经腹肠道超声在克罗恩病术后复发及合并症中的诊断价值

目的评估经腹肠道超声在检测克罗恩病（CD）术后吻合口复发方面的准确性。 方法选取2015年5月至2018年1月北京协和医院就诊的CD术后患者32例，行肠道超声检查，以肠镜和（或）手术病理和（或）临床评分为"金标准"，将患者分为复发组与缓解组。采用χ²检验，评价超声征象在复发组与缓解组中的差异，采用四格表计算肠道超声诊断CD术后吻合口复发的敏感度、特异度、准确性阳性预测值和阴性预测值。 结果复发组患者30例，缓解组患者2例。以吻合口处肠壁厚度>0.3 cm及肠壁结构不清为诊断标准时，超声对CD复发的敏感度、特异度、阳性预测值和阴性预测值分别为97%、100%、100%、67%。确诊29例，超声诊断吻合口及其他部位肠瘘共15例（15/32）的准确性为100%，诊断吻合口狭窄共8例（8/32），准确性为100%。 结论肠道超声在CD术后吻合口临床复发有特征性表现，在CD术后复发的监测和随访上有应用价值。     

Contrast-enhanced ultrasound of the small bowel in Crohn’s disease

Crohn’s disease (CD) is a chronic transmural inflammatory disease of the gastrointestinal tract characterized by episodes of inflammation alternating with periods of remission. Unenhanced grey-scale ultrasound may evaluate the localisation and the length of the affected intestinal segments and may detect transmural complications, including fistulas, abscesses and phlegmons, but it is less accurate to assess the CD activity. Contrast-enhanced ultrasound has become an important imaging modality in patients with CD for the grading of disease activity, the differentiation between small bowel stricture due to inflammation or mural fibrosis, and for the assessment of the response to specific therapy. New dedicated software packages allow the accurate quantification of the enhancement within the small bowel wall after microbubble contrast agent injection to obtain different kinetic semi-quantitative parameters—the percentage of the maximal enhancement, the time-to-the peak enhancement, and the area under the time–intensity curve—which are very useful to differentiate the inflammatory oedema from fibrosis and to differentiate responders from non-responders to the specific therapy among patients with CD.     

Activity of Crohn disease: value of Color-Power-Doppler and contrast-enhanced ultrasonography

Diagnosis and follow-up of Crohn disease (CD) often require invasive instrumental examinations, with a high risk of iatrogenic damage. Ultrasound (US) examination of bowel walls could be the first choice in managing patients with CD. We evaluated the role of tissue color power Doppler (CPD) and B-mode US with intravenous injection of contrast medium in the detection of disease activity. In our series, 52 patients with CD underwent US examination. Each study was completed with tissue CPD and US with intravenous injection of contrast medium (Sono Vue) to evaluate intestinal wall vascularization as an index of disease activity. We then compared our results with those from clinical and laboratory tests and follow-up. Data from US examination with intravenous injection of Sono Vue partly agreed with clinical and laboratory tests and CPD in disease activity evaluation but were most useful in the follow-up. Bowel US examination associated with CPD and in particular US contrast medium injection can be used to detect CD activity and modulate therapy and follow-up.     

Non-invasive diagnosis of Crohn’s disease: All that glitters is not gold

Crohn’s disease (CD) is associated with occurrence of inflammation in the digestive tract. Diagnosing intestinal bowel diseases can be difficult because bowel disease can be tricky as it does not have unique symptoms. Endoscopy and histopathological tests play a crucial role in the diagnosis and management of inflammatory bowel diseases. Various techniques can be used to diagnose CD. Nevertheless, the diagnosis of CD mostly requires having patients in the hospital. During the SARS-CoV-2 pandemic, that might not be very feasible, as minimizing contact is essential, but can an alternative diagnosis technique be enough to provide a definitive diagnosis?     

