CT and MR ENTEROGRAPHY: Findings in Crohn’s Disease

Amy K. Hara MD Associate Professor Mayo Clinic Arizona

Financial disclosures Research agreement with GE Healthcare

Talk outline: CTE and MRE 1) CTE/MRE utilization at Mayo Clinic 2) Technique 3) Interpretation 5) Performance

Mayo Clinic Arizona: SBFT 1200

SBFT

No. Exams

1000 800 600 400 200 0 2003

2004

2005

2006

2007

2008

Mayo Mayo Clinic Clinic Arizona: Arizona: CTE CTE vs vs SBFT SBFT CTE SBFT

1200

No. Exams

1000 800 600 400 200 0 2003

2004

2005

2006

2007

2008

Mayo Mayo Clinic Clinic Arizona: Arizona: MRE/CTE/SBFT MRE/CTE/SBFT CTE SBFT MRE

No. Exams

1200 1000 800 600 400 200 0 2006

2007

2008

ROUTINE ROUTINE CTE CTE Time

Oral contrast

45 min

1 bottle (450 cc)

Detector collimation

30 min

1 bottle (450 cc)

Reconstructed width

15 min

1 bottle (450 cc)

Recon interval

0 min

CT Scan

Axial / Cor/ Sagittal

3 mm

Total:

1350 cc

kVp

80-120

Oral contrast = Volumen

64-row 0.6 mm 1 mm 0.8 mm

* No glucagon

Positive vs neutral oral contrast Positive Oral

Neutral Oral

Same pt, different scans

IV IV contrast contrast timing: timing: Enteric Enteric phase phase 45-50s* 45-50s* Liver: late arterial

45s

Liver: early venous

60-70s

55-65s 50s *Schindera et al. Radiology 2007;243(2):438-444. Vandenbroucke F et al. Acta Radiol 2007;23:1-9

Radiation dose Protocol

Eff Dose (mSv)

Single phase CTE

7-20*

*Lee SS et al. Radiology 2009. 251(3):751-61. Jaffe TA et al. AJR 2007. 189(5):1015-22. Fletcher JG et al. AJR 2010 In press.

Reducing kVp 120 kVp 17 mSv LARGE Width > 44 cm

100 kVp 8 mSv

80 kVp 2.5 mSv

AVERAGE Width 31-44 cm

SMALL Width < 30 cm

Different pts Yu L, Hua L, Fletcher JG, McCollough CM. Medical Physics, Vol. 37, No. 1, January 2010

Reduced Reduced kVp: kVp: improved improved iodine iodine conspicuity conspicuity

80 kVp

140 kVp

Same pt, same scan (Dual energy CT)

Low Dose CTE with ASIR Routine dose: 14 mSv

Low dose CTE with ASIR: 4 mSv

CTDI 18

CTDI 5

5/23/08

1/2/09

36 yo M BMI = 19

Noise-reducing filters Adv: Less $$ than ASIR, works multiple scanners/vendors

Low Dose + FBP

Low Dose + FBP + filter

Same pt, same scan (colovesical fistula from Crohn’s)

MR enterography COR T2 SSFSE

Indications: • < 30 yrs old • Follow-up for CD Oral contrast: same as CTE

MR enterography Ax/cor FIESTA

Thick/thin SSFSE Ax/cor post-gad

Bad MRE more common than bad CTE

Minimize Minimize Underdistention Underdistention Reasons for underdistention: – Pt won’t drink – Rapid bowel transit • Gastric bypass • Ileocecal resection

– Delayed bowel transit • Gastroparesis, medications

– Delayed workflow

Gastric bypass

Optimizing Optimizing oral oral contrast/timing contrast/timing

Routine

3 Volumen / 45-60 min

•Ileocecal resection •Gastric bypass

2 Volumen+H20/30-45min

“I can’t drink anything!”

