Magnetic Resonance Imaging

Transcription

1 5th SESSION HOW TO INVESTIGATE THE SMALL BOWEL Chairpeople: S. Cucchiara, F. Maccioni Magnetic Resonance Imaging Emanuele Casciani Responsabile U.O.S. Diagnostica del trauma in Urgenza U.O.C. Radiologia d Urgenza, Direttore Prof. GF Gualdi Azienda Policlinico Umberto I, Università La Sapienza - Roma

2 Esophagus, stomach and colon are studied with routine endoscopic methods while evaluating clinical/endoscopic SB is difficult Imaging is an important step in the diagnosis and follow-up of SB diseases The ideal imaging should be Non-invasive No X-ray Repeatable Able to give information about the lumen/mucosa/ intestinal wall and surrounding structures Inexpensive

3 MR enterography Adequate preparation (distension of SB loops) of children for the MRI examination is vital to achieve good results

4 Triks and tips for imaging children in MRI How to image a young ill, non-cooperative child in MRI with parents?

5 Triks and tips for imaging children in MRI The mock MRI procedure involves children undergoing a simulated scan with the assistance of a play therapist prior to the actual diagnostic scan The mock MRI acts as a screening tool, to prepare the children, by familiarizing them with the environment, sounds, and equipment The mock MRI reduced the n of pts who have required anesthetic Carter AJ. Pediatric Radiology 2010 reduced the time required for the diagnostic scan de Amorim e Silva. Australasian Radiology 2006

6 Problems and tips for imaging children in MRI It is helpful to separate IV cannulation the procedures is a major of cause of anxiety IV placement and in the young MR exam patients by placing presenting for MRI the cannula before examination the MR exam Drink at least Improve 1 liter the of taste saline of solution drink! Enter into a tube Spaceship!! Children typically find it difficult to satisfactorily hold To teach their to breath, maintain creating apnea significant before the challenges MR exam in abdominal imaging

7 Techniques in scanning children Free MR breathing enteroclysis MR enterography under sedation sequences in 1-year in old 4-year old male High male Resolution with with Meckel CD MR at Diverticulum enterography colonoscopy colonography in 16- year old famale with Crohn s Disease

8 The 2 European evidence-based Consensus on the diagnosis and management of Crohn's disease Initial investigation should consist of colonoscopy (including terminal ileal intubation) with multiple biopsies, upper GI endoscopy with multiple biopsies, and small bowel imaging. The technique used to examine the SB will depend on local expertise; but dynamic contrast-enhanced MRI can reliably show most lesions of Crohn's disease without exposure to ionizing radiation. Van Assche G and European Crohn's and Colitis Organisation Journal of Crohn's and Colitis 2010; 4:

9 ACR Appropriateness Criteria on Crohn's disease 2011 Child or young adult. Initial presentation. Suspected Crohn disease J Am Coll Radiol ACR Appropriateness Criteria on Crohn's disease

10 Small-Bowel Crohn Disease Spectrum of findings Active inflammation Patients may exhibit characteristics of more than Penetrating Disease one disease subtype Fibro-stenosing Disease Disease Location and extent: jejunum, ileum, colon Stricture It is common for a single resected bowel specimen to contain areas of acute and chronic inflammation, and fibrosis Extraenteric Assessment Fistulas and sinuses, abscess, colonic abnormalities Perianal fistulas Differential diagnosis Di Nardo G, Aloi M, Oliva S, Civitelli F, Casciani E, Cucchiara S. Investigation of small bowel in pediatric Crohn's disease. IBD 2012;18:

11 Differences in the location and activity of CD lesions between adult and pediatric patients with MRI High activity (score 3): PP 34 % vs AP 9 % Involvement of terminal ileum was significantly different in the two groups: 100 % of AP vs 58 % of PP. Conversely, the colon was diseased in 84 % of PP vs 64 % of AP (left colonic segments in PP) Maccioni F, et al. Eur Radiol 2012 In older children the location of CD is similar to the AP: terminal ileum (50% 70%) The significant difference between PP and AP CD can best be demonstrated in patients less than 5 years of age: these patients tend to have significant large bowel involvement (isolated or colon and SB disease together) Kelsen J, Baldassano RN. Inflamm Bowel Dis PP are more likely to have upper gastrointestinal involvement than their adult peers. Levine A. Dig Dis. 2009

12 Active Inflammation MRI findings CD Nicolò 8 y-old Stratified or layered appearance on contrast-enhanced T1-w fatsuppressed image CD Elena 13 y-old Increased mesenteric vascularity (comb sign) on contrast-enhanced fat-suppressed T1-w fat-suppressed image

13 MRI Findings Wall thickness (mm) RCE (relative contrast enhancement) Edema Ulcers/pseudopolyps Enlarged lymph nodes According to Severity of Endoscopic Lesions (CDEIS) Sensitivity 81% Specificity 89% Rimola J, et al. Gut 2011; 58: 1113 Mary J, Modigliani R. Gut 1989; 30: 983

14 MR Enterography vs Pediatric Crohn s Disease Activity Index (PCDAI) PCDAI and MRE score were found to have a statistically significant positive correlation of 0.37 (P= ) Because PCDAI is a validated tool to assess disease severity, this suggests that MRE has a potential role in assessing clinical significant degrees of mucosal inflammation What remains to be seen is whether MRE is sensitive enough to adequately predict complete mucosal healing [clinical remission in CD] Silverstein J, et al JPGN 2012

