Multiplanar and Multiparametric MR Enterography in Crohn's disease

Transcription

1 Multiplanar and Multiparametric MR Enterography in Crohn's disease Poster No.: C-2387 Congress: ECR 2015 Type: Educational Exhibit Authors: F. Barbiera, E. Murmura, L. S. Maltese, B. Murmura, M Accardi, A. Carroccio, L. La Grutta, M. Midiri, L. Volterrani ; Sciacca/IT, Palermo/IT, Siena/IT Keywords: Abdomen, Gastrointestinal tract, Small bowel, MR, Contrast agentintravenous, Diagnostic procedure, Pathology DOI: /ecr2015/C-2387 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 26

2 Learning objectives To optimize small-bowel MR protocols; to describe the most important findings in Crohn's disease (CD). Page 2 of 26

3 Background CD is a type of inflammatory bowel disease (IBD) that may affect any part of the gastrointestinal tract from mouth to anus. It frequently affects young patients and it results in a chronic inflammatory disorder characterized by cumulative structural damage to the bowel with a progression from inflammation to penetrating disease and fibrosis over time. A large arsenal of medical treatment options are available, and the challenge is to identify patterns of disease behavior early to tailor treatment, identify complications, and use surgical options appropriately. [1] The study of patients with CD requires clinical examination and laboratorial, endoscopic, histological and radiological techniques. All these techniques combined will appraise CD activity and allow adequate treatment planning. Conventional endoscopy with biopsy is the reference standard for assessing mucosal disease activity and is central to the management of CD. It is invasive, however and it cannot be used for evaluation beyond the colon and last few centimeters of the ileum; it gives also little information about transmural and extraenteric disease extent. It is also frequently limited by colonic strictures. [1] Although CD may involve any part of the digestive tract, small bowel involvement occurs in at least 70% of the patients. As this section of the digestive tract is not easily accessible by conventional endoscopic techniques and because the inflammatory process may penetrate beyond the bowel wall, cross-sectional imaging is frequently employed in CD patients, both for assessing small bowel disease severity and for detection of extraluminal complications. [2] Magnetic Resonance Enterography (MRE) is an accurate tool for assessment of CD to identify patterns of disease and complications. The principal indications to perform MRE are: confirm the diagnosis evaluate the extension of the disease Page 3 of 26

4 acute relapse with suspicion of stricture and/or intestinal obstruction treatment failure complications Page 4 of 26

5 Findings and procedure details Patients should undergo 2 days of low residue diet. 12 hours before the examination, the patient is asked to drink about 2L of Polyethylene glycol (Selg-Esse) to clean bowel. Bowel distention is the key for an adequete examination: it is important to provide us an accurate interpretation because collapsed bowel loops can hide lesions or give the false appearance of wall thickening, abscess or enlarged lymph nodes. Luminal distension is achieved by administration of enteric contrast agent - Polyethylene glycol (Selg-Esse) - before the examination. Patients are asked to drink 1,5L in about minutes. Then, immediately before the examination, in the MR room, they are asked to drink another 300 ml. In our institution, MRE is performed with a 1.5T system using 8-channel phased- array coil; the patient is usually imaged in prone position to reduce motion artifacts and allow compression and separation of small bowel loops with better luminal distension. This position reduces also the area to be imaged and may help to separate them from the pelvis [3, 4, 5]. Our protocol includes in order: - Coronal, axial and sagittal FIESTA-T2W; - Dynamic thick SSFSE-T2 (70 mm); - Spasmolytic administration (Glucagon); - Coronal LAVA-T1; - Contrast administration; Page 5 of 26

6 - Coronal LAVA-T1 (30, 60, 90 seconds delay); - Sagittal and axial LAVA-T1 All sequences are acquired with breath hold. Coronal, axial and sagittal FIESTA-T2W This sequence gives valuable information regarding bowel distention, bowel wall thickening, and extent of disease; it produces clear images despite bowel peristalsis. In our experience, the sagittal plane, completing axial and coronal planes, allows to evaluate optimally the distal ileal loop, but also it better defines bowel anatomy and extension of wall thickening, stenosis, fistulas (Fig.1-7). Dynamic thick SSFSE-T2 This is typically acquired in coronal plane (Fig.8), but sometimes we acquired in oblique planes oriented to the affected segments (Fig.9). Motility assessed by cine sequences has been shown to correlate significantly with the levels of inflammatory markers like C-reactive protein [6, 7]. Cine images have also been shown to improve lesion detection in Crohn disease [8] and they can be used in three ways: - first, they can help to better assess any undistended loop If the undistended loop shows normal peristalsis, it may not be inflamed. - second, inflamed bowel loops usually do not move or move less, thus cine images can be one of the ways to detect inflamed bowel loops. - lastly, cine images also help to see strictures. The strictured segment will not distend fully and will be fixed. If narrowing is obstructive, then the proximal bowel will show dilatation [6]. Page 6 of 26