Lots of H20 / 30 min

Optimizing Optimizing oral oral contrast/timing contrast/timing •Delayed transit

Routine

3 Volumen / 60-75min 3 Volumen / 45-60 min

•Ileocecal resection •Gastric bypass

2 Volumen+H20/30-45min

“I can’t drink anything!”

Lots of H20 / 30 min

Still underdistended? Check Check workflow workflow

CT

Time of first drink

Time of scan

2005 2005 Actual Actual scan scan time time for for 60 60 min min protocol protocol 120 110 100 90

min

80 70 60 50 0

1

2

3

4

5

6

7

8

9

10

11

pts

Workflow delays Reasons: •Pt didn’t arrive early enough for 60 min oral contrast protocol •Pt didn’t show up on time •Scanner running behind

Workflow delays Reasons:

Solutions:

•Pt didn’t arrive early enough for 60 min oral contrast protocol

•Changed pt instructions for earlier arrival

•Pt didn’t show up on time

•Change from 60 to 45 min protocol

•Scanner running behind

•Tech/Nurse education

12

CTE Interpretation

Normal small bowel wall Enhancement: Homogeneous Distended Bowel Wall Thickness (BWT) < 3 mm

Lumen

Normal small bowel wall Enhancement: Homogeneous Distended Bowel Wall Thickness (BWT) < 3 mm MRE

CTE

NORMAL NORMAL or or ABNORMAL ABNORMAL SB? SB?

Normal Normal Enhancement: Enhancement: Jejunum Jejunum >> Ileum Ileum 150 150

100 100

HU 50 50

00 Jejunum Jejunum

Ileum Ileum

Booya et al. Radiology 2006.

Normal Normal bowel bowel wall wall thickness: thickness: Distended Distended Jejunum Jejunum >> ileum ileum Jejunum

88

66

mm 44

Ileum 22

Jej Jej

Ileum Ileum

00 Distended Distended

Baker et al. AJR 2009;192:417-423

Normal Normal bowel bowel wall wall thickness: thickness: Collapsed Collapsed Jejunum Jejunum >> ileum ileum Jejunum

Jejunum

88

66

mm

Jej Jej

Ileum Ileum

44

Ileum

Ileum 22

00 Collapsed Collapsed Baker et al. AJR 2009;192:417-423

Normal Normal or or CD? CD? Is there abnormal enhancement?

Normal underdistended jejunum

Crohn’s Disease

Normal Normal or or CD? CD? Is there abnormal enhancement?

Normal underdistended ileum

Crohn’s Disease

Compare Compare bowel bowel loops loops in in SAME SAME segment segment Compare: Jejunum to Jejunum Ileum to Ileum

Small Small Bowel: Bowel: Normal Normal vs vs Crohn’s Crohn’s Disease Disease 88

66

mm

CD CD

44 Normal Normal

22

00 BWT BWT Baker et al. AJR 2009;192:417-423

Small Small Bowel: Bowel: Normal Normal vs vs Crohn’s Crohn’s Disease Disease 120 120

HU

CD CD

80 80 Normal Normal

40 40

00 Enhancement Enhancement Baker et al. AJR 2009;192:417-423

Putting it all together.. Study Baker et al 2009

Finding for CD

Sens

Spec

Enhancement + BWT > 3 mm

89%

81%

Enhancement only

89%

74%

Enhancement only

76%

76%

BWT > 3 mm only

63%

89%

Booya et al 2006

MR enterography Cor thin SSFSE: BWT

Cor post-gad: enhancement

CTE and MRE CTE

MRE post gad

Same pt, different scans

BOWEL BOWEL WALL WALL STRATIFICATION STRATIFICATION == BWT BWT ++ mucosal mucosal enhancement enhancement Bilaminar

Trilaminar

(Mucosa/Submucosa)

(Mucosa/Submucosa/Serosa)

