Assessment of Crohn's disease-associated small bowel strictures and fibrosis on cross-sectional imaging: a systematic review - PubMed (original) (raw)

. 2019 Jun;68(6):1115-1126.

doi: 10.1136/gutjnl-2018-318081. Epub 2019 Apr 3.

Arne Bokemeyer 1, Mark Baker 2, Ren Mao 3 4, Claire E Parker 5, Tran Nguyen 5, Christopher Ma 5 6, Julián Panés 7, Jordi Rimola 8, Joel G Fletcher 9, Vipul Jairath 5 10 11, Brian G Feagan 5 10 11, Florian Rieder 4 12; Stenosis Therapy and Anti-Fibrotic Research (STAR) Consortium.

Affiliations

Assessment of Crohn's disease-associated small bowel strictures and fibrosis on cross-sectional imaging: a systematic review

Dominik Bettenworth et al. Gut. 2019 Jun.

Abstract

Patients with Crohn's disease commonly develop ileal and less commonly colonic strictures, containing various degrees of inflammation and fibrosis. While predominantly inflammatory strictures may benefit from a medical anti-inflammatory treatment, predominantly fibrotic strictures currently require endoscopic balloon dilation or surgery. Therefore, differentiation of the main components of a stricturing lesion is key for defining the therapeutic management. The role of endoscopy to diagnose the nature of strictures is limited by the superficial inspection of the intestinal mucosa, the lack of depth of mucosal biopsies and by the risk of sampling error due to a heterogeneous distribution of inflammation and fibrosis within a stricturing lesion. These limitations may be in part overcome by cross-sectional imaging techniques such as ultrasound, CT and MRI, allowing for a full thickness evaluation of the bowel wall and associated abnormalities. This systematic literature review provides a comprehensive summary of currently used radiologic definitions of strictures. It discusses, by assessing only manuscripts with histopathology as a gold standard, the accuracy for diagnosis of the respective modalities as well as their capability to characterise strictures in terms of inflammation and fibrosis. Definitions for strictures on cross-sectional imaging are heterogeneous; however, accuracy for stricture diagnosis is very high. Although conventional cross-sectional imaging techniques have been reported to distinguish inflammation from fibrosis and grade their severity, they are not sufficiently accurate for use in routine clinical practice. Finally, we present recent consensus recommendations and highlight experimental techniques that may overcome the limitations of current technologies.

Keywords: Crohn’s disease; fibrosis.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

PubMed Disclaimer

Conflict of interest statement

Competing interests: DB is on the advisory board or consultant for AbbVie, Dr Falk Foundation, Ferring, MSD, Pharmacosmos, Roche, Takeda, Tillotts Pharma and Vifor. MB receives support from Siemens Healthineers in the form of salary support, hardware and software for investigating the effect of lower exposure CT in detecting active Crohn’s disease. CEP is an employee of Robarts Clinical Trials. JP has received consultancy fees from AbbVie, Arena, Boehringer Ingelheim, Galapagos, Genentech, Janssen, MSD, Novartis, Pfizer, Robarts, Second Genome, Takeda, Theravance, TiGenix and Topivert. JR is on the advisory board or consultant for Robarts Clinical Trials, Takeda and TiGenix and received research grant from AbbVie and Genentech. JGF receives grants to his institution from Siemens Healthineers and Medtronic. VJ receives salary support from the John and Susan McDonald Endowed IBD Chair at Western University, London, Ontario, Canada; consulting fees from AbbVie, Eli Lilly, GlaxoSmithKline, Arena Pharmaceuticals, Genentech, Pendopharm, Sandoz, Merck, Takeda, Janssen, Robarts Clinical Trials, Topivert and Celltrion; speaker fees from Takeda, Janssen, Shire, Ferring, AbbVie and Pfizer. BGF has received grant/research support from Millennium Pharmaceuticals, Merck, Tillotts Pharma, AbbVie, Novartis Pharmaceuticals, Centocor, Elan/Biogen, UCB Pharma, Bristol-Myers Squibb, Genentech, ActoGenix and Wyeth Pharmaceuticals; consulting fees from Millennium Pharmaceuticals, Merck, Centocor, Elan/Biogen, Janssen-Ortho, Teva Pharmaceuticals, Bristol-Myers Squibb, Celgene, UCB Pharma, AbbVie, AstraZeneca, Serono, Genentech, Tillotts Pharma, Unity Pharmaceuticals, Albireo Pharma, Given Imaging, Salix Pharmaceuticals, Novonordisk, GSK, ActoGenix, Prometheus Therapeutics and Diagnostics, Athersys, Axcan, Gilead, Pfizer, Shire, Wyeth, Zealand Pharma, Zyngenia, GiCare Pharma and Sigmoid Pharma; and speaker’s bureau fees from UCB, AbbVie and J&J/Janssen. FR is on the advisory board or consultant for AbbVie, Allergan, Celgene, Gossamer, Receptos, Thetis, UCB, Samsung, Pliant, Boehringer Ingelheim, Metacrine, Takeda, Allergan, Helmsley, RedX and Roche. RM has no conflicts of interest to declare.