7 Spasmolytic administration (Glucagon) Bowel peristalsis can cause motion artifacts and blurring. To avoid motion artifacts and blurring due to bowel peristalsis, an antiperistaltic drug is administered. Generally, we administer Glucagon (Glucagen; Novo Nordisk, Bagsvaerd, Denmark) i.m or i.v; in diabetic patients hyoscine butylbromide (Buscopan; Boehringer Ingelheim, Ingelheim, Germany) is used instead. Coronal LAVA-T1 A quick T1 weighted scan, useful in assessing for post-contrast enhancement. Coronal Lava T1W has optimal spatial resolution for evaluation bowel loop, bowel wall thickness, mesentery, nodes, abscess and fistula Contrast administration We administer 1mmol/Kg of Gadobutrol (Gadovist ; Bayer Schering Pharma; Berlin, Germany). Coronal LAVA-T1 (30, 60, 90 seconds delay) We perform a contiguous thin section fat suppressed T1-weighted sequence with the same coverage as the precontrast coronal LAVA-T1 sequence. The purpose of this sequence is to assess bowel wall and mesenteric nodal enhancement and to evaluate for the presence of any rim-enhancing fluid collections, fistulas and extraintestinal abnormalities. Sagittal and axial LAVA-T1 These two planes are useful to complete the examination for better evaluation bowel loop involvement; in particular three planes approach evaluates optimally the distal ileal loop, Page 7 of 26

8 extension of wall thickening and enhancement, but also it better defines bowel anatomy, stenosis, fistulas (Fig.10-15). Now, we don't perform routinely DWI sequences because relatively few studies are been published, but there is good sensitivities of DWI for assessing acute inflammation with a significant decrease of ADC values in acutely inflamed segments, even if absolute value of ADC shows great inter study variability. Our experience We studied 36 consecutive patients (20 men and 17 women; mean age 37 years old) with this protocol and we found 22 CD. All patients with CD showed mesenteric lymphadenopathy and bowel wall thickening, mucosal irregularity and mural enhancement after gadolinium injection on T1-w sequences. 2 patients (9%) had entero-enteric fistulas (Fig.6, 16). Enteroenteric fistulas can form a complex network between adherent small bowel loops and have a stellate appearance (fibrotic and desmoplastic reaction), with multiple tracts, sharp angulation and bowel loops radiating from a central point, on contrast-enhance MR sequences. 10 cases (45%) had strictures with bowel obstruction and dilated (more than 3 cm) bowel loops proximal to the stricture. Finally, 13 patients (59%) had also mesenteric fat hypertrophy. In all cases, the multiplanar approach (axial, coronal and sagittal planes) gave an important contribution to a better evaluation of pathological findings. Page 8 of 26

9 Images for this section: Fig. 1: FIESTA T2 - Coronal, axial and sagittal planes: bowel wall thickening and mucosal irregolarity of distal ileal loop (blue arrow). Mltiplanar approach allows to evaluate optimally the distal ileal loop Page 9 of 26

10 Fig. 2: FIESTA T2 - Coronal, axial and sagittal planes: bowel wall thickening and mucosal irregolarity of ascending colon and distal ileal loop (blue arrow) Page 10 of 26

11 Fig. 3: FIESTA T2 - Coronal, axial and sagittal planes: patient with mobile cecum syndrome and two segments of distal loop appears thinckened and with mucosal irregularity (arrow in coronal and axial planes, arrowed in sagittal plane). The arrows in the two sagittal planes (FIESTA T2 and LAVA T1 after administration of contrast agent) mark the distal ileal loop and ileo-cecal valve Page 11 of 26

12 Fig. 4: FIESTA T2 - Coronal, axial and sagittal planes: thickening of the ileocolic anastomosis after surgery (blue arrow) Page 12 of 26

13 Fig. 5: FIESTA T2 - Coronal, axial and sagittal planes: bowel wall thickening and mucosal irregolarity of distal ileal loop with a stricture and dilated bowel loops proximal to the stricture (blue arrow) Page 13 of 26