Intracavitary Contrast-Enhanced Ultrasound in the Management of Post-Surgical Gastrointestinal Fistulas

The goal of this study was to investigate intracavitary contrast-enhanced ultrasound (IC-CEUS) measures in the management of post-surgical gastrointestinal (GI) fistula throughout detection, treatment and follow-up. From June 2010 to August 2016, patients who were administered ultrasound contrast agent (UCA) via a drainage tube for IC-CEUS were enrolled and retrospectively analyzed. They were suspected of having GI anastomotic fistulas or had been found to have fluid collections with ultrasound that were accompanied by abdominal pain or fever after surgical procedures. Forty-two patients met the inclusion criteria and were enrolled into this study. Twenty-two were confirmed to have GI fistulas confirmed by standard references. None were detected by conventional ultrasound. Although IC-CEUS successfully detected GI fistulas in 16 patients, it missed GI fistulas in 6 patients. One patient was misdiagnosed with a GI fistula. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the diagnosis of GI fistulas by IC-CEUS were 72.7% (16/22), 95.0% (19/20), 94.1% (16/17), 76.0% (19/25) and 83.3% (35/42), respectively. Twenty peritoneal fluid collections in 14 patients were related to fistulas by IC-CEUS based on the distribution of ultrasound contrast agents. Additional drainage was performed in 14 fistula-related fluid collections. Eight GI fistulas were judged to be cured after IC-CEUS re-evaluation, and the drainage tubes were removed from these patients. In conclusion, IC-CEUS can greatly improve the ability to diagnose post-surgical GI fistulas and may also play an important role in interventional treatment and follow-up.     

Assessment of the extension and the inflammatory activity in Crohn’s disease: comparison of ultrasound and MRI

Objective  The purpose of this prospective study was twofold: to examine the efficacy of MRI and sonography in the assessment of Crohn’s disease (CD) activity in comparison with clinical scoring and biologic tests and to compare both techniques in the evaluation of extension and transmural complications. Material and methods  Thirty patients with histologically proven Crohn’s disease were prospectively examined the same day first with sonography and after MRI. Sonographic exam included evaluation of bowel wall thickness, vascularity pattern, and perienteric changes. Thirty minutes prior to MRI imaging, patients were given 250 mL of dilute sodium phosphate solution and additional 750 mL of water orally. MRI images evaluation included bowel wall thickening, bowel wall enhancement, and perienteric changes. The gastrointestinal tract was divided into five segments. Findings and extension of the both techniques were verified by means of barium studies, surgery, or/and colonoscopy. The sonographic and MR findings were compared with clinical and laboratory data. Results  About 53 of 119 (45%) bowel segments showed pathological changes in gold standard tests. Sonography was superior to MRI in the localization of affected bowel segments (sensitivity: US 91%; MRI 83%; intertechniques agreement, kappa: 0.905) and in recognizing transmural complications (sensitivity: US 80%; MRI 72%), although significant differences were not found (p > 0.05). A statistically significant correlation between color Doppler flow and MR bowel wall enhancement (segment-by-segment analysis and per patient analysis; p > 0.5), and between perienteric changes in both techniques (p > 0.5) were found. Wall thickness measured on sonography was significantly greater in the group of patients with clinical activity (p = 0.023) or with clinical-biologic activity (p = 0.024). Grades of hyperemia and MR contrast enhancement of patients with clinical–biologic activity was higher than in patients without clinical–biologic activity (p = 0.019; p = 0.023). Conclusion  In summary, both ultrasound and MRI are sensitive to localize the affected bowel segments and to detect transmural complications in patients with Crohn’s disease. A significant correlation between color Doppler flow and bowel wall enhancement on MRI was found. Sonographic wall thickness, color Doppler flow, and bowel wall enhancement on MRI are related with clinical or biologic activity.     

经腹肠道超声对克罗恩病的诊断价值及其表现

目的 探讨经腹肠道超声诊断克罗恩病(CD)的价值。方法 对33例CD患者行经腹肠道超声检查,分析超声图像,并与内镜和(或)消化道造影结果相对照;对肠壁血流进行分级,并检测C反应蛋白(CRP)。结果 CD超声主要表现为受累肠壁不同程度增厚,呈"靶环征"、"三明治征";增厚肠壁回声层次多消失,内膜面呈平板状或"鹅卵石样改变";超声可显示深裂隙状溃疡及较大的黏膜溃疡、并能发现肠管蠕动异常。CD易并发肠管狭窄、炎性包块、肠瘘、穿孔及脓肿;受累肠壁周围出现"爬行脂肪征"。病变类型以小肠-结肠型最多见(16/33,48.48%),其次为小肠型(11/33,33.33%),结肠型占15.15%(5/33),胃-回肠型占3.03%(1/33)。受累肠壁血流分级与CRP存在显著相关(r=0.59,P<0.01),一致性中等(Kappa=0.58,P<0.01)。结论 经腹肠道超声检查在CD的诊断和随访中具有独特优势。     

