L’ecografia nell’ambulatorio delle Malattie Infiammatorie Intestinali
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Presentazione a cura del dott Fabrizio Pizzolante- M.A.S.T.E.R. ECM in Gastroenterologia: ecografia in gastroenterologia: potenzialità e limiti
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L’ecografia nell’ambulatorio delle Malattie Infiammatorie Intestinali
- 1. ECOGRAFIA IN GASTROENTEROLOGIA: POTENZIALITA’ E LIMITI L’ecografia nell’ambulatorio delle Malattie Infiammatorie Intestinali MASTER IN GASTROENTEROLOGIA IRCCS S. LUCIA ROMA
- 2. GIUS • Diagnosis/follow up • Opportunity to examine non-invasively and in physiological condition the bowel • Extra-intestinal features • Complications • US, CEUS, elastography, SICUS
- 3. JCC 2010
- 4. JCC 2013
- 5. Diagnostic workup Clinical suspicion Patient’s history Family history Physical examination Abdominal examination EIMs Perianal examination Blood work (acute phase reactants) Faecal cultures, C. diff Parasites, Calpro Ultrasonography MRI enteroclysis CT enteroclysis SBE/SBFT Colonoscopy + Ileoscopy + biopsies MRIUltrasonography Pelvic MRI Upper endoscopy For individual cases: Suggestive of Crohn’s disease Paediatrics Abscesses Paediatrics Incomplete colonoscopy Perianal disease VCE/DBE
- 6. Horsthuis E, et al. Radiology 2008 PER-PATIENT U.S. C.T. M.R.I. SCINTIGRAPHY p NUMBER OF STUDIES 11 7 11 9 SENSITIVITY 89.7 84.3 93 87.8 n.s. SPECIFICITY 95.6 95 92 84.5 n.s. PER-SEGMENT U.S. C.T. M.R.I. SCINTIGRAPHY p NUMBER OF STUDIES 11 7 11 9 SENSITIVITY 73.3 67.4* 70.4 77.3 n.s. SPECIFICITY 92.9 90.2 94.0 90.3 n.s. Inflammatory Bowel Disease Diagnosed with US, MR, Scintigraphy, and CT: Meta-analysis of Prospective Studies
- 7. Panes J, et al. APT 2011 Extension assessment technique Sensitivity % Specificity % Transabdominal US (8 studies) 74 - 96 67-98 CT enterography (1 study) 88 88 MRI enterography (5 studies) 38 - 88 88 – 100 Accuracy of ultrasonography, computed tomography and magnetic resonance imaging in the assessment of disease extension and activity in Crohn’s disease Activity assessment technique Sensitivity % Specificity % Transabdominal US (6 studies) 48 - 96 82-100 CT enterography (8 studies) 65 - 95 50 - 100 MRI enterography (16 studies) 55 - 100 46 – 100
- 8. Panes J, et al. APT 2011 Efficacy of ultrasonography, computed tomography and magnetic resonance imaging in the assessment of disease severity in Crohn’s disease Severity assessment technique Transabdominal US (12 studies) Various grades of correlation with endoscopy, clinical activity indices, biomarkes CT enterography (2 studies) Correlation with clinical activity indices and endoscopy MRI enterography (9 studies) Various grades of correlation with endoscopy
- 9. GIUS • cost-effective • non-invasive • radiation-free • easily accessible imaging modality • allows trans-mural assessment of the bowel wall • operator-dependence. Ultrasound unit Low frequency (1–6 MHz) and a high frequency (5–15 MHz) transducer.
- 10. Ultraschall in Med 2017
- 11. GIUS is undertaken using a transabdominal approach. Patient preparation: fasting The ultrasound transducer is applied to the abdominal wall, with gel used as an acoustic conductor. Standard two-dimensional brightness (B) mode is typically used. A low frequency transducer is initially used to elucidate gross anatomy at a deeper level, and a high frequency transducer is subsequently used for a detailed interrogation of the bowel wall
- 12. Systematic technique to survey entire intestine in abdomen Overlapping vertical sweeps of low and high-frequency up and down (manner of lawnmower)
- 13. Graded compression US Pulyaert originally described this technique in 1986 “Gradual progressive increase in pressure the operator applies to the probe while making gentle sweeping movements” Radiology, 1986 Step Probe Area(s) of scanning Organs visualized 0 C All 4 quadrants with curvilinear probe Any free fluid 1 L LLQ for calibrating scan parameters Sigmoid colon crossing psoas and anterior to iliac vessels 2 L RLQ Find ascending colon Find IC valve Find terminal ileum 3 L If found pathology, specifically scanning this area Bowel of interest (point of tenderness or abnormally suspected) 4 L “Moving the lawn” Check entire colon Check entire small bowel 5 L Additional views Bowel of interest
- 14. Focused examination aims to identify both luminal and extraintestinal pathology including mesenteric lymphadenopathy and inflammatory fat, as well as complications such as fistulae, abscesses and visceral pathology.
