Predicting Risk of Surgery in Patients With Small Bowel Crohn’s Disease Strictures Using Computed Tomography and Magnetic Resonance Enterography

Background We aimed to determine if patient symptoms and computed tomography enterography (CTE) and magnetic resonance enterography (MRE) imaging findings can be used to predict near-term risk of surgery in patients with small bowel Crohn’s disease (CD). Methods CD patients with small bowel strictures undergoing serial CTE or MRE were retrospectively identified. Strictures were defined by luminal narrowing, bowel wall thickening, and unequivocal proximal small bowel dilation. Harvey-Bradshaw index (HBI) was recorded. Stricture observations and measurements were performed on baseline CTE or MRE and compared to with prior and subsequent scans. Patients were divided into those who underwent surgery within 2 years and those who did not. LASSO (least absolute shrinkage and selection operator) regression models were trained and validated using 5-fold cross-validation. Results Eighty-five patients (43.7 ± 15.3 years of age at baseline scan, majority male [57.6%]) had 137 small bowel strictures. Surgery was performed in 26 patients within 2 years from baseline CTE or MRE. In univariate analysis of patients with prior exams, development of stricture on the baseline exam was associated with near-term surgery (P = .006). A mathematical model using baseline features predicting surgery within 2 years included an HBI of 5 to 7 (odds ratio [OR], 1.7 × 105; P = .057), an HBI of 8 to 16 (OR, 3.1 × 105; P = .054), anastomotic stricture (OR, 0.002; P = .091), bowel wall thickness (OR, 4.7; P = .064), penetrating behavior (OR, 3.1 × 103; P = .096), and newly developed stricture (OR: 7.2 × 107; P = .062). This model demonstrated sensitivity of 67% and specificity of 73% (area under the curve, 0.62). Conclusions CTE or MRE imaging findings in combination with HBI can potentially predict which patients will require surgery within 2 years.

Longitudinal Bowel Behavior Assessed by Bowel Ultrasound to Predict Early Response to Anti-TNF Therapy in Patients with Crohn's Disease: A Pilot Study

Background Early changes in bowel behavior during anti-TNF induction therapy in Crohn’s disease (CD) are relatively unknown. We determined (a) onset of changes in bowel behavior in CD patients receiving anti-TNF therapy by ultrasound; and (b) the feasibility of shear wave elastography (SWE) in predicting early response to anti-TNF therapy. Methods Consecutive ileal/ileocolonic CD patients programmed to initiate anti-TNF therapy were enrolled. Bowel ultrasound was performed at baseline, and at weeks 2, 6, and 14. Changes in bowel wall thickness, Doppler signals of the bowel wall (Limberg score), and SWE values were compared using a linear mixed model. Early response to anti-TNF therapy was based on a composite strategy of clinical and colonoscopy assessment at week 14. Results Of the 30 patients enrolled in this study, 20 patients achieved a response to anti-TNF therapy at week 14. The bowel wall thickness and SWE value of the response group showed a significant downward trend compared with the non-response group (P=0.003, P=0.011). Bowel wall thickness, the Limberg score, and SWE values were significantly reduced as early as week 2 compared with baseline (P<0.001, P<0.001, P=0.003) in the response group. Baseline SWE values (21.3±8.7 vs. 15.3±4.7 kPa, P=0.022) and bowel wall thickness (8.5±2.3 vs. 6.9±1.5 mm, P=0.027) in the non-response group were significantly higher than in the response group. Conclusions This pilot study suggested that changes in bowel ultrasound behavior could be assessed as early as week 2 after starting anti-TNF therapy. Bowel ultrasound together with elasticity imaging could predict early response to anti-TNF therapy.

Bowel Ultrasound: a Non-invasive, Easy to Use Method to Predict the Need to Intensify Therapy in Inflammatory Bowel Disease Patients