14 Fig. 6: FIESTA T2 - Coronal, axial and sagittal planes: bowel wall thickening and mucosal irregolarity of distal ileum (blue arrow). There are also entero-enteric fistulas Page 14 of 26

15 Fig. 7: FIESTA T2 - Coronal, axial and sagittal planes: bowel wall thickening and mucosal irregolarity of distal ileal loop (blue arrow) Page 15 of 26

16 Fig. 8: SSFSE-T2 sequence: stenosis of distal ileal loop (blue circle) in the same patient in Fig.1 Page 16 of 26

17 Fig. 9: a: SSFSE-T2 sequence acquired in oblique planes oriented to the affected segment to obtain a better evaluation of disease extension b: SSFSE-T2 sequence acquired in oblique planes oriented to the affected segment to a better evaluation of distal ileal loop stricture (circle) Page 17 of 26

18 Fig. 12: LAVA T1 - Coronal, axial and sagittal planes: bowel wall thickening, mucosal irregolarity and enhancement of bowel wall in the same patients in Fig.4 (blue arrow) Page 18 of 26

19 Fig. 13: LAVA T1 - Coronal, axial and sagittal planes: bowel wall thickening, mucosal irregolarity and enhancement of bowel wall in the same patients in Fig.5 (blue arrow). Page 19 of 26

20 Fig. 14: LAVA T1 - Coronal, axial and sagittal planes: bowel wall thickening, mucosal irregolarity and enhancement of bowel wall in the same patients in Fig.6 (blue arrow) Page 20 of 26

21 Fig. 15: LAVA T1 - Coronal, axial and sagittal planes: bowel wall thickening, mucosal irregolarity and enhancement of bowel wall in the same patients in Fig.7 (blue arrow) Page 21 of 26

22 Fig. 16: FIESTA T2 and LAVA T1 after contrast agent administration (axial plane): enteroenteric fistula confirmed surgically Page 22 of 26

23 Fig. 11: LAVA T1 - Coronal, axial and sagittal planes: bowel wall thickening, mucosal irregolarity and enhancement of bowel wall in the same patients in Fig.2 (blue arrow) Page 23 of 26

24 Fig. 10: LAVA T1 - Coronal, axial and sagittal planes: bowel wall thickening, mucosal irregolarity and enhancement of bowel wall in the same patients in Fig.1 (blue arrow) Page 24 of 26

25 Conclusion The multiparametric and multiplanar approach is successful in the evaluation of intra and extra-enteric manifestations of CD, playing an important role in diagnosis and clinical management. Page 25 of 26

26 References [1] Makanyanga JC1, Taylor SA. Current and future role of MR enterography in the management of Crohn disease. AJR Am J Roentgenol Jul;201(1): doi: /AJR [2] Amitai MM1, Ben-Horin S, Eliakim R, Kopylov U. Magnetic resonance enterography in Crohn's disease: a guide to common imaging manifestations for the IBD physician. J Crohns Colitis Sep 1;7(8): doi: /j.crohns Epub 2012 Nov 1. [3] Amzallag-Bellenger E1, Oudjit A, Ruiz A, Cadiot G, Soyer PA, Hoeffel CC. Effectiveness of MR enterography for the assessment of small-bowel diseases beyond Crohn disease. Radiographics Sep-Oct;32(5): doi: / rg [4] Masselli G, Casciani E, Polettini E, Gualdi G. Comparison of MR enteroclysis with MR enterography and conventional enteroclysis in patients with Crohn's disease. Eur Radiol 2008;18(3): [5] Cronin CG, Lohan DG, Mhuircheartaigh JN, et al. MRI small-bowel follow-through: prone versus supine patient positioning for best small-bowel distention and lesion detection. AJR Am J Roentgenol 2008;191(2): [6] Chavhan GB1, Babyn PS, Walters T. MR enterography in children: Principles, technique, and clinical applications. Indian J Radiol Imaging Apr;23(2): doi: / [7] Bickelhaupt S, Pazahr S, Chuck N, Blume I, Froehlich JM, Cattin R, et al. Crohn's disease: Small bowel motility impairment correlates with inflammatory-related markers C-reactive protein and calprotectin. Neurogastroenterol Motil 2013 Mar 18. [8] Froehlich JM, Waldherr C, Erturk SM, Patak MA. MR motility imaging in Crohn's disease improves lesion detection compared with standard MR imaging. Eur Radiol 2010;20: Page 26 of 26