- 15. GIUS Abnormalities of the bowel • bowel wall thickening • preservation or loss of echostratification • Elasticity • Motility • Vessels • Haustra Extra intestinal abnormalitis • Mesentery • Limph nodes • fluids Ultraschall in Med 2017
- 16. GIUS
- 17. Wall layers from the lumen: 1) the hyperechoic layer corresponds to the interface between the mucosa and the lumen and is not a part of the actual GI wall 2) the hypoechoic layercorresponds to the mucosa without the intergface between the submucosa and mucosa 3) the hypechoic layer to the submucosa including this interface echo 4) the hypoechoic layer to most of the proper muscle layer 5) the hyperechic interface echo between the proper muscle and the serosa Ultraschall in Med 2017
- 18. 1) hyperechoic mucosa/lumen 2) hypoechoic mucosa 3) hyperechoic submucosa 4) hypoechoic proper muscle 5) hyperecohic interface proper muscle and the serosa
- 20. Colour Doppler ultrasound optimised to detect blood flow within the bowel wall is routinely implemented to identify hypervascularity suggestive of active inflammation. ColorDoppler
- 21. ColorDoppler active inflammation neoangiogenesis. Mural blood flow at color Doppler imaging (CDI) has been viewed for many years as a reflection of active inflammation, allowing for monitoring of disease activity. On the other hand, if color Doppler signal is absent, this may suggest inactive disease in the case of IBD or ischemia in the setting of acute or chronic abdominal pain
- 22. CD
- 24. Mesentery and omentum • The normal mesentery appears at US as a series of mildly hypoechoic parallel layers; it is easily seen when ascites is present, appearing as a series of hy- perechoic folds, which arise from the posterior wall of the peritoneal cavity; • Mesentery may be affected by several systemic and gastrointestinal diseases. As it reflects the overall visceral adiposity, increased mesenteric fat thickness (> 1 cm) may correlate with metabolic syndrome and cardiovascular diseases; chronic and acute inflammatory disorders and some neoplastic diseases affecting the bowel may show mesenteric hypertrophy, also named fat wrapping or creeping fat presenting as a firm, abundant hyperechoic tissue, surrounding the bowel loops. • Despite the accuracy of US in the description and detection of mesenteric abnormalities, it is limited by inferior panoramic view compared to CT and MRI. Ultraschall in Med 2017
- 26. Lymph nodes • In adults normal mesenteric lymph nodes appear as oval, elongated or U-shaped hypo- or mild hypo-echoic nodules with the shorter diameter < 4 mm and larger diameter usually < 15-17 mm. • In enlarged mesenteric nodes, the size, number, site, shape and echogenicity are not specific for the underlying diseases. However, the analysis of all these features may help in discriminating between infectious, inflammatory or potential neoplastic causes. Ultraschall in Med 2017
- 27. Lymph nodes
- 28. SICUS Small intestine contrast ultrasonography (SICUS) involves examination of the small bowel following ingestion of a neutral contrast agent (typically 200–500mL of a polyethylene-glycol solution). SICUS is highly accurate in detecting small bowel Crohn’s disease-related inflammation, as well as stricturing and penetrating complications. SICUS increases trainee accuracy in identifying small bowel pathology and improves the detection of proximal small bowel lesions in Crohn’s disease. The primary disadvantage of SICUS is the necessity for patient preparation, which limits its application as a point-of-care tool. Ultraschall in Med 2017
- 29. Transperineal US Transperineal ultrasound involves detailed examination of the perineum using a small high-frequency curvilinear or linear trans- ducer, and compared with endoanal ultrasound is less invasive and better tolerated by patients. Transperineal ultrasound is accurate in detecting and classifying perianal fistulising disease, as well as detecting perianal abscesses. Importantly, the transducers used for assessment of the transperineal ultrasound are the same trans- ducers used for evaluation of the intestinal tract. Ultraschall in Med 2017
- 30. Contrast-enhanced ultrasound active inflammation neoangiogenesis. Mural blood flow at color Doppler imaging (CDI) has been viewed for many years as a reflection of active inflammation, allowing for monitoring of disease activity. On the other hand, if color Doppler signal is absent, this may suggest inactive disease in the case of IBD or ischemia in the setting of acute or chronic abdominal pain
- 31. Contrast-enhanced ultrasound • Contrast-enhanced ultrasound (CEUS) involves the use of an intra- venous contrast agent, typically containing sulfur hexafluoride microbubbles. • CEUS is helpful in characterisation of suspected abscesses and inflammatory phlegmons, confirming and tracking the route of a fistula and may help to distinguish between fibrotic and inflammatory stricturing disease. • CEUS may also be helpful in quantitatively determining disease activity in IBD.