Background and Aims: Bowel ultrasound (BU) is a non-invasive, inexpensive, widely available tool, valuable for inflammatory bowel disease (IBD) assessment. The aim of the present study was to investigate the clinical utility of BU to predict the need to intensify therapy in IBD patients. Methods: One hundred seventeen IBD patients (89 Crohn’s disease, and 28 ulcerative colitis) diagnosis established at least 6 months before enrolment, undergoing maintenance therapy were prospectively included in the study. Bowel ultrasound investigated the following parameters: the bowel wall thickness (BWT), loss of wall stratification, the presence of the bowel wall Doppler signal, the visible lymph nodes, the mucosal hyperechoic spots, and the irregular external bowel wall. The patients were followed-up for 6 months, registering the need to escalate the treatment regimen. Subgroup analyses were conducted for patients requiring immediate treatment intensification (37 subjects), due to active disease at baseline and patients with subsequent treatment intensification, in the 6 months follow-up period (21 cases) in comparison to patients that required no therapeutic optimization (59). Results: During the follow-up, 49.6% of patients needed treatment escalation. All the investigated BU variables were significantly associated with the main outcome. In the multivariate analysis, the mean BWT (p<0.0001), and the presence of the bowel wall Doppler signal (p=0.007) were independent predictors of the main outcome. For the subgroup analyses: mean BWT (p=0.0001) and the presence of the bowel wall Doppler signal (p=0.01) were independent predictors for immediate treatment intensification (active disease at baseline) and mean BWT (p=0.0003) and the lack of bowel wall stratification (p=0.05) were independent predictors for the need of subsequent therapeutic optimization. Logistic regression prediction models and prediction scores (BU score) had the best AUROC values (>0.91) when compared to traditional biomarkers of active inflammation, such as C reactive protein or fecal calprotectin. Conclusion: Bowel ultrasound could be used as a non-invasive, easy to use diagnostic tool to predict the need to intensify therapy in patients with IBD.

Is surgical exploration necessary in asymptomatic intestinal pneumatosis after lung transplantation?

Pneumatosis intestinalis is described as gas within the bowel wall and can be a sign of bowel ischaemia with a pending perforation. The described patient presented with the incidental diagnosis of pneumatosis intestinalis with free intraperitoneal gas on CT scan. His medical history included a successful lung transplantation. We here describe the clinical decision-making and evaluate our case with previous cases in the literature.

Laparoscopic Treatment of Early Postoperative Ileus After Laparotomy.

Aim. The case report demonstrates a successful laparoscopic treatment of early postoperative small bowel obstruction after open strangulated umbilical hernia repair with mesh.Case report. An 86-year-old female was admitted to the hospital due to abdominal pain for 2 days localised in the umbilical region. A diagnosis of strangulated umbilical hernia was set, and emergency operative therapy was performed. On the third postoperative day the patient showed symptoms of bowel obstruction, confirmed on CT. An emergency laparoscopy proceeded. It revealed small intestine loop fixation to the mesh through the peritoneal defect. While separating the intestine a defect in bowel wall was found and sutured laparoscopically. Patient was discharged from the hospital on the 8th postoperative day.Conclusion. Laparoscopic treatment after open hernia surgery is an alternative access for redo surgery in early postoperative period. It provides acceptable results even in contaminated area without needs to reopen surgical wound.

Ultrasonographic Evaluation of Bowel Wall Thickness and Intramural Blood Flow in Ulcerative Colitis

Background Ulcerative colitis, a type of inflammatory bowel disease that merely affects the mucosa and submucosa of colon in the form of inflammatory ulcers. Colonoscopy is the gold standard for its diagnosis. For optimal monitoring of disease activity in UC patients, colonoscopy should be performed on a regular basis. However, repeated colonoscopies represent a logistic and economic challenge, as well as significant burden for the patients. Objectives Our study aimed to provide an extensive overview of the main pathologic features of gut wall vessels and bowel wall thickness at US examination of UC. Patients and Methods This prospective case control study was done on 40 patients confirmed to have UC attending to Outpatient Clinics of Internal Medicine and Gastroenterology Department – Ain-Shams University from October 2018 to Augost 2019. They were divided into two groups: Relapse group: Include 20 patients with active UC disease. Remission group: Include 20 patients with inactive UC disease (in remission state). These two groups were matched with 20 healthy individuals, matched for age and gender and considered to be a control group. Disease activity was categorized according to the endoscopic Mayo score.Ultrasound and endoscopic findings were compared for each colon segment except for the rectum. Results The peak incidence of affected patients was 30–40 years of age. Female predominance compared to male with a ratio of 2.6:1. 20% of remission patients complaining from 1-2 bowel movement while 45% and 50% of relapsing patients suffer from 3-4 and 5 bowel movement respectively. 100%, 100%, 20% and 15% of relapsing patients suffer from bleeding per rectum, abdominal pain, tenesmus and urgency. Higher ESR and CRP and lower hemoglobin in relapsing compared to remission group. Furthermore, The last group has higher value of ESR and CRP and lower value of hemoglobin compared to control group. BWT was significantly thicker in relapse group (4.8±0.7 mm) than of remission (3.55±0.5 mm) compared to control group (1.6±0.5) (p value &lt;0.001). BWT at a cut-offs &gt; 4 mm discriminating between cases with relapse from those with remission and at a cut-offs &gt;4 mm discriminating between mild endoscopic severity from moderate and severe UC. Furthermore, BWT at a cut-offs &gt;4.6 mm discriminating between mild and moderate endoscopic severity from severe UC. Vascular signal number at a cut-offs &gt;1 discriminating between cases with relapse from those with remission and at a cut-offs &gt;2 discriminating between mild and moderate endoscopic severity of UC. Conclusion Abdominal ultrasound is a widely available non-invasive method for imaging of UC. It provides a high sensitivity, specificity and accuracy in diagnosis and monitoring of UC activity.