Sonography of Gastrointestinal Tract Diseases

Sonographic evaluation of the gastrointestinal (GI) tract may be difficult because of overlying intraluminal bowel gas and gas‐related artifacts. However, in the absence of these factors and with the development of high‐resolution scanners and the technical experience of radiologists, sonography can become a powerful tool for GI tract assessment. This pictorial essay focuses on sonographic findings of GI tract lesions compared with endoscopic, computed tomographic, and magnetic resonance imaging findings. Neoplastic and non‐neoplastic diseases and postoperative complications are illustrated, and the distinctive sonographic characteristics of these entities are highlighted.     

超声胃镜在上消化道隆起病变诊断与治疗中的价值

目的 探讨超声胃镜对上消化道隆起性病变的诊断与治疗价值.方法 应用超声胃镜对118例上消化道隆起性病变患者进行检查及引导治疗.结果 118例上消化道隆起病变位于食管38例,其中食管平滑肌瘤23例、食管平滑肌肉瘤2例、食管息肉4例、食管囊肿2例、食管癌3例、食管孤立性静脉瘤1例、食管脂肪瘤1例、食管腔外压迫2例;位于胃80例,其中胃间质瘤26例、胃平滑肌瘤14例、胃脂肪瘤4例、胃底静脉瘤2例、异位胰腺4例、胃壁外压迫26例、未见异常4例,胃壁外压迫病变主要为脾脏（16/26,61.5％）,其次是肝左叶、胆囊、胰腺囊肿、胰腺囊腺癌等.118例中行内镜下手术治疗45例,有3例（6.6％）发生创面边缘少量渗血,无一例发生大出血及穿孔等严重并发症;术后随访38例,创面均已愈合良好,无复发病例.术后病理确诊41例,超声胃镜与手术病理结果符合率为91.1％（41/45）.结论 超声胃镜诊断上消化道黏膜下隆起性病变较为准确,能对病变的性质及起源做出诊断,并对治疗方法的选择提供参考.     

Accuracy of abdominal ultrasound for the diagnosis of small bowel obstruction in the emergency department

BACKGROUND: Emergency physicians frequently encounter patients with acute small bowel obstructions (SBO). Although computed tomography (CT) imaging is the current gold standard in the assessment of patients with suspected SBO in the emergency department, a few studies have examined the use of ultrasound as an alternative imaging technique.METHODS: We evaluated the accuracy of ultrasound performed in the ED by a variety of providers (physicians with various levels of training, physician assistants) compared to CT imaging in 47 patients with suspected SBOs.RESULTS: Our data demonstrated a sensitivity of 93.8% and a specificity of 93.3% when compared to abdominal CT, and a sensitivity of 94.3% and specificity of 95.2% using a composite endpoint of abdominal CT and discharge diagnosis.CONCLUSION: Ultrasound can play an important role in the identification of small bowel obstructions in ED patients.     

Colonic Crohn’s disease: value of magnetic resonance colonography for detection and quantification of disease activity

Conventional colonoscopy combined by histological examination, represents the standard for the evaluation of colorectal pathologies and usually is the first examination for the evaluation of patients with suspected or established diagnosis of Crohn’s disease (CD). However, information provided by colonoscopy is limited to mucosal alterations since the technique is unable to evaluate transmural changes or presence of extraluminal complications such as abscesses or fistula. Technological advances in magnetic resonance (MR) raised expectations on the potential role of this imaging modality for evaluation of the gastrointestinal tract based on the high spatial and tissue resolution as well as lack of ionizing radiation. Available evidence indicates that MR colonography (MRC) can be a useful tool as an alternative or complementary to endoscopy for the detection of activity and assessment of severity in colonic CD. In this article, we review the technical aspects of MRC and the spectrum of findings that provide valuable information for the evaluation of colonic CD. Potential applications and limitations of MRC are also discussed.     