- 32. CEUS subjective assessment • Assessment of the degree and pattern of mural and mesenteric enhancement • With experience, observation of the wash-in and decline of contrast agent in the bowel wall may be interpreted as reflective of mild disease with low peak and rapid decline and of more severe disease with a higher peak intensity and longer duration of enhancement. • Additionally, the vascularization of the mesentery can be evaluated subjectively by demonstration of a comb sign (representing the filling of prominent straight intestinal arterial branches in the mesenteric arcade)
- 35. CEUS Indications • Disease activity • Indeterminate cases • Differentiation of strictures in IBD • Monitoring response to therapy
- 36. Elastography Ultrasound elastography provides a measure of the stiffness of tissue, representing a novel tool that may help in delineating between inflammatory and fibrotic components of intestinal strictures.
- 38. Panes J, et al. JCC 2013; Panes J, et al. APT 2011; Rieder F, et al. Gut 2013; Sensitivity, Specificity for Detecting Stricture in CD in Different Imaging Tools ECCO–ESGAR statement 3C US, CT and MRI and SBE / SBFT have a high sensitivity and specificity for the diagnosis of stenosis affecting the small bowel [EL 2]. Diagnostic accuracy of MRI and CT for stenosis is based on the use of luminal contrast. In partially obstructing stenosis, enteroclysis may provide higher sensitivity than enterography [EL 2]. Cross-sectional imaging using CT, US, MRI [EL 2] and WBC scintigraphy [EL 3] may assist in differentiating between predominantly inflammatory or fibrotic strictures [EL 5]. Stricture assessment technique Sensitivity % Specificity % Transabdominal US (3 studies) 73 - 96 90 - 100 CT enterography (5 studies) 85 – 93 100 MRI enterography (8 studies) 75 - 100 91 – 100
- 39. Panes J, et al. JCC 2013; Panes J, et al. APT 2011; Sensitivity, Specificity for Detecting Fistula/Abscess in CD in Different Imaging Tools Fistula assessment technique Sensitivity % Specificity % Transabdominal US (3 studies) 67 - 100 89 - 100 CT enterography (7 studies) 68 – 100 91 - 100 MRI enterography (6 studies) 75 - 100 71 – 100 Abscess assessment technique Sensitivity % Specificity % Transabdominal US (3 studies) 80 - 100 92 - 94 CT enterography (5 studies) 86 – 100 95 - 100 MRI enterography () 86 - 100 91 – 100 ECCO–ESGAR statement 3D US, CT, and MRI have a high accuracy for the assessment of penetrating complications (i.e., fistula, abscess) [EL 1] and for monitoring disease progression [EL 4]. For deep-seated fistulas MRI and CT are preferable to US [EL 4]. US and CT are widely available and facilitate early abscess drainage [EL 4].
- 42. RCU
- 43. Conclusions GIUS… • cost-effective • non-invasive • radiation-free • easily accessible imaging modality • allows transmural assessment of the bowel wall • Diagnosis/follow up • operator-dependence.
Editor's Notes
- 5
- Thirty-three studies, from a search that yielded 1406 articles, were included in the final analysis. Mean sensitivity estimates for the diagnosis of IBD on a per-patient basis were high and not significantly different among the imaging modalities (89.7%, 93.0%, 87.8%, and 84.3% for US, MR imaging, scintigraphy, and CT, respectively). Mean per-patient specificity estimates were 95.6% for US, 92.8% for MR imaging, 84.5% for scintigraphy, and 95.1% for CT; the only significant difference in values was that between scintigraphy and US (P .009). Mean per-bowelsegment sensitivity estimates were lower: 73.5% for US, 70.4% for MR imaging, 77.3% for scintigraphy, and 67.4% for CT. Mean per-bowel-segment specificity estimates were 92.9% for US, 94.0% for MR imaging, 90.3% for scintigraphy, and 90.2% for CT. CT proved to be significantly less sensitive and specific compared with scintigraphy (P .006) and MR imaging (P .037) Conclusion: No significant differences in diagnostic accuracy among the imaging techniques were observed. Because patients with IBD often need frequent reevaluation of disease status, use of a diagnostic modality that does not involve the use of ionizing radiation is preferable.
