. Radiographics Eur Radiol 2013

16 Technique and Protocol-Sequences Optional Additional fat-suppressed FSE T2 W in another plane Axial and coronal SSFP sequence with fat suppression Cine motility Diffusion-weighted imaging Free-breathing 0-50 to mm max Axial but coronal not recommended DynamicCE mayprovideadditionalinformation in the formof quantitative measurements of CE Delayed(delayed hyperenhancement sign of fibrosis, needs multicenter validation) Zappa M InflammBowelDis 2011

17 PEG Truffi Haste DWI Glucagon EG T1 Gado FS

18 Patchy inflammation/entire GI tract/all layers Extraintestinal manifestations Risk of cancer Crohn s Disease Courtesy Dr Rimola

19 Crohn s Disease Pariente B et al. Inflamatory bowel disease 2011

20 Crohn s Disease-Role of imaging Limitations of ileocolonoscopy Sometimesincomplete, up to 18 % Severe inflammation Technical reasons Proximal ileal disease with skipping of terminal ileum Cannot reach upper GI Needs sedation, anesthesia, and preparation Additional information Penetrating disease with overlying normal mucosa Beyond Stenosis and around the bowel Extraintestinal manifestations: PSC, sacroileitis etc.. => Change in management in around50 % Siddiki HA AJR 2009 Bruining DH IBD 2008 Higgins P IBD 2007

21 Crohn s Disease Detect disease and differentiation from other SB diseases In case of acute symptoms or in case of doubt between UC and CD with negative biopsies. Capsule endoscopy if still negative Initial work-up: Classify location and phenotype of disease. Extent (number, length) of disease Assessment of complications and surveillance of treatment (Inflammatory activity: mild, moderate, or severe) Follow-up if clinical or biological change Postsurgical evaluation Van Assche J Crohns Colitis 2010

22 Crohn s Disease Why MRE? Comparedto CT, no significantdifferencesfor CD location, extent MR Se/Spfor diagnosisof CD 78 and 85 % Se/Spfor assessmentof diseaseactivity80 and 82 %. In elderlypatients and in emergency setting preferct (perforation) Brenner DJ. N EnglJ Med 2007 FiorinoG IBD 2011 Panes G APT 2011 Rimola IBD 2011

23 Crohn sdisease-featuressuggestive Thickening of activityand severityof disease Deep ulcerations edema Inactive < 6 mm > Active CD Sp92 %, Se 63 % SevereCD > 11 mm Se 41 %, Sp92 % Zappa M IBD 2011

24 Crohn sdisease-featuressuggestive of activityand severityof disease Target sign Marked enhancement Rimola J Gut 2009 RimolaJ InflammBowelDis 2011 Steward MJ EurJ Radiol Punwani Radiology 2009 Zappa IBD 2011

25 Extramural signs Comb sign Lymph nodes

26 Crohn sdisease-complications-fistula

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28 M ES M B R

29 Crohn sdisease-complications-fistula T2 T1

30 Crohn sdisease-complications-fistula

31 Crohn sdisease-complications- Inflammatorymass

32 Crohn s disease- Complications- Inflammatory mass

33 Crohn sdisease-complications-abscess

34 Crohn sdisease-complications-abscess

35 Crohn sdisease-complications-abscess

36 Featuressuggestive of long-standing disease

37 Location and length of the disease Haste

38 Location and length of the disease Do not overinterpret colonic abnormalities

39 Location and length of the disease

40 Complications-Stenosis Definition not consensual but two indirect signssuggestive of stenosis Dilatation = Localized, persistent bowelnarrowingwhose functional effects may be judged from prestenotic dilatation Van Assche G JCC 2010 Pathological wall thickness (> 4 mm), with a markedly narrowed lumen just below a significant dilation of the lumen (diameter> 25 mm) Parente F Gut 2002 Loss of peristaltism Treatment Fibrousstenosis: surgeryor endoscopy Inflammatory: medical Inflammation score correlated with the fibrosis score (r=0.63, p=0.0001)

41 Complications-Stenosis Predominantly Fibrotic Mild thickening Short Few peri-bowel wall signs Absence of hyperintensity on T2 Late enhancement-7 mm Rimola J Am J Gastroenterol 2015 Zappa M IBD 2011

42 Complications-Stenosis Predominantly inflammatory Marked thickening Long Peri-Bowel wall blurring and comb sign Hyperintensity on T2 Ulcerations and complications

43 Scores Maria=> wall thickness-relative contrast enhancement- edema- ulceration- London=> wall thickness-mural T2 scoremural enhancement-perimural T2 score Clermont=> wall thickness-adc-edemaulceration

44 Scores

45 Never Forget

46 Recurrence % will undergo surgery and will recur during the following ten years

47 Advanced techniques-diffusion Detection of inflammation recurrence +++ Limitations: bowell movement and poor jejunal studies Long acquisition times: 3 to 4 minutes for diffusion with respiratory triggering Reproducibility of ADC samples? Active wall inflammation in CD determines a restricted diffusion- unclear how it correlates to the degree of wall inflammation and/or fibrosis Non inferiorityof DWI comparedto gadolinium for detectionof inflammatory lesions of CD Seo N Radiology 2016

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49 Conclusion Valid alternative to ileocolonoscopy and assess more proximal segments Accurate in detecting complications Analyse global distension and anatomy Look for last ileum History of surgery=> look for CT scan Detect wall thickening > mm (Haste) Analyse Number Location Length Morphology Thickness T2 signal Presence of ulcerations Enhancement» Intensity» Pattern

50 Conclusion Extramural findings Mesentery Lymph nodes Combsign Lipomatosis Complications Abscess anatomy++/ dd= pelviccaecum Stenosis=> type? Dilatation or not Fistula-inflammatory mass Anoperineal disease? Associated signs: thrombosis, CSP

51 Conclusion-Lemann score To assess digestive damage at a given time To measure the cumulative structural bowel damage caused by CD over time To identify CD patients with high risk of rapid damage progression To study the effect of early therapeutic intervention ondamage progression

52 Conclusion-Lemann score

53 Tumors Other Diseases Othersmallbowelconditions, as an alternative to CT or to endoscopic techniques Amzallag-Bellenger E. Radiographics2012 Amzallag-Bellenger E. EurRadiol2012 Amzallag-Bellenger E. Eur Radiol 2013

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57 OtherDiseases Mostly children but later peaks (4th and 6th) Diagnosismade withbiopsies but imaging suggestive Duodenum and proximal jejunum mostly Atrophyof jejunum(< 10 folds/5 cm of jejunum) Dilatation of jejunumwithabsence of valvulae conniventes Reversal of normal jejunalileal folds pattern Imaging for patient non respondingto gluten-free regimen Look for lymphadenopathyand size of spleen (prognostic factor)

58 ES M R M B Other Diseases

59 Other OtherDiseases Diseases

60 Conclusion Easy to perform, quick High contrast resolution, although still lacking spatial resolution