SP3.1.17 Assessment of the utility of CT to predict the requirement for resection at laparotomy in patients presenting with acute mesenteric arterial insufficiency

Introduction Mesenteric ischaemia as a consequence of arterial atherosclerosis is associated with significant morbidity and mortality. Practice has been influenced by the rise in cross-sectional imaging. In Glasgow a policy of laparotomy for patients presenting with acute mesenteric ischaemia at the time of mesenteric revascularisation has been adopted. We have sought to define whether CT can predict visceral necrosis and a requirement for tissue resection at the primary revascularisation. Methods This was a retrospective review of interventions performed for mesenteric ischaemia. Radiological variables described in the context of mesenteric ischaemia were defined. The primary CT report was reviewed to define whether these features were recorded and whether a diagnosis of mesenteric ischaemia was suggested. Imaging was then retrospectively reviewed with reference to the dataset by a radiologist. The radiologist was asked to offer a subjective opinion as to whether there was mesenteric infarction. These data were compared with laparotomy findings. Results There were 129 interventions performed for mesenteric ischaemia over the study period and 147 laparotomies. There was no specific radiological variable that was consistently reported in the primary or secondary CT review. However when bowel wall thinning, hypoattenuation or portal venous gas reported (independently) they seemed to be specific as in each case there was mesenteric infarction at laparotomy. Conclusion Even with retrospective radiological assessment there is no reliable feature that will predict mesenteric infarction and a requirement for tissue resection. As such a policy of laparotomy in patients who considered physiologically well enough would appear to be justified.

Early Diagnosis of Neutropenic Enterocolitis by Bedside Ultrasound in Hematological Malignancies: A Prospective Study

(1) Background: Neutropenic enterocolitis (NEC) is a life-threatening complication following chemotherapy with high mortality rates. Early diagnosis is crucial to improve outcomes. We designed a large prospective study employing bedside ultrasonography (US) as a novel approach to allow early diagnosis and prompt treatment to reduce mortality. (2) Methods: NEC was defined as US or computed tomography (CT)-proven bowel wall thickness ≥ 4 mm at the onset of at least one of the following symptoms: fever and/or abdominal pain and/or diarrhea during neutropenia. From 2007 to 2018, 1754 consecutive patients underwent baseline bedside US that was invariably repeated within 12 h from the onset of symptom(s) suggestive of NEC. (3) Results: Overall, 117 episodes of NEC were observed, and overall mortality was 9.4%. Bowel wall thickening was invariably absent in the negative control group. Abdominal pain associated with one or more symptoms correlated with the highest relative risk (17.33), sensitivity (89.7%), specificity (100%), and accuracy (96.2%) for diagnosis. The combination of abdominal pain and fever at onset significantly correlated with worse survival (p < 0.0001, OR 13.85). BWT (p = 0.046), type of therapy (p = 0.049) and blood culture positivity (p = 0.003) correlated with worse survival. (4) Conclusions: Bedside ultrasound is a non-invasive and radiation free imaging technique for early diagnosis of NEC and its prompt treatment significantly reduced mortality.

Difficulties in the Radiation Diagnosis of Acute Mesenteric Thrombosis in Patients with Chronic Critical Illness

Acute mesenteric ischemia is an acute disruption of blood supply to part of the intestine, which, if untreated, leads to bowel wall necrosis and a patient’s death. Computed tomography (CT) plays a leading role in detecting mesenteric ischemia and in making the initial diagnosis, especially in patients with chronic critical illness, when productive contact is impossible. The final diagnosis is established during surgery or postmortem examination. Timely diagnosis and surgical treatment are a basic tool to reduce high mortality rates from this disease. The article presents the possibilities of CT in imaging and making the primary diagnosis of mesenteric ischemia and mesenteric thrombosis.