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Dynamic contrast-enhanced ultrasound of the bowel wall with quantitative assessment of Crohn ’ s disease activity in childhood

View Article: PubMed Central - PubMed

ABSTRACT

Background: Contrast-enhanced ultrasound (CEUS) has become an established non-invasive, patient-friendly imaging technique which improves the characterization of lesions. In addition, dynamic contrast-enhanced ultrasound (DCE-US) provides valuable information concerning perfusion of examined organs. This review addresses current applications of CEUS in children, focused on DCE-US of the bowel wall in patients with Crohn disease, which enables realtime assessment of the bowel wall vascularity with semi-quantitative and quantitative assessment of disease activity and response to medical treatment.

Conclusions: Crohn’s disease is a chronic inflammatory relapsing disease. Frequent imaging re-evaluation is necessary. Therefore, imaging should be as little invasive as possible, children friendly with high diagnostic accuracy. US with wide varieties of techniques, including CEUS/DCE-US, can provide an important contribution for diagnosing and monitoring a disease activity. Even if the use of US contrast agent is off-label in children, it is welcome and widely accepted for intravesical use, and a little less for intravenous use, manly in evaluation of parenchymal lesions. To our knowledge this is the first time that the use of DCE-US in the evaluation of activity of small bowel Crohn disease with quantitative assessment of kinetic parameters is being described in children. Even if the results of the value and accuracy of different quantitative kinetic parameters in published studies in adult population often contradict one another there is a great potential of DCE-US to become a part of the entire sonographic evaluation not only in adults, but also in children. Further control studies should be performed.

No MeSH data available.


Postprocesing results obtained from raw data imported in workstation with dedicated quantification software (Workstation UltraExtend FX with IGR protocol): (A) Time-intensity curve (TIC), and (B) the table of results of the calculated quantitative kinetic parameters from TIC.
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j_raon-2015-0042_fig_003: Postprocesing results obtained from raw data imported in workstation with dedicated quantification software (Workstation UltraExtend FX with IGR protocol): (A) Time-intensity curve (TIC), and (B) the table of results of the calculated quantitative kinetic parameters from TIC.

Mentions: In our case a 13-year-old boy with known Crohn’s disease was admitted to the hospital be-cause of the acute exacerbation of the disease, presented by vomiting, severe abdominal cramps, weight loss and inappetence. He had been diagnosed with isolated small bowel Crohn’s disease two years ago. At the time of the diagnosis remission had been induced by exclusive enteral nutrition and it was well maintained by azathioprine (2.5 mg/kg daily) for 2 years. At the time of the exacerbation, he had elevated laboratory markers (erythrocyte sedimentation rate [ESR] 43, CRP 25) and faecal calprotectin (310 mg/kg, normal value < 50 mg/kg of stool). The estimated PCDAI was 37. The abdominal US showed aperistaltic segments of the small intestine with a thickened wall surrounded by echogenic mesentery and enlarged lymph nodes. The terminal ileum and colon were normal on US. MR enterography confirmed irregular thickened segments of the small bowel wall with entero-enteric fistulas and intense enhancement of the effected bowel wall. Upper endoscopy and ileocolonoscopy showed normal mucosa of the upper gastrointestinal tract, ileum and colon. Anti-TNFa (infliximab) biological treatment was introduced. Control US and control MR enterography showed only a slightly improvement of the inflammation. Laboratory findings were normal, except for the increased calprotectin. Anti-TNFa treatment was continued and the patient was in clinical remission. Three months later he complained of fatigue, inappetence and some weight lost. At that time laboratory markers were normal (normal ESR and CRP), only calprotectin was elevated (495 mg/kg). Estimated PDCAI was 40.The boy refused to perform control MR enterography for the disease activity evaluation because he felt sick after drinking the contrast medium and had nausea after the application of glucagon. Therefore, DCE-US of the bowel wall was suggested to evaluate its inflammatory activity and a written informed consent by him and his parents was obtained (Figures 1 and 2). The boy was very cooperative during the examination. He tolerated it very well, without any side effects compared to previous MR enterography. The quantitative analyses of TIC suggest according to some literature and our own experiences that there is still a quite active inflammation of jejunum: time-to-peak enhancement was short, less than 5 seconds, the intensity of the enhancement was high (Figure 3). Time-to-peak peak intensity (TTP) less than 7 seconds and intense enhancement of the bowel wall are sings for active inflammation of the bowel wall.40 According to the clinical condition and the results of DCE-US, anti-TNFa treatment was optimized: the application interval was shortened from 8 to 4 weeks. Five months later control US and the blood inflammatory parameters were normal, PCDAI was below 10 and calprotectin decreased to 56 mg/kg. The boy is doing clinically well now, shows no fatigue and he is gaining weight and height.To our knowledge, no study evaluating DCE-US of the bowel wall with quantitative assessment of Crohn’s disease activity in children has yet been published. Our case shows the importance of DCE-US as a non-invasive method for children with Crohn’s disease, especially during follow-up of the disease activity. In this case the results of DCE-US combined with clinical signs and elevated calprotectin presented the main indicator, which influenced the therapy regime.Figure 1