Jones 48842645

Heine

Stratification Stratification is is not not specific specific for for CD CD

Crohn’s Disease

Graft vs Host Dx

Radiation Enteritis

CD: CD: Asymmetric Asymmetric bowel bowel wall wall involvement involvement

Sanchez 68030089 Garrett 68706381

Garrett 68706381

+ CTE for CD, now what? • Is there active disease? • Skip lesions/ multifocal disease

Carreo 48121420

• Complications – Penetrating Dx • Fistulas/abscesses – Stricture/obstruction

CTE: CTE: Differentiating Differentiating active active vs vs chronic chronic CD CD N = 96 pts with CTE and endoscopy CTE finding Mural hyperenhancement Bowel wall thickening Mural stratification Comb sign Inc. mesenteric fat atten

Bodily K et al. Radiology 2006;238:505-516.

CTE: CTE: Differentiating Differentiating active active vs vs chronic chronic CD CD N = 96 pts with CTE and endoscopy CTE finding

Sens (%)

Mural hyperenhancement

80

Bowel wall thickening

75

Mural stratification

60

Comb sign

35

Inc. mesenteric fat atten

10

Bodily K et al. Radiology 2006;238:505-516.

CTE CTE findings findings correlates correlates to to endoscopic endoscopic severity severity • N = 143 pts with CD • CTE findings (bowel wall enhancement, comb sign, fat density) vs endoscopic and histologic severity scores • RESULTS: – Endo scores correlate with all CTE signs – Histo scores correlate best with CTE enhancement

Columbel et al. Gut 2006;55:1561-1567

Mild disease Capsule

Moderate disease Ileoscopy

Severe disease Capsule

COMB SIGN (definition) Dilated vasa recta *most SPECIFIC marker of active dx

Sanchez 68030089

*Booya F et al. Radiology 2006;241(3)787-795.

FAT HALO SIGN Can be normal finding in obese pts 100 80

%

60 40 20 0 no CD

CD

No CD: Harisinghani M et al. AJR 2003.181:781-784. CD: Amitai MM et al. Clin Rad 2007.62:994-997.

Multifocal disease (skip lesions) Ileal involvement: 57-89% Ileum only = 33% SB + colon = 50% Gawronski 68582956

CTE for Colitis SB + colon = 50% Colitis only = 15-20%

Sens Spec Overall

74% 90%

Mod-severe dx

93% 91%

Exc. distention

89% 86%

Johnson KJ et al. Emerg Radiol 2009

Incidence Incidence of of Penetrating Penetrating Disease/ Disease/ Strictures Strictures N=989 pediatric pts with CD 100

Strictures Penetrating Dx

80

%

60 40 20 0 1

5

10

Years since diagnosis Gupta N et al. Inflamm Bowel Dis 2009

Incidence Incidence of of Penetrating Penetrating Disease/ Disease/ Strictures Strictures N= 2002 adults with CD 100

Strictures Penetrating Dx

80

%

60 40 20 0 5

20

Years since diagnosis Cosnes J et al. Inflamm Bowel Dis 2002.

Penetrating Disease N=357 adult pts with CD TOTAL

21%

Fistulas

17%

Abscess

4%

Phlegmon

3%

Bruining DH et al. Inflamm Bowel Dis 2008;14(12):1701-1706..

Types of fistulas *Enteroenteric

9.5%

Enterocutaneous

2.8%

Perianal

2%

*new finding is 60% pts

Bruining DH et al. Inflamm Bowel Dis 2008;14(12):1701-1706..

Types of fistulas Enteroenteric

9.5%

Enterocutaneous

2.8%

Perianal

2%

Bruining DH et al. Inflamm Bowel Dis 2008;14(12):1701-1706..

Types of fistulas Enteroenteric

9.5%

Enterocutaneous

2.8%

Perianal

2%

Bruining DH et al. Inflamm Bowel Dis 2008;14(12):1701-1706..

