MR ENTEROGRAPHY IN EVALUATING CROHN S DISEASE

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1 MR ENTEROGRAPHY IN EVALUATING CROHN S DISEASE LAMYA ATWEH MD NOVEMBER 20, 2015 Department of Diagnostic Radiolgy American University of Beirut Medical Center

2 INTRODUCTION MRE established role in Crohn s disease Complementary information / indispensible adjunct Establish diagnosis Evaluate disease activity Assess complications Assess treatment response

3 INTRODUCTION Sensitivity of up to 93% in diagnosing IBD High interobserver agreement between imaging and surgery Up to 50% of patients had a change in management (surgery/medical)

4 OUTLINE How do I do it? MR Enterography preparation MR Enterography technique MR Enterography advantages / disadvantages MR Enterography in Crohn s disease Active disease / fibrostenotic disease / mixed disease MR Enterography in complications of Crohn s disease Extra-enteric findings

5 OUTLINE How do I do it? MR Enterography preparation MR Enterography technique MR Enterography advantages / disadvantages MR Enterography in Crohn s disease Active disease / fibrostenotic disease / mixed disease MR Enterography in complications of Crohn s disease Allows for extra-enteric findings

6 MRE PREPARATION Magnet: 1.5T or higher Patient screening Pacemakers and foreign bodies Surgical clips artifacts / hip prosthesis artifacts Claustrauphobic or anxious patients: caution with sedatives Compromise ability to breath hold

7 MRE PREPARATION NPO for 4-6 hours 2L VoLumen over 2 hours biphasic PEG (polyethylene glycol; best after VoLumen) Water Buscopan (Hyoscine-N-butylbromide) 20 mg IV before T2 sequence Antiperistaltic to decrease bowel motion Glucagon (0.5-1 mg) IV contrast: Dotarem 0.1 ml/kg

8 OUTLINE How do I do it? MR Enterography preparation MR Enterography technique MR Enterography advantages / disadvantages MR Enterography in Crohn s disease Active disease / fibrostenotic disease / mixed disease MR Enterography in complications of Crohn s disease Allows for extra-enteric findings

9 MRE TECHNIQUE Coronal T2 weighted images Axial T2 weighted images in 2 stacks Axial diffusion and ADC maps Dynamic 3D e-thrive pre and post contrast (breath held) Arterial, portal venous, systemic venous, delay Axial e-thrive post contrast in 2 stacks

10 NORMAL MRE Coronal T2 Axial T2

11 NORMAL MRE Axial diffusion Axial ADC map

12 NORMAL MRE Coronal e-thrive Arterial phase Coronal e-thrive Venous phase

13 OUTLINE How do I do it? MR Enterography preparation MR Enterography technique MR Enterography advantages / disadvantages MR Enterography in Crohn s disease Active disease / fibrostenotic disease / mixed disease MR Enterography in complications of Crohn s disease Allows for extra-enteric findings

14 PROBLEMS WITH MRI CT preferred over MRI Bowel motion Artifacts Limitations on spatial resolution Recent advances: high quality images for anatomy and inflammation Long scan times Price

15 ADVANTAGES OF MRI No Radiation cumulative radiation in young patients requiring lifetime imaging Multiple post-contrast phases Imaging at multiple time points facilitate distinction between peristalsis and stenosis Information on motility Provides information on diffusivity Gadolinium Less nephrotoxicity Less allergic reactions

16 IMAGING FINDINGS Provide assessment of the disease extent and activity Differentiate active inflammatory from fibrostenosing disease Impact patient management (intensify or optimize immunosuppressive therapies) Early intervention if stricturing or penetrating complications

17 OUTLINE How do I do it? MR Enterography preparation MR Enterography technique MR Enterography advantages / disadvantages MR Enterography in Crohn s disease Active disease / fibrostenotic disease / mixed disease MR Enterography in complications of Crohn s disease Allows for extra-enteric findings

18 ACTIVE INFLAMMATION Imaging findings Bowel wall thickening (due to edema and infiltration with inflammatory cells) Restricted diffusion Prominence of the vasa recta, mesenteric stranding Stratified pattern of mural enhancement Mucosal ulcerations

