Imaging in the Evaluation of the Young Patient With Inflammatory Bowel Disease
What the Gastroenterologist Needs to Know
Corresponding Author
Sudha A. Anupindi
Department of Radiology, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
Address correspondence and reprint requests to Sudha A. Anupindi, MD, Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 34 St & Civic Center Blvd, Philadelphia, PA 19104 (e-mail: [email protected]).Search for more papers by this authorAndrew B. Grossman
Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
Search for more papers by this authorKatherine Nimkin
Department of Radiology, Division of Pediatric Imaging, Massachusetts General Hospital, Boston
Search for more papers by this authorPetar Mamula
Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
Search for more papers by this authorMichael S. Gee
Department of Radiology, Division of Pediatric Imaging, Massachusetts General Hospital, Boston
Search for more papers by this authorCorresponding Author
Sudha A. Anupindi
Department of Radiology, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
Address correspondence and reprint requests to Sudha A. Anupindi, MD, Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 34 St & Civic Center Blvd, Philadelphia, PA 19104 (e-mail: [email protected]).Search for more papers by this authorAndrew B. Grossman
Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
Search for more papers by this authorKatherine Nimkin
Department of Radiology, Division of Pediatric Imaging, Massachusetts General Hospital, Boston
Search for more papers by this authorPetar Mamula
Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
Search for more papers by this authorMichael S. Gee
Department of Radiology, Division of Pediatric Imaging, Massachusetts General Hospital, Boston
Search for more papers by this authorThe authors report no conflicts of interest.
ABSTRACT
Imaging plays a pivotal role in the diagnosis and management of children and young adults with inflammatory bowel disease. The clinician is presented with numerous imaging options, and it can be challenging to decide which test is the best option. In this article we review the present imaging techniques available in the evaluation of inflammatory bowel disease, with emphasis on the advantages, disadvantages, and radiation burden of each test. Finally, we highlight a few common clinical scenarios and propose an imaging algorithm to approach these diagnostic challenges.
REFERENCES
- 1Jamieson DH, Shipman PJ, Isreal DM, et al. Comparison of multidetector CT and barium studies of the small bowel: inflammatory bowel disease in children. AJR Am J Roentgenol 2003; 180: 1211–1216.
- 2Soon SY, Ansari A, Sanderson JD. Small-bowel barium follow-through is rarely required in patients with a normal ileoscopy and terminal ileal biopsy and a normal or unremarkable colonoscopy. Scand J Gastroenterol 2004; 39: 1293–1295.
- 3Giles E, Hanci O, McLean A, et al. Optimal assessment of paediatric IBD with MRI and barium follow-through. J Pediatr Gastroenterol Nutr 2012; 54: 758–762.
- 4Stenerson M, Vittinghoff E, Heyman MB, et al. Role of small bowel follow-through in diagnosing inflammation of the terminal ileum in pediatric patients. J Pediatr Gastroenterol Nutr 2010; 51: 433–436.
- 5Batres LA, Maller ES, Ruchelli E, et al. Terminal ileum intubation in pediatric colonoscopy and diagnostic value of conventional small bowel contrast radiography in pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2002; 35: 320–323.
- 6Anupindi SA, Ayyala R, Kelson J, et al. Imaging of inflammatory bowel disease in children. In: LS Medina, CC Blackmore, K Applegate, eds. Evidence-Based Imaging: Improving the Quality of Imaging in Patient Care. New York: Springer; 2011. 571–592.
10.1007/978-1-4419-7777-9_35 Google Scholar
- 7Duigenan S, Gee MS. Imaging of pediatric patients with inflammatory bowel disease. AJR Am J Roentgenol 2012; 199: 907–915.
- 8Huprich JE, Fletcher JG. CT enterography: principles, technique and utility in Crohn's disease. Eur J Radiol 2009; 69: 393–397.
- 9Horsthuis K, Stokkers PC, Stoker J. Detection of inflammatory bowel disease: diagnostic performance of cross-sectional imaging modalities. Abdom Imaging 2008; 33: 407–416.
- 10Johnston JH, Podberesky DJ, Yoshizumi TT, et al. Comparison of radiation dose estimates, image noise, and scan duration in pediatric body imaging for volumetric and helical modes on 320-detector CT and helical mode on 64-detector CT. Pediatr Radiol 2013; 43: 1117–1127.
- 11Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012; 380: 499–505.
- 12Miglioretti DL, Johnson E, Williams A, et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr 2013; 167: 700–707.