Bowel Ultrasound State of the Art: Grayscale and Doppler Ultrasound,Contrast Enhancement,and Elastography in Crohn Disease

Bowel ultrasound (US) is accurate for assessing bowel inflammation and complications in Crohn disease. Additionally, contrast‐enhanced US provides a quantitative, objective measurement of inflammatory activity in inflammatory bowel disease, and shear wave elastography predicts the stiffness of bowel, an increase of which suggests less response to medical therapy, often necessitating surgery. Overall, bowel US is an excellent, safe, and repeatable choice for routine surveillance and for urgent imaging. We describe an approach to evaluating inflammatory bowel disease and review its features on standard grayscale US with Doppler imaging and show how contrast‐enhanced US and shear wave elastography can distinguish between inflammatory and fibrostenotic bowel.     

肠道超声检查在克罗恩病及其黏膜愈合的随访监测中的应用

克罗恩病（Crohn''s disease，CD）是炎症性肠病的一种，肠道超声检查（intestinal ultrasound，IUS）在CD患者初诊及随访中具有重要作用。相比于胃肠镜、磁共振肠道成像（magnetic resonance enterography，MRE）以及计算机断层扫描肠道成像（Computed tomography enterography，CTE）等检查方式，IUS具有无辐射、价格低廉、患者耐受好、重复性高等优点。实现和维持CD患者的黏膜愈合（Mucosal healing，MH）对维持临床缓解和无手术生存率有重要的临床意义。本文综述了IUS在CD及其MH中的应用现状     

Persistent Enhancement on Contrast-Enhanced Ultrasound Studies of Severe Crohn's Disease: Stuck Bubbles?

A small population of patients with severe Crohn's disease (CD) exhibit atypical lack of intensity decline on intestinal contrast-enhanced ultrasound. From a retrospective CD cohort examined with contrast-enhanced ultrasound, 104 patients were identified. Twenty study patients with severe active disease exhibited high peak enhancement (>23 dB) and minimal decline. From the same cohort, 84 control patients also exhibited high peak enhancement >23dB, but with typical intensity decline. Patient outcomes were assessed. Time–intensity curve analysis revealed a significantly higher (p < 0.0001) area under the curve (44.7 ± 1.5 dB·s), washout time and intensities at 60s and 120s in the study population compared with controls (40.0 ± 1.1 dB·s). Study patients had a worse overall outcome with surgery in 30% versus 10% (p?=?0.027) during follow-up. Heightened enhancement with lack of decline on contrast-enhanced ultrasound suggests microbubbles are stuck within the inflamed bowel wall for an extended period. This observation occurs in patients with severe disease and a bad outcome.     

Gastrointestinal endoscopic ultrasonography

Although conventional endoscopy provides excellent visualization of gastrointestinal mucosa, it provides little information about intramural or nearby extramural lesions. The imaging of intraabdominal structures by conventional transabdominal ultrasound is degraded by ultrasound energy attenuation with distance. The provision of an ultrasound probe on a flexible gastrointestinal endoscope, to form an echoendoscope, provides excellent imaging of the gastrointestinal wall and of adjacent extramural structures. During the last two decades, endoscopic ultrasound, using an echoendoscope, has revolutionized the diagnosis and treatment of gastrointestinal diseases that affect the submucosa, deep bowel wall, and adjacent extramural structures. This article reviews the role of endoscopic ultrasound in the diagnosis and treatment of gastrointestinal disease, including standard and promising new applications, as well as standard and emerging new technology.     

Ileal Crohn’s disease: CEUS determination of activity

Transabdominal ultrasound is currently accepted as a clinical first-line tool in the assessment of Crohn’s disease activity. During recent years, great improvements have been achieved in ultrasound examination with the introduction of high-frequency transducers, ultrasonographic microbubble contrast agents, and dedicated contrast-specific ultrasound software. Therefore, contrast-enhanced ultrasonography (CEUS) is emerging as one of the most important imaging techniques in the diagnosis and follow-up of patients with ileal Crohn’s disease. It is non-invasive and non-ionizing, easily repeatable, well-tolerated by patients and has significant diagnostic accuracy. Moreover, the possibility to monitor response to therapies, describing, and quantifying contrast enhancement behavior by specific software, represents an interesting aspect of its utilization, considering the still open questions about the correct use of immunosuppressive and biological agents. The aim of our review is to provide an updated overview of the role of CEUS in the patients who have an ileal localization of Crohn’s disease, defining its qualitative and quantitative features.     