Figures

Figure 1

Figure 1

Transabdominal ultrasonography, CT and MR enterography demonstrating a distal ileal stricture. (A) Ultrasound image depicting the three core items for stricture diagnosis wall thickness (W, bracket), luminal narrowing (L, bracket) and prestenotic dilation (D, double arrow). (B–D) CT enterography demonstrating a distal ileal stricture with imaging findings of active inflammation and partial small bowel obstruction. (B) Coronal image demonstrating a distal ileal stricture with wall thickening, luminal narrowing and mural stratification and hyperenhancement (large white arrow). Active inflammatory Crohn’s disease is also present in the terminal ileum (arrowhead), as is a short segment jejunal stricture (small white arrow). (C) Enlarged axial image through distal ileal stricture better demonstrates luminal narrowing and increased wall thickness (W, bracket). (D) Sagittal image through distal ileal stricture shows prestenotic bowel dilation (D, arrows) and luminal narrowing within the stricture (L, bracket). (E–G) MR enterography demonstrating a distal ileal stricture with imaging findings of active inflammation. (E) Coronal half-Fourier single-shot fast spin echo (HASTE) shows ileal stricture with wall thickening and luminal narrowing (large white arrow) with upstream dilation (D, arrows). (F) Axial HASTE shows cross section through the stricture demonstrating increased wall thickness and how wall thickening is measured (W, white bracket). (G) Postcontrast axial 3D volumetric interpolated breath hold examination (VIBE) shows wall thickening and mural stratification and hyperenhancement, indicating inflammation with luminal narrowing (L, bracket). The three core items for stricture diagnosis are increased wall thickness, luminal narrowing and prestenotic dilation. CTE, CT enterography; MRE, MR enterography.

Figure 2

Figure 2

Proposed ranges for key items used for stricture detection in cross-sectional imaging modalities. US, ultrasound.

Similar articles

Cited by

References

    1. Thia KT, Sandborn WJ, Harmsen WS, et al. . Risk factors associated with progression to intestinal complications of Crohn’s disease in a population-based cohort. Gastroenterology 2010;139:1147–55. 10.1053/j.gastro.2010.06.070 - DOI - PMC - PubMed
    1. Vernier-Massouille G, Balde M, Salleron J, et al. . Natural history of pediatric Crohn’s disease: a population-based cohort study. Gastroenterology 2008;135:1106–13. 10.1053/j.gastro.2008.06.079 - DOI - PubMed
    1. Rieder F, Fiocchi C, Rogler G. Mechanisms, management, and treatment of fibrosis in patients with inflammatory bowel diseases. Gastroenterology 2017;152:340–50. 10.1053/j.gastro.2016.09.047 - DOI - PMC - PubMed
    1. Bettenworth D, Gustavsson A, Atreja A, et al. . A pooled analysis of efficacy, safety, and long-term outcome of endoscopic balloon dilation therapy for patients with stricturing crohn’s disease. Inflamm Bowel Dis 2017;23:133–42. 10.1097/MIB.0000000000000988 - DOI - PubMed
    1. Rieder F, Latella G, Magro F, et al. . European crohn’s and colitis organisation topical review on prediction, diagnosis and management of fibrostenosing crohn’s disease. J Crohns Colitis 2016;10:873–85. 10.1093/ecco-jcc/jjw055 - DOI - PubMed

Publication types

MeSH terms

LinkOut - more resources