Magnetic resonance enterography for predicting the clinical course of Crohn's disease strictures

Abstract

Background and Aims Strictures are the most common Crohn's disease complication, but their natural history is unknown. This study aimed to characterize inflammation, predict prognosis, and understand the impact of drug therapy using magnetic resonance enterography (MRE). Methods Patients with a stricture diagnosed on MRE over a 5‐year period were reviewed for MRE disease extent and inflammation, clinical course, C‐reactive protein, response to anti‐TNF therapy, endoscopic dilatation, hospitalization, and surgery. Results 136 patients had 235 strictures (77, one and 59, ≥ 2 strictures). Treatment: 46% of patients underwent surgery after a median 6 months; median follow‐up for those not requiring surgery was 41 months. Predictors of surgery: Hospitalization because of obstruction predicted subsequent surgery (OR 2.50; 95% CI 1.06–5.90) while anti‐TNF therapy commenced at stricture diagnosis was associated with a reduced risk (OR 0.23; 95% CI 0.05–0.99). MRE characteristics associated with surgery were proximal bowel dilatation ≥ 30‐mm diameter (OR 2.98; 95% CI 1.36–6.55), stricture bowel wall thickness ≥ 10‐mm (OR 2.42; 95% CI 1.11–5.27), and stricture length > 5‐cm (OR 2.56; 95% CI 1.21–5.43). 81% of patients with these three adverse MRE features required surgery versus 17% if none were present (P < 0.001). Accuracy for these three MRE variables predicting surgery was high (AUC 0.76). Conclusion Magnetic resonance enterography findings in Crohn's disease strictures are highly predictive of the disease course and the need for future surgery. MRE may also identify who would benefit from treatment intensification. Anti‐TNF therapy is associated with reduced risk of surgery and appears to alter the natural history of this complication.

Which MRI Score and Technique Should Be Used for Assessing Crohn’s Disease Activity?

“…Fernandes et al [45] confirmed these data, showing that a lower percentage of small bowel CD patients achieving transmural healing required surgery, hospital admission, and therapy escalation (0%, 3%, and 15.2%, respectively) compared to patients with endoscopic mucosal healing (11.5%, 17.3%, and 36.5%, respectively) or active disease (11.6%, 24%, and 54.3%, respectively) after 12 months of follow-up [45]. Interestingly, both the MRE characteristics (proximal bowel dilatation ≥30 mm diameter (OR: 2.98; 95% CI: 1.36-6.55), stricture bowel wall thickness ≥10 mm (OR: 2.42; 95% CI: 1.11-5.27), and stricture length >5 cm (OR: 2.56; 95% CI: 1.21-5.43)) [46], as well as the disease pathways diagnosed using MRE (presence of perianal disease (OR: 9, 95% CI: 2-39, p = 0.003), stenoses (OR: 3.4, 95% CI: 1-11, p = 0.04), or intra-abdominal fistulas (OR: 10.6, 95% CI: 2-46, p = 0.002)) [47], were significantly related with a higher risk of surgery. A study by Deepak et al [48] investigated the natural history of CD patients managed through a strategy of treating to a target of radiological transmural remission along with a median follow-up of almost 5 years.…”

Positionspapier zur Befunderhebung von Darmultraschallbefunden bei chronisch entzündlichen Darmerkrankungen

“…Die aktuell gängige Definition beschreibt eine Einengung des Lumens mit einer prästenotischen Dilatation > 25 mm des vorgeschalteten Darmsegments [16,54,55]. Die Forderung nach einer prästenotischen Dilatation reduziert möglicherweise die Sensitivität für die Detektion von Stenosen [56,57,58,59,60]. Der Vorteil der Darmsonografie liegt darin, dass die Motilität des vorgeschalteten Darmsegmentes zur Identifizierung der Stenose als Kriterium mit herangezogen werden kann.…”

Intestinal stricture in Crohn's disease: A 2020 update

“…Inflammatory strictures can also be distinguished from fibrotic ones in CD by other combination modalities, such as the magnetization transfer (MT) ratio of magnetization transfer imaging with T2WI of conventional MRI 46 and dynamic contrast‐enhanced MRI with intravoxel in coherent motion 43 . In addition, MRE may predict disease progression and the need for future surgery in CD with strictures; surgery‐related MRE features include proximal bowel dilatation diameter ≥30 mm, stricture wall thickness ≥10 mm and stricture length >5 cm 47 …”