19 ACTIVE INFLAMMATION Axial post contrast e-thrive Axial diffusion

20 ACTIVE INFLAMMATION Axial T2 Axial diffusion and ADC map

21 ACTIVE INFLAMMATION Axial T2 Axial e-thrive post contrast delay Axial e-thrive post contrast delay

22 ACTIVE INFLAMMATION Axial and coronal e-thrive post contrast delay

23 ACTIVE INFLAMMATION - ULCERATION

24 OUTLINE How do I do it? MR Enterography preparation MR Enterography technique MR Enterography advantages / disadvantages MR Enterography in Crohn s disease Active disease / fibrostenotic disease / mixed disease MR Enterography in complications of Crohn s disease Allows for extra-enteric findings

25 FIBROSTENOTIC DISEASE Imaging findings Bowel wall thickening (due to deposition of collagen) Homogeneous mural enhancement Luminal narrowing with associated pre-stenotic bowel dilatation Rely more on lack of findings typically associated with active inflammation rather than direct visualization of fibrotic tissues

26 FIBROSTENOTIC DISEASE Axial T2 Axial diffusion Coronal T2 Axial Post contrast e-thrive delay

27 FIBROSTENOTIC DISEASE Coronal T2 Coronal post contrast e-thrive

28 OUTLINE How do I do it? MR Enterography preparation MR Enterography technique MR Enterography advantages / disadvantages MR Enterography in Crohn s disease Active disease / fibrostenotic disease / mixed disease MR Enterography in complications of Crohn s disease Allows for extra-enteric findings

29 MIXED DISEASE Has features of both; fibrostenotic disease and active inflammation

30 MIXED DISEASE Coronal T2 Coronal post contrast e-thrive

31 MIXED DISEASE Axial post contrast e-thrive delay Axial diffusion and ADC maps

32 OUTLINE How do I do it? MR Enterography preparation MR Enterography technique MR Enterography advantages / disadvantages MR Enterography in Crohn s disease Active disease / fibrostenotic disease / mixed disease MR Enterography in complications of Crohn s disease Allows for extra-enteric findings

33 COMPLICATIONS OF CROHN S Abscess Fistulae Sinus tracts

34 MRE - FISTULA Axial T2

35 MRE - FISTULA Axial T2

36 MRE - FISTULA Axial T2

37 MRE - FISTULA Axial T2

38 MRE - FISTULA Axial T2

39 MRE - FISTULA Axial T2

40 MRE - FISTULA Axial diffusion and ADC maps Axial diffusion and post contrast e-thrive

41 MRE JEJUNAL INFLAMMATION Coronal T2 Coronal e-thrive post contrast venous

42 MRE SINUS TRACT Coronal T2 Coronal and axial e-thrive post contrast

43 MRE PERIRECTAL ABSCESS Axial e-thrive post contrast delay

44 OUTLINE How do I do it? MR Enterography preparation MR Enterography technique MR Enterography advantages / disadvantages MR Enterography in Crohn s disease Active disease / fibrostenotic disease / mixed disease MR Enterography in complications of Crohn s disease Allows for extra-enteric findings

45 EXTRA-ENTERIC FINDINGS Cholelithiasis Urinary tract calculi Sacroiliitis

46 CONCLUSION MRE indispensible adjunct Establish diagnosis Information on disease activity Assess complications Assess treatment response Supports clinical decision-making

47 REFERENCES Santillan CS. MR Imaging Techniques of the Bowels. Magn Reson Imaging Clin N Am 22 (2014) 1 11 Al-Hawary MM, Zimmermann EM, Hussain HK. MR Imaging of the Small Bowel in Crohn Disease. Magn Reson Imaging Clin N Am 22 (2014) Yacoub JH, Oto A. New Magnetic Resonance Imaging Modalities for Crohn Disease. Magn Reson Imaging Clin N Am 22 (2014) Cheriyan DG, Slattery E, McDermott S, Kilcoyne A, Kingston C, Keegan D, Mulcahy HE, Doherty GA, Malone DE, Murphy SJ. Impact of magnetic resonance enterography in the management of small bowel Crohn's disease. Eur J Gastroenterol Hepatol 25(5)(2013) 550-5

48 THANK YOU

children Crohn s disease in MR enterography for GI Complications Microscopy Characterization Primary sclerosing cholangitis Anorectal fistulae

children Crohn s disease in MR enterography for GI Complications Microscopy Characterization Primary sclerosing cholangitis Anorectal fistulae MR enterography for Crohn s disease in children BOAZ KARMAZYN, MD PEDIATRIC RADIOLOGY ASSOCIATE PROFESSOR Characterization Crohn disease Idiopathic chronic transmural IBD Increasing incidence Age 7/100,000