15 Crohn s Disease evolution Active inflammation In remission Comb sign and enlarged lymph-nodes Wall thickness and pseudopolyps Stratified appearance Submucosal Edema Settembre 2009 Giugno 2010

16 Penetrating disease: abscess Raffaella, 16 y-old

17 Terminal ileitis and perianal fistula Antonio 12 y-old Pelvic MRI should be the initial procedure because it is accurate and non-invasive, although it is not needed routinely in simple fistulae Van Assche G and European Crohn's and Colitis Organisation Journal of Crohn's and Colitis 2010; 4:

18 Fibro-stenosing disease SB occlusion Active disease

19 Aloi M, Viola F, D'Arcangelo G, Di Nardo G, Civitelli F, Casciani E, Oliva S, Nuti F, Dilillo A, Cucchiara S. Disease course and efficacy of medical therapy in stricturing paediatric Crohn's disease. Dig Liver Dis Disease course and efficacy of medical therapy in stricturing paediatric Crohn's disease A stricturing phenotype is not uncommon at the diagnosis of CD in children (36% had an early stenosis, while 64% developed it at the follow-up) Purely inflammatory MR features of stenosis predict a high rate of response to medical therapy. In the absence of these features, early surgery could be considered as an effective approach to PP with stricturing CD

20 Functional MR techniques for Crohn s Disease Motility imaging DWI

21 MR enterography vs US Same accuracy for active inflammation in CD Martinez MJ Abd Im 2009; Pauls S Eur Radiol 2006; Miao YM Clinical Radiol 2002 Sensitivity MR (98%) > US (76%) respect to endoscopy Potthast S et Eur Radiol 2002 Accuracy US (89%) > MR (73%) [no MR enterography] Pascu M et al Inflamm Bowel Dis 2004 No studies with state of the art methods MR enterography vs CE Good correlation for individuation and CD locations MR < CE for mucosal abnormalities, but MR > CE for transmural/extramural abnormalities Casciani E, Di Nardo G, Oliva S, Cucchiara S, Gualdi G. MR enterography versus capsule endoscopy in paediatric patients with suspected Crohn s disease. Eur Radiol 2011

22 Peutz-Jeghers Syndrome Almost 70% of PJS patients undergo a laparotomy before adulthood and many of them require repeated laparotomies over their lifetimes Lifetime incidence of malignancy is 60%, most commonly in the SB Current guidelines recommend biennial examination of the SB to detect large polyps Initial data have shown CE to be a superior technique to barium studies for detecting polyps, but CE has some limitations, such as: Size estimation and anatomic localization of polyps may be inaccurate Polyps can be double-counted or missed altogether (retrograde peristalsis, rapid capsule transit, and limited video frame capture rate) Brown G, et al. Endoscopy 2006; Schulmann K, et al. Am J Gastroenterol 2005 Mata A, et al. Gastrointest Endosc 2005; Soares J, et al. Endoscopy 2004

23 Peutz-Jeghers Syndrome MR enterography is a promising alternative to CE for SB surveillance in adults with PJS (19 patients) CE is more comfortable for the patient MR may be less prone to miss large polyps and may be more reliable in their size assessment MR offers the potential for detecting extraluminal cancers Gupta A, et al. AJR 2010 In 8 PJS patients concordance between MRE and endoscopy was 72.6% for polyps <15 mm 93% for polyps >15 mm Maccioni F, et al. Abdom Imaging 2012

24 Peutz-Jeghers Syndrome Same patient

25 ...Crohn s Disease and beyond Appendicitis Diana 16 y-old Diarrhea, fever, abdominal pain US: Terminal ileum wall thickening

26 ...Crohn s Disease and beyond Meckel Diverticulum Raffaella, 17 y-old

27 ...Crohn s Disease and beyond Celiac Disease MRI is not for diagnosis (symptoms, blood test, biopsy) Non-Hodgkin Lymphoma Ascaris lombricoides! Reversal of the fold pattern, with more prominent folds in the ileum than in the jejunum

28 ...Crohn s Disease and beyond SB giant cavernous Annalisa, 6 y-old with syncope Anemia Hb 3.5 mg/dl Negative upper and lower GI endoscopy hemangioma T2-w T2-w fat-suppressed contrast-enhanced T1-w fatsuppressed (delayed phase) contrast-enhanced T1-w fatsuppressed (venous phase)

29 ...Crohn s Disease and beyond Alessandra, 9 y-old 3 years vomiting and diarrhea Colonoscopy: only the sigmoid colon was explored Descending colon volvulus

30 Why MR enterography Non-invasive, no X-ray, repeatable, Better than other methods Able to give information on lumen/mucosal/ intestinal wall and surrounding structures When MR enterography IBD (staging, active inflammation, follow-up, perianal fistula, ) Familial polyposis follow-up Problem solving TAKE HOME POINTS

31 TAKE HOME POINTS Where and How MR enterography Specialized pediatric hospital with High-field MR scan Specialized staff and equipment Gastrointestinal subspecialty for radiologists There is no one size fits all approach to imaging children and pediatric MRI requires dedicated specialist knowledge, flexibility, and expert input from the technologist, nurse and doctor!!