- 13McCollough CH, Chen GH, Kalender W, et al. Achieving routine submillisievert CT scanning: report from the summit on management of radiation dose in CT. Radiology 2012; 264: 567–580.
- 14Bender GN, Maglinte DD, Kloppel VR, et al. CT enteroclysis: a superfluous diagnostic procedure or valuable when investigating small-bowel disease? AJR Am J Roentgenol 1999; 172: 373–378.
- 15Herlinger H. A modified technique for the double-contrast small bowel enema. Gastrointest Radiol 1978; 3: 201–207.
- 16Maglinte DD, Kelvin FM, O'Connor K, et al. Current status of small bowel radiography. Abdom Imaging 1996; 21: 247–257.
- 17Maglinte DD, Chernish SM, Kelvin FM, et al. Crohn disease of the small intestine: accuracy and relevance of enteroclysis. Radiology 1992; 184: 541–545.
- 18Dixon PM, Roulston ME, Nolan DJ. The small bowel enema: a ten year review. Clin Radiol 1993; 47: 46–48.
- 19Maglinte DD, Sandrasegaran K, Lappas JC. CT enteroclysis: techniques and applications. Radiol Clin North Am 2007; 45: 289–301.
- 20Ryan ER, Heaslip IS. Magnetic resonance enteroclysis compared with conventional enteroclysis and computed tomography enteroclysis: a critically appraised topic. Abdom Imaging 2008; 33: 34–37.
- 21Minordi LM, Vecchioli A, Mirk P, et al. CT enterography with polyethylene glycol solution vs CT enteroclysis in small bowel disease. Br J Radiol 2011; 84: 112–119.
- 22Gee MS, Nimkin K, Hsu M, et al. Prospective evaluation of MR enterography as the primary imaging modality for pediatric Crohn disease assessment. AJR Am J Roentgenol 2011; 197: 224–231.
- 23Darge K, Anupindi SA, Jaramillo D. MR imaging of the abdomen and pelvis in infants, children, and adolescents. Radiology 2011; 261: 12–29.
- 24Anupindi SA, Darge K. Imaging choices in inflammatory bowel disease. Pediatr Radiol 2009; 39 (suppl 2): S149–S152.
- 25Quencer KB, Nimkin K, Mino-Kenudson M, et al. Detecting active inflammation and fibrosis in pediatric Crohn's disease: prospective evaluation of MR-E and CT-E. Abdom Imaging 2013; 38: 705–713.
- 26Courtier J, Ohliger M, Rhee SJ, et al. Shooting a moving target: use of real-time cine magnetic resonance imaging in assessment of the small bowel. J Pediatr Gastroenterol Nutr 2013; 57: 426–431.
- 27McGee K. The role of a child life specialist in a pediatric radiology department. Pediatr Radiol 2003; 33: 467–474.
- 28MacKenzie JD, Vasanawala SS. Advances in pediatric MR imaging. Magn Reson Imaging Clin N Am 2008; 16: 385–402.v.
- 29Gee MS, Harisinghani MG. MRI in patients with inflammatory bowel disease. J Magn Reson Imaging 2011; 33: 527–534.
- 30Darge K, Anupindi SA, Jaramillo D. MR imaging of the bowel: pediatric applications. Magn Reson Imaging Clin N Am 2008; 16: 467–478.vi.
- 31Essary B, Kim J, Anupindi J, et al. Pelvic MRI in children with Crohn disease and suspected perianal involvement. Pediatr Radiol 2007; 37: 201–208.
- 32Shenoy-Bhangle A, Nimkin K, Goldner D, et al. MRI predictors of treatment response for perianal fistulizing Crohn disease in children and young adults. Pediatr Radiol 2013.
- 33Fidler JL, Guimaraes L, Einstein DM. MR imaging of the small bowel. Radiographics 2009; 29: 1811–1825.
- 34Fidler J. MR imaging of the small bowel. Radiol Clin North Am 2007; 45: 317–331.
- 35Chalian M, Ozturk A, Oliva-Hemker M, et al. MR enterography findings of inflammatory bowel disease in pediatric patients. AJR Am J Roentgenol 2011; 196: W810–W816.
- 36Dillman JR, Smith EA, Khalatbari S, et al. I.v. glucagon use in pediatric MR enterography: effect on image quality, length of examination, and patient tolerance. AJR Am J Roentgenol 2013; 201: 185–189.
