Ultrasonographic Detection and Assessment of the Severity of Crohn's Disease Recurrence after Ileal Resection
Nadia Pallotta; Maurizio Giovannone; Patrizio Pezzotti; Alessandro Gigliozzi; Fausto Barberani; Daria Piacentino; Naima Abdulkadir Hassan; Giuseppina Vincoli; Mauro Tosoni; Alfredo Covotta; Adriana Marcheggiano; Mauro Di Camillo; Enrico Corazziari
Authors and Disclosures
BMC Gastroenterology. 2010;10(78) © 2010 BioMed Central, Ltd.
Abstract and Introduction
Abstract
Background: Recurrence and severity of Crohn's disease mucosal lesions after "curative" ileal resection is assessed at endoscopy. Intramural lesions can be detected as increased wall thickness at Small Intestine Contrast Ultrasonography (SICUS).
Aims. To assess after ileal resection whether: 1) SICUS detects recurrence of Crohn's disease lesions, 2) the intestinal wall thickness measured at the level of ileo-colonic anastomosis predicts the severity of endoscopic lesions, 3) the extension of intramural lesions of the neo-terminal ileum is useful for grading severity of the recurrence, 4) the combined measures of wall thickness of the ileo-colonic anastomosis and of the extension of intramural lesions at level of the neo-terminal ileum may predict the endoscopic Rutgeerts score
Methods: Fifty eight Crohn's disease patients (M 37, age range 19–75 yrs) were prospectively submitted at 6–12 months intervals after surgery to endoscopy and SICUS for a total of 111 observations.
Results: Six months or more after surgery wall thickness of ileo-colonic anastomosis > 3.5 mm identified 100% of patients with endoscopic lesions (p < 0.0001). ROC curve analysis, combining wall thickness of ileo-colonic anastomosis and the extension of intramural lesions of neo-terminal ileum, discriminated (0.95) patients with, from those without, endoscopic lesions. Performing two multiple logistic regression analyses only wall thickness of ileo-colonic anastomosis and extension of neo-terminal ileum intramural lesions were significantly associated with absence or presence of endoscopic lesions. An ordinal polychotomus logistic model, considering all investigated variables, confirmed that only SICUS variables were associated with endoscopic grading of severity.
Conclusions: In patients submitted to ileal resection for Crohn's disease non-invasive Small Intestine Contrast Ultrasonography 1) by assessing thickness of ileo-colonic anastomosis accurately detects initial, minimal Crohn's disease recurrence, and 2) by assessing both thickness of ileo-colonic anastomosis and extension of intramural lesions of neo-terminal ileum grades the severity of the post-surgical recurrence.
Background
In patients submitted to surgery for ileo-colonic Crohn's disease (CD), recurrence of CD intestinal lesions at the level of ileo-colonic anastomosis and neo-terminal ileum is extremely common. Indeed, it is now firmly established that surgery, even though apparently radical and despite initial clinical remission, does not offer a definitive cure. So far the natural course of initial, minimal postoperative lesions at the level of neo-terminal ileum has been assessed with ileo-colonoscopy and a seminal prospective endoscopic cohort study demonstrated that the severity of postoperative recurrent CD lesions is the best predictor of the clinical outcome.[1] Endoscopy, however, is an invasive procedure that reduces the patient's compliance to regular follow-up controls preventing the detection of early and low grade recurrent lesions.[2,3] Furthermore, the intramural nature of Crohn's disease intestinal lesions cannot be assessed with endoscopy. Small intestine contrast ultrasonography (SICUS) performed after the ingestion of oral contrast makes possible to measure the wall thickness and the luminal diameter of the small bowel.[4,5] In Crohn's disease of the small bowel intramural lesions cause an increased thickness of the intestinal wall that can be accurately detected with the non invasive SICUS.[6,7] In patients submitted to ileal resection, previous oral contrast ultrasound studies,[8,9] assessing the wall thickness of the neo-terminal ileum, showed a low sensitivity in detecting initial, low grade CD recurrence (i.e. Rutgeerts score 1 and 2) that may be limited only to the ileo-colonic anastomosis.[1] Therefore the aims of the present study were to assess in CD patients submitted to ileal resection whether
1. a non invasive technique such as SICUS can be used to detect minimal CD lesions, i.e. low grade recurrence limited to ileo-colonic anastomosis
2. the intestinal wall thickness measured at the level of ileo-colonic anastomosis can predict the severity of endoscopic lesions according to Rutgeerts score
3. the evaluation of the extension of intramural lesions at the level of the neo-terminal ileum may be useful for grading the severity of the recurrence
4. the combined measures of wall thickness of the ileo-colonic anastomosis and the extension of wall thickening of the neo-terminal ileum may predict the endoscopic Rutgeerts score
Nadia Pallotta; Maurizio Giovannone; Patrizio Pezzotti; Alessandro Gigliozzi; Fausto Barberani; Daria Piacentino; Naima Abdulkadir Hassan; Giuseppina Vincoli; Mauro Tosoni; Alfredo Covotta; Adriana Marcheggiano; Mauro Di Camillo; Enrico Corazziari
Authors and Disclosures
BMC Gastroenterology. 2010;10(78) © 2010 BioMed Central, Ltd.
