Contrast-enhanced ultrasonography (CEUS) and strain elastography (SE) are diagnostic imaging methods, which are still not routinely used in the clinical management of inflammatory bowel diseases. However, there are studies in the literature reporting on the use of both CEUS and SE in patients with bowel obstruction due to Crohn's disease, documenting the usefulness of these two methods in the differentiation between inflammation and fibrosis affecting the bowel wall. The aim of this case report is to evaluate the usefulness of CEUS and SE performed in a patient with Crohn's disease, who was admitted to hospital with bowel obstruction due to terminal ileal stricture and submitted to ileocecal resection. CEUS and SE identified and to some extent also characterized the inflammatory and fibrotic processes affecting the bowel wall. Macroscopic and microscopic examinations of the surgical specimen confirmed the presence of inflammatory phenomena (exudates, ulcers, and fistulas) and fibrosis as suggested by ultrasound (US) imaging methods.Sommario L' ecografia con mezzo di contrasto (CEUS) e la elastografia strain (SE) sono metodiche recenti, ancora poco utilizzate nel management clinico delle malattie infiammatorie croniche intestinali. Riguardo alle stenosi intestinali nel morbo di Crohn, in Letteratura sono pubblicati studi sia con la CEUS che con la SE che hanno documentato l'utilità delle due metodiche nel differenziare la natura flogistica o fibrotica del tratto patologico. Scopo di questo report è di valutare l'utilità delle due metodiche in un paziente affetto da morbo di Crohn, ricoverato per occlusione intestinale da stenosi dell'ultima ansa ileale ed operato di resezione dell'ileo terminale e del ceco. La CEUS e la Elastografia Strain hanno permesso la documentazione ed in un certo grado anche una misura dei processi flogistici e fibrotici a carico della parete intestinale affetta. L'esame macroscopico e microscopico del tratto resecato ha consentito di confermare la presenza dei fenomeni flogistici e fibrotici come ipotizzato con le due metodiche ecografiche.

Real-time strain elastography is not routinely performed in clinical practice for characterizing gastrointestinal tract diseases, and there are few studies in the literature on the subject. The recent EFSUMB guidelines suggest the use of this method in the diagnosis of neoplastic lesions and in the characterization of bowel strictures in patients with Crohn's disease. The purpose of this pictorial essay is to evaluate the feasibility of strain elastography in some pathologies of the colon frequently encountered in daily clinical practice and to compare elastography images with corresponding endoscopic and radiographic images. In our opinion, strain elastography is useful for characterizing diseases of the colon as it can add valuable diagnostic information to grayscale ultrasound imaging. However, diagnostic accuracy and clinical relevance of this information should be confirmed by further prospective research-targeted studies.

Ultrasound (US) is the first-line investigation in patients with abdominal symptoms and it has a role in the diagnosis and monitoring of inflammatory bowel diseases. Strain elastography (SE) is a US method for estimating tissue elasticity. This method is still not routinely used in clinical practice, although it is suggested by the EFSUMB Guidelines for the characterization of intestinal stenosis in Crohn's disease. The purpose of this Pictorial Essay is to confirm the feasibility of elastography in Crohn's disease in clinical practice by comparing elastography images with corresponding endoscopic or radiological images. At present, diagnostic accuracy of SE is reported in the literature only in connection with detection of bowel wall fibrosis in advanced cases of Crohn's disease. However, in our opinion, SE can add useful diagnostic information to grayscale and color Doppler US by providing a more accurate characterization of the bowel wall in the various manifestations of Crohn's disease.

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Strain elastography is a recently developed ultrasound method that seems to contribute to the diagnosis and monitoring of inflammatory bowel diseases. This pictorial essay aims to present the feasibility of strain elastography in clinical practice by comparing visual observation and semiquantitative parameters with endoscopic or radiological images in some common cases of Crohn's disease. In our opinion, strain elastography with visual observation is easily performed in connection with B-mode ultrasound and color Doppler imaging and may provide relevant information. Strain elastography with the elaboration of semiquantitative parameters is not as immediate as the visual observation method, but it seems to provide more objective data and seems more appropriate for monitoring the evolution of the disease. However, for the elastographic method to extensively contribute in inflammatory bowel diseases, standardization and further studies are required to confirm the promising results already reported in the literature. Keywords Gastrointestinal ultrasound • Strain elastography • Bowel strain elastography • Crohn's disease SOMMARIO L'elastografia Strain è una recente metodica ecografica che sembra avere un ruolo nella diagnosi e nel monitoraggio delle malattie infiammatorie intestinali. Lo scopo di questo Pictorial Essay è di verificare la fattibilità dell'elastografia Strain nella pratica clinica confrontando l'osservazione visiva e i parametri semi-quantitativi con immagini endoscopiche o radiologiche in alcuni casi comuni di malattia di Crohn. A nostro parere, l'elastografia strain con osservazione visiva è facilmente eseguibile in connessione con l'ecografia B-mode ed il color Doppler e può fornire informazioni rilevanti. L'elastografia strain con l'elaborazione di parametri semiquantitativi non è immediata come il metodo di osservazione visiva, ma sembra fornire dati più oggettivi e sembra più appropriata per monitorare l'evoluzione della malattia. Tuttavia, affinché il metodo elastografico possa avere un ruolo più diffuso nelle malattie infiammatorie dell'intestino, sono necessari la standardizzazione del metodo e ulteriori studi che confermino i risultati promettenti già riportati in letteratura.