- 37Tolan DJ, Greenhalgh R, Zealley IA, et al. MR enterographic manifestations of small bowel Crohn disease. Radiographics 2010; 30: 367–384.
- 38Alison M, Kheniche A, Azoulay R, et al. Ultrasonography of Crohn disease in children. Pediatr Radiol 2007; 37: 1071–1082.
- 39Canani RB, de Horatio LT, Terrin G, et al. Combined use of noninvasive tests is useful in the initial diagnostic approach to a child with suspected inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2006; 42: 9–15.
- 40Maconi G, Sampietro GM, Parente F, et al. Contrast radiology, computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohn's disease: a prospective comparative study. Am J Gastroenterol 2003; 98: 1545–1555.
- 41Maconi G, Toniolini M, Monteleoni M, et al. Transperineal perineal ultrasound versus magnetic resonance imaging in the assessment of perianal Crohn's disease. Inflamm Bowel Dis 2013; 19: 2737–2743.
- 42Sauer CG. Radiation exposure in children with inflammatory bowel disease. Curr Opin Pediatr 2012; 24: 621–626.
- 43Pedersen N, Duricova D, Elkjaer M, et al. Risk of extra-intestinal cancer in inflammatory bowel disease: meta-analysis of population-based cohort studies. Am J Gastroenterol 2010; 105: 1480–1487.
- 44Mason M, Siegel CA. Do inflammatory bowel disease therapies cause cancer? Inflamm Bowel Dis 2013; 19: 1306–1321.
- 45Siegel CA, Maden SM, Persing SM, et al. Risk of lymphoma associated with combination anti-tumor necrosis factor and immunomodulator therapy for the treatment of Crohn's disease: a meta-analysis. Clin Gastroenterol Hepatol 2009; 7: 874–881.
- 46Kotlyar DS, Osterman MT, Diamond RH, et al. A systematic review of factors that contribute to hepatosplenic T-cell lymphoma in patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2011; 9: 36.e1–41.e1.
- 47Einstein AJ. Effects of radiation exposure from cardiac imaging: how good are the data? J Am Coll Cardiol 2012; 59: 553–565.
- 48Fletcher JG, Kofler JM, Coburn JA, et al. Perspective on radiation risk in CT imaging. Abdom Imaging 2013; 38: 22–31.
- 49Fuchs Y, Markowitz J, Weinstein T, et al. Pediatric inflammatory bowel disease and imaging-related radiation: are we increasing the likelihood of malignancy? J Pediatr Gastroenterol Nutr 2011; 52: 280–285.
- 50Huang JS, Tobin A, Harvey L, et al. Diagnostic medical radiation in pediatric patients with inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2011; 53: 502–506.
- 51Cardis E, Vrijheid M, Blettner M, et al. The 15-country collaborative study of cancer risk among radiation workers in the nuclear industry: estimates of radiation-related cancer risks. Radiat Res 2007; 167: 396–416.
- 52Desmond AN, O'Regan K, Curran C, et al. Crohn's disease: factors associated with exposure to high levels of diagnostic radiation. Gut 2008; 57: 1524–1529.
- 53Amis ES Jr, Butler PF, Applegate KE, et al. American College of Radiology white paper on radiation dose in medicine. J Am Coll Radiol 2007; 4: 272–284.
- 54Eisenberg JD, Harvey HB, Moore DA, et al. Falling prey to the sunk cost bias: a potential harm of patient radiation dose histories. Radiology 2012; 263: 626–628.
- 55Durand DJ. A rational approach to the clinical use of cumulative effective dose estimates. AJR Am J Roentgenol 2011; 197: 160–162.
- 56Morgan WF, Bair WJ. Issues in low dose radiation biology: the controversy continues. A perspective. Radiat Res 2013; 179: 501–510.
- 57Dillman JR, Ladino-Torres MF, Adler J, et al. Comparison of MR enterography and histopathology in the evaluation of pediatric Crohn disease. Pediatr Radiol 2011; 41: 1552–1558.
- 58Silverstein J, Grand D, Kawatu D, et al. Feasibility of using MR enterography for the assessment of terminal ileitis and inflammatory activity in children with Crohn disease. J Pediatr Gastroenterol Nutr 2012; 55: 173–177.
- 59Absah I, Bruining DH, Masumoto JM, et al. MR enterography in pediatric inflammatory bowel disease: retrospective assessment of patient tolerance, image quality, and initial performance estimates. AJR Am J Roentgenol 2012; 199: W367–W375.