Crohn s Disease. bowel. Two picks of diagnosis - 2nd and 6th decades of life. Multifactorial - Genetic and Environmental.

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2 Crohn s Disease Chronic and Inflammatory disease of the small and or large bowel. Two picks of diagnosis - 2nd and 6th decades of life. Multifactorial - Genetic and Environmental. In Israel: 40,000 patients. Rate of 451/100,000 1 st in the world

3 Crohn s Disease Relapsing disease. Highly variable among patients. Progressive disease from inflammatory to stricturing or penetrating type. 1 Natural History of Pediatric Crohn s Disease: A Population-Based Cohort Study; VERNIER MASSOUILLE G. et al.; Gastroenterology 2008

4 Crohn s Disease Patients are in risk to developing disease complications (abscess, fistula, strictures) Better monitoring of Crohn s Disease (CD) patients will help us recognize patients in risk for relapses and complications.

5 SHARE study* SHARE study: 3-years prospective study Collaboration between the Gastroenterology and Radiology departments. Develop an algorithm to predict relapse in Crohn s disease patients, based on: Magnetic Resonance Enterography Video Capsule Endoscopy Lab examinations * Funded by Helmsley Charitable Fund

6 SHARE study

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8 Magnetic Resonance Enterography (MRE) One of the main tools in diagnosing, staging and monitoring of CD patients. Non-ionizing radiation. High contrast resolution. Low incidence of adverse events related to IV contrast employed (Gadolinium).

9 Clermont score A recently validated MRE based quantitative score for Crohn s disease. Based on: Diffusion weighted imaging Apparent diffusion coefficient (ADC) Ulcers Edema Wall thickening

10 Clermont score DWI (Diffusion Weighted Imaging): Image sequence based upon the differences in the motion of water molecules between tissues. ADC (Apparent Diffusion Coefficient): Quantitative parameter of DWI. Measures the magnitude of free diffusion of water molecules.

11 C.N., 19 y. old female Fiesta sequence

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54 Same patient DWI sequence

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102 Video capsule endoscopy Traditional endoscopy is not reachable beyond the duodenum and proximal to the ileocecal valve. In clinical use since Enable visualization of the entire small bowel mucosa. Non invasive, user friendly, painless technique. Aphtae

103 Lewis score A validated video capsule quantitative activity score for mucosal inflammation in Crohn s disease. Includes three parameters: 1. Villous edema 2. Ulcer 3. Stenosis

104 Lewis score results: Lewis score mucosal healing : LS < 135 mild to moderate inflammation: LS moderate to severe inflammation: LS >790

105 Purpose To evaluate the correlation between MRE and VCE-derived activity scores in the distal small bowel

106 Methods 53 patients with known quiescent small bowel Crohn s disease (CDAI<120) were prospectively recruited. All patients underwent MRE followed by VCE. The distal small bowel, defined as the distal 20 cm of terminal ileum, was evaluated in all patients.

107 Methods MRE preparation: Distention of the small bowel 1.5 liter oral contrast (360 ml of Osmitrol 20% diluted in 1.14 liter water) 500 ml every 20 minutes one hour before exam IV injection of 150 ml saline with 0.3 mg of glucagon in slow drip 15 minutes prior to exam IV injection of contrast agent (Gadolinium)

108 Methods MRE protocol (1.5T GE Optima MR 450w scanner with GEM Suite) : T2 SSFSE coronal T2 SSFSE + fat sat coronal 2D FIESTA + fat sat coronal, axial and sagittal FIESTA CINE (dynamic) coronal DWI multi b- values axial LAVA coronal and axial pre and post Gadolinium

109 Methods Distal small bowel was evaluated for the following paramters: ADC, wall thickness, ulcer and edema. Clermont score was calculated using the formula: X ADC (mm 2 /s) X wall thickness (mm) X ulcers X wall edema

110 Methods Lewis score was also calculated: *Recently validated in established CD (Cotter, Endoscopy, 2014)

111 Statistical analyses Clermont (MRE) and Lewis scores (VCE) were correlated using Spearman s rank (r) correlation. Receiver operating characteristic (ROC) curves were generated for correlation of Clermont score to the presence of any mucosal inflammation (LS 135) and to the presence of moderate to severe inflammation ( LS>790), and area under the curves (AUC) were calculated.

112 Results The Clermont score (MRE) correlated significantly with the Lewis Score (Video Capsule), (r=0.53, p=0.001)

113 Results The AUC was moderate (AUC=0.74) for prediction of any mucosal inflammation (LS 135) And excellent (AUC=0.91) for prediction of moderate to severe inflammation (LS 790)

114 Clermont and Lewis correlation 52 y.o female

115 Conclusions Significant correlation between MRE and Video Capsule based indices of inflammation in the distal small bowel of Crohn s disease. The correlation between the modalities was higher in patients with endoscopically moderate to severe disease compared to mild to moderate

116 Clinical relevance The MRE (Clermont score) can be used to non-invasively quantify distal small bowel Crohn's disease, and thus help guide clinical decisions regarding prognosis and treatment

117 Thank you