Dynamic contrast-enhanced ultrasound of the bowel wall with quantitative assessment of Crohn ’ s disease activity in childhood
Postprocesing results obtained from raw data imported in workstation with dedicated quantification software (Workstation UltraExtend FX with IGR protocol): (A) Time-intensity curve (TIC), and (B) the table of results of the calculated quantitative kinetic parameters from TIC.
© Copyright Policy
Related In: Results  -  Collection

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getmorefigures.php?uid=PMC5120573&req=5

j_raon-2015-0042_fig_003: Postprocesing results obtained from raw data imported in workstation with dedicated quantification software (Workstation UltraExtend FX with IGR protocol): (A) Time-intensity curve (TIC), and (B) the table of results of the calculated quantitative kinetic parameters from TIC.
Mentions: In our case a 13-year-old boy with known Crohn’s disease was admitted to the hospital be-cause of the acute exacerbation of the disease, presented by vomiting, severe abdominal cramps, weight loss and inappetence. He had been diagnosed with isolated small bowel Crohn’s disease two years ago. At the time of the diagnosis remission had been induced by exclusive enteral nutrition and it was well maintained by azathioprine (2.5 mg/kg daily) for 2 years. At the time of the exacerbation, he had elevated laboratory markers (erythrocyte sedimentation rate [ESR] 43, CRP 25) and faecal calprotectin (310 mg/kg, normal value < 50 mg/kg of stool). The estimated PCDAI was 37. The abdominal US showed aperistaltic segments of the small intestine with a thickened wall surrounded by echogenic mesentery and enlarged lymph nodes. The terminal ileum and colon were normal on US. MR enterography confirmed irregular thickened segments of the small bowel wall with entero-enteric fistulas and intense enhancement of the effected bowel wall. Upper endoscopy and ileocolonoscopy showed normal mucosa of the upper gastrointestinal tract, ileum and colon. Anti-TNFa (infliximab) biological treatment was introduced. Control US and control MR enterography showed only a slightly improvement of the inflammation. Laboratory findings were normal, except for the increased calprotectin. Anti-TNFa treatment was continued and the patient was in clinical remission. Three months later he complained of fatigue, inappetence and some weight lost. At that time laboratory markers were normal (normal ESR and CRP), only calprotectin was elevated (495 mg/kg). Estimated PDCAI was 40.The boy refused to perform control MR enterography for the disease activity evaluation because he felt sick after drinking the contrast medium and had nausea after the application of glucagon. Therefore, DCE-US of the bowel wall was suggested to evaluate its inflammatory activity and a written informed consent by him and his parents was obtained (Figures 1 and 2). The boy was very cooperative during the examination. He tolerated it very well, without any side effects compared to previous MR enterography. The quantitative analyses of TIC suggest according to some literature and our own experiences that there is still a quite active inflammation of jejunum: time-to-peak enhancement was short, less than 5 seconds, the intensity of the enhancement was high (Figure 3). Time-to-peak peak intensity (TTP) less than 7 seconds and intense enhancement of the bowel wall are sings for active inflammation of the bowel wall.40 According to the clinical condition and the results of DCE-US, anti-TNFa treatment was optimized: the application interval was shortened from 8 to 4 weeks. Five months later control US and the blood inflammatory parameters were normal, PCDAI was below 10 and calprotectin decreased to 56 mg/kg. The boy is doing clinically well now, shows no fatigue and he is gaining weight and height.To our knowledge, no study evaluating DCE-US of the bowel wall with quantitative assessment of Crohn’s disease activity in children has yet been published. Our case shows the importance of DCE-US as a non-invasive method for children with Crohn’s disease, especially during follow-up of the disease activity. In this case the results of DCE-US combined with clinical signs and elevated calprotectin presented the main indicator, which influenced the therapy regime.Figure 1

View Article: PubMed Central - PubMed

ABSTRACT

Background: Contrast-enhanced ultrasound (CEUS) has become an established non-invasive, patient-friendly imaging technique which improves the characterization of lesions. In addition, dynamic contrast-enhanced ultrasound (DCE-US) provides valuable information concerning perfusion of examined organs. This review addresses current applications of CEUS in children, focused on DCE-US of the bowel wall in patients with Crohn disease, which enables realtime assessment of the bowel wall vascularity with semi-quantitative and quantitative assessment of disease activity and response to medical treatment.

Conclusions: Crohn&rsquo;s disease is a chronic inflammatory relapsing disease. Frequent imaging re-evaluation is necessary. Therefore, imaging should be as little invasive as possible, children friendly with high diagnostic accuracy. US with wide varieties of techniques, including CEUS/DCE-US, can provide an important contribution for diagnosing and monitoring a disease activity. Even if the use of US contrast agent is off-label in children, it is welcome and widely accepted for intravesical use, and a little less for intravenous use, manly in evaluation of parenchymal lesions. To our knowledge this is the first time that the use of DCE-US in the evaluation of activity of small bowel Crohn disease with quantitative assessment of kinetic parameters is being described in children. Even if the results of the value and accuracy of different quantitative kinetic parameters in published studies in adult population often contradict one another there is a great potential of DCE-US to become a part of the entire sonographic evaluation not only in adults, but also in children. Further control studies should be performed.

No MeSH data available.