- Ultrasonography seems to have a superior overall accuracy for the detection of disease localised in the terminal ileum and colon, except for the rectum and MRI has superior accuracy compared with US for the detection of lesions in the jejunum and more proximal ileum (89% vs. 73%). Direct comparison of CT and MRI for assessment of location and extension of inflammatory lesions demonstrated a similar diagnostic accuracy. STATEMENT 2 (i) Assessment of disease extension in the small bowel should be based on radiological imaging techniques. MRI and US have a high diagnostic accuracy for assessment of disease extension. Selection between MRI and US should be based on the anatomical location to be explored, local expertise and availability. [EL 1b, RG A] (ii) For the assessment of jejunal and ileal lesions MRI is preferred over US for its higher sensitivity particularly for jejunal lesions. [EL 2b, RG B] (iii) Assessment of disease extension in the colon and terminal ileum should be based on endoscopy and completed with imaging techniques in cases of incomplete procedures. [EL 1b, RG A] (iv) Ultrasonography and MRI can be used as imaging methods for disease extension in the terminal ileum and colon. Higher availability and tolerance may render US a preferred technique. [EL 1b, RG A]. (v) Indirect evidence suggests a similar diagnostic accuracy for CT, but radiation exposure is a limitation for repeated use of this technique. [EL 5, RG D] Ultrasonography has a high diagnostic accuracy for assessment of disease activity in the terminal ileum and colon [EL 1b, RG A]. MRI may achieve a similar sensitivity if adequate luminal distension is achieved. [EL 1b, RG A] (ii) Computed tomography can also be used to assess activity in the terminal ileum as accuracy is similar to other diagnostic techniques for this location [EL 1b, RGA]. Information is insufficient for determining accuracy of CT for colonic disease. (iii) Ultrasonography, MRI and CT have a higher accuracy for assessing disease activity in terminal ileum than barium contrast studies. [EL 1b, RG A] (iv) As a result of lack of radiation US or MRI should be preferred over CT for evaluation of disease activity and severity, particularly in young patients. [EL 5, RG D]
- STATEMENT 4 A high correlation exists between the severity of intestinal lesions assessed by endoscopy and the intensity of US, MRI or CT changes. [EL 2b, RG B] (ii) A weak correlation exists between findings of crosssectional imaging techniques and clinical activity indexes or biomarkers. [EL 1b, RG A] (iii) Ultrasonography, MRI or CT can be used in clinical practice for the assessment of disease severity. [EL 1b, RG A]
- Esempio di impiego dell’eografia: ileo terminale caratterizzato da ispessimento paretale, ed alterazione della stratificazione parietale per imbibizione edematosa (aspetto ipoecogeno). Al colorDoppler vivaci segnali transmurali; in alo a sinistra ispessimento reattivo del mesentere periviscerale.
- AA24% of enhancement gain 70 s–7 min
- (i) Ultrasonography, CT and MRI have a high sensitivity and specificity for the diagnosis of intra-abdominal fistulas, with similar diagnostic accuracies. [EL 2b, GR B] (ii) Diagnostic accuracy of cross-sectional imaging techniques (US, CT and MR) for diagnosis of fistulas is higher than that of SBFT and should be preferred over the latter. [EL 2b, GR B] (iii) Combinations SBFT with a cross-sectional imaging modality may increase the diagnostic accuracy over either technique alone. [EL 2b, GR B] (iv) As a result of lack of radiation US or MR should be the preferred over CT for the detection of complications. Selection between MR and US will depend on local expertise and availability. [EL 5 GR D] Ultrasonography, CT and MRI have a high sensitivity for the diagnosis of intra-abdominal abscesses. Diagnostic accuracy of US is slightly lower than that of CT and MRI because of false positive cases. [EL 2b, GR B] (ii) Systematic combination of cross-sectional diagnostic modalities does not significantly improve the diagnostic accuracy for the detection of intra-abdominal abscesses complicating CD, but CT or MRI may be used to confirm doubtful US lesions. [EL 5, GR D] (iii) Cross-sectional techniques have a lower sensitivity for the detection of deep abscesses (e.g. retrogastric, deep pelvis). [EL 2b, GR B]