Abstract and Introduction
Abstract
Background: Recurrence and severity of Crohn's disease mucosal lesions after "curative" ileal resection is assessed at endoscopy. Intramural lesions can be detected as increased wall thickness at Small Intestine Contrast Ultrasonography (SICUS).
Aims. To assess after ileal resection whether: 1) SICUS detects recurrence of Crohn's disease lesions, 2) the intestinal wall thickness measured at the level of ileo-colonic anastomosis predicts the severity of endoscopic lesions, 3) the extension of intramural lesions of the neo-terminal ileum is useful for grading severity of the recurrence, 4) the combined measures of wall thickness of the ileo-colonic anastomosis and of the extension of intramural lesions at level of the neo-terminal ileum may predict the endoscopic Rutgeerts score
Methods: Fifty eight Crohn's disease patients (M 37, age range 19–75 yrs) were prospectively submitted at 6–12 months intervals after surgery to endoscopy and SICUS for a total of 111 observations.
Results: Six months or more after surgery wall thickness of ileo-colonic anastomosis > 3.5 mm identified 100% of patients with endoscopic lesions (p < 0.0001). ROC curve analysis, combining wall thickness of ileo-colonic anastomosis and the extension of intramural lesions of neo-terminal ileum, discriminated (0.95) patients with, from those without, endoscopic lesions. Performing two multiple logistic regression analyses only wall thickness of ileo-colonic anastomosis and extension of neo-terminal ileum intramural lesions were significantly associated with absence or presence of endoscopic lesions. An ordinal polychotomus logistic model, considering all investigated variables, confirmed that only SICUS variables were associated with endoscopic grading of severity.
Conclusions: In patients submitted to ileal resection for Crohn's disease non-invasive Small Intestine Contrast Ultrasonography 1) by assessing thickness of ileo-colonic anastomosis accurately detects initial, minimal Crohn's disease recurrence, and 2) by assessing both thickness of ileo-colonic anastomosis and extension of intramural lesions of neo-terminal ileum grades the severity of the post-surgical recurrence.
Background
In patients submitted to surgery for ileo-colonic Crohn's disease (CD), recurrence of CD intestinal lesions at the level of ileo-colonic anastomosis and neo-terminal ileum is extremely common. Indeed, it is now firmly established that surgery, even though apparently radical and despite initial clinical remission, does not offer a definitive cure. So far the natural course of initial, minimal postoperative lesions at the level of neo-terminal ileum has been assessed with ileo-colonoscopy and a seminal prospective endoscopic cohort study demonstrated that the severity of postoperative recurrent CD lesions is the best predictor of the clinical outcome.[1] Endoscopy, however, is an invasive procedure that reduces the patient's compliance to regular follow-up controls preventing the detection of early and low grade recurrent lesions.[2,3] Furthermore, the intramural nature of Crohn's disease intestinal lesions cannot be assessed with endoscopy. Small intestine contrast ultrasonography (SICUS) performed after the ingestion of oral contrast makes possible to measure the wall thickness and the luminal diameter of the small bowel.[4,5] In Crohn's disease of the small bowel intramural lesions cause an increased thickness of the intestinal wall that can be accurately detected with the non invasive SICUS.[6,7] In patients submitted to ileal resection, previous oral contrast ultrasound studies,[8,9] assessing the wall thickness of the neo-terminal ileum, showed a low sensitivity in detecting initial, low grade CD recurrence (i.e. Rutgeerts score 1 and 2) that may be limited only to the ileo-colonic anastomosis.[1] Therefore the aims of the present study were to assess in CD patients submitted to ileal resection whether
1. a non invasive technique such as SICUS can be used to detect minimal CD lesions, i.e. low grade recurrence limited to ileo-colonic anastomosis
2. the intestinal wall thickness measured at the level of ileo-colonic anastomosis can predict the severity of endoscopic lesions according to Rutgeerts score
3. the evaluation of the extension of intramural lesions at the level of the neo-terminal ileum may be useful for grading the severity of the recurrence
4. the combined measures of wall thickness of the ileo-colonic anastomosis and the extension of wall thickening of the neo-terminal ileum may predict the endoscopic Rutgeerts score