Strictures with SBO Neg SBFT and patency capsule

Oksner 47579883 Garrett 68706381

Impacted videocapsule by stricture

Crohn’s: CTE vs surgical results N= 36 pts with CD and surgical correlation Results for CTE: • Presence of stricture = 100% • Presence of fistula = 100% • Abscess = 100%

Vogel et al. Dis Colon Rectum 2007;00:1-9.

CTE PERFORMANCE

Crohn’s: CTE vs SB barium exams Sensitivity % Barium CTE

STUDY

Pts

Bodily et al Radiology 2006

96

80

N/A

Doerfler Abd Img 2003

38

89

(enteroclysis)

Solem GI ENDO 2008

38-41

82

65

*Lee et al Radiology 2009

30

90

88

10/10

3/10

*Detecting Complications

78

Crohn’s: CTE vs SB barium exams Sensitivity % Barium CTE

STUDY

Pts

Bodily et al Radiology 2006

96

80

N/A

Doerfler Abd Img 2003

38

89

(enteroclysis)

Solem GI ENDO 2008

38-41

82

65

*Lee et al Radiology 2009

30

90

88

78

*Detecting Complications

10/10

3/10

*Interobs agreement

81%

54%

Crohn’s: CTE vs SB barium exams Sensitivity % Barium CTE

STUDY

Pts

Bodily et al Radiology 2006

96

80

N/A

Doerfler Abd Img 2003

38

89

(enteroclysis)

Solem GI ENDO 2008

38-41

82

65

30

90

88

Lee et al RSNA 2007

LOW DOSE CTE

78

Sens

(-33-66%) Siddiki et al RSNA 2007

52

82-94

CD: CTE vs MRE vs SBFT # Pts

CTE sens/spec

MRE SBFT sens/spec sens/spec

Siddiki et al. AJR 2009*

33

95/89

90/67

N/A

Lee SS et al. Radiology 2009**

30

90/89

93/95

88/93

*Image quality CTE >> MRE (p> SBFT (p ileum • Distended BWT < 3 mm • BWT if collapsed: – Jejunum – 7mm – Ileum - 5mm

CD: CD: BWT BWT ++ mucosal mucosal enhancement enhancement (bi/trilaminar stratification) (bi/trilaminar stratification) *often asymmetric enhancement/ BWT *Enhancement is best indicator of active dx

Lumen

Active Active CD: CD: Comb Comb sign sign Specific but not sensitive sign of active CD

Lumen

Penetrating Disease * Most common type: Enteroenteric fistulas

Fistula

Lumen

Lumen

Be careful: Fat Halo Sign Seen in pts without and with CD In pts with CD: related to years since diagnosis

Lumen

Thank you

The primary reason to use a neutral oral contrast agent rather than a high density oral contrast agent in patients with Crohns is to identify: A. B. C. D. E.

Bowel wall thickening Mucosal hyperenhancement Abscesses Engorged vasa recta (“comb sign”) Fistulas

The primary reason to use a neutral oral contrast agent rather than a high density oral contrast agent in patients with Crohns is to identify: A. B. C. D. E.

Bowel wall thickening Mucosal hyperenhancement Abscesses Engorged vasa recta (“comb sign”) Fistulas

Which finding is LEAST reliable for Crohn’s Disease? A. B. C. D. E.

Mucosal hyperenhancement Engorged vasa recta (“comb sign”) Fistulas Submucosal fat deposition Asymmetric bowel wall involvement

Which finding is LEAST reliable for Crohn’s Disease? A. B. C. D. E.

Mucosal hyperenhancement Engorged vasa recta (“comb sign”) Fistulas Submucosal fat deposition Asymmetric bowel wall involvement

When evaluating for normal/abnormal bowel enhancement, an ileal bowel loop should be compared to enhancement in the: A. B. C. D. E.

Stomach Duodenum Jejunum Ileum Colon

When evaluating for normal/abnormal bowel enhancement, an ileal bowel loop should be compared to enhancement in the: A. B. C. D. E.

Stomach Duodenum Jejunum Ileum Colon