常规超声检查及超声造影在克罗恩病诊断中的应用价值

目的探讨常规超声检查及超声造影在克罗恩病（CD）诊断中的应用价值。 方法2012年12月至2015年6月于南京大学医学院附属金陵医院超声诊断科行常规超声检查及超声造影的CD患者19例。所有患者均经内镜检查及手术病理结果证实。其中处于炎症活动期12例,缓解期7例。分析其常规超声检查及超声造影声像图特征,并根据时间-强度曲线得出达峰时间（TTP）及达峰强度（PI）。采用Wilcoxon秩和检验比较炎症活动期与缓解期CD患者TTP、PI差异。 结果19例CD患者常规超声检查表现为受累肠管壁不同程度增厚,肠壁分层不清,肠管活动僵硬,肠壁彩色血流信号丰富。超声造影后12例炎症活动期CD患者中5例表现为黏膜下层普遍高增强,7例表现为由管壁内侧（黏膜层）开始往外侧的肠壁全层增强;7例缓解期CD患者中5例表现为管壁外侧往内侧的肠壁全层增强,2例表现为肠壁低或无增强。时间-强度曲线显示炎症活动期CD患者TTP为（8.33±0.92）s,缓解期CD患者TTP为（10.62±1.61）s,炎症活动期CD患者TTP早于缓解期CD患者,且差异有统计学意义（Z=-2.537,P<0.05）;炎症活动期CD患者PI为（27.67±1.61）dB,缓解期CD患者PI为（25.48±1.49）dB,炎症活动期CD患者PI高于缓解期CD患者,且差异有统计学意义（Z=-2.451,P<0.05）。 结论常规超声检查及超声造影有助于CD的诊断,超声造影对CD病变活动性评价更具有特殊应用价值。     

The value of small bowel wall contrast enhancement after sulfur hexafluoride-filled microbubble injection to differentiate inflammatory from fibrotic strictures in patients with Crohn's disease

We analysed the value of contrast-enhanced ultrasound to differentiate inflammatory from fibrotic ileal strictures in patients with Crohn's disease (CD). Twenty-eight patients (17 male and 11 female; mean age ± SD, 48.5 ± 17.17 years) with a biopsy-proven diagnosis of CD were included. In each patient, the terminal ileal loop was scanned by a convex-array probe (2-5 MHz) before and after sulphur hexafluoride-filled microbubble injection. The digital cine-clip registered after microbubble injection during the first-pass dynamic enhancement was quantified in gray-scale levels by a dedicated software through manually drawn regions-of-interest (ROIs) encompassing the anterior bowel wall. Time-intensity curves from patients with inflammatory and fibrotic ileal strictures, fitted according to the theoretical gamma variate curve, were compared. Inflammatory vs. fibrotic ileal strictures differed in the percentage of maximal enhancement (45.86 ± 5.32 vs. 37.33 ± 16.24%; p < 0.05) and area under the enhancement curve (1168.25 ± 437.65 vs. 570.47 ± 323.08; p < 0.05), whereas the difference in time to peak enhancement was found not significant (9.25 ± 4.21 vs. 12.01 ± 7.34 s; p > 0.05). The quantitative analysis of small bowel wall contrast enhancement after microbubble contrast agent injection may differentiate inflammatory from fibrotic ileal strictures in patients with CD.     

Acute severe pancreatitis: contrast-enhanced sonography

Early assessment and differentiation of oedematous acute pancreatitis and necrotizing or severe acute pancreatitis allow distinct therapeutic algorithms. Spiral computed tomography is currently considered the gold standard for staging of acute severe pancreatitis. Conventional transabdominal ultrasound plays only a limited role in the staging of acute pancreatitis. The problem is that with this procedure a detection of pancreatic necrosis is difficult because it cannot assess organ perfusion. Through the use of contrast-enhancers, however, even ultrasound can nowadays examine the vascularization behaviour of the pancreas and liver parenchyma in sufficient detail. The aim of the present update article is to explain the usefulness of contrast-enhanced ultrasound in the detection of parenchymal necrosis in patients with acute severe pancreatitis.     

高频超声在儿童炎症性肠病中的诊断价值

目的 探讨高频超声在儿童炎症性肠病中的诊断价值。方法 对比正常体检儿童及炎症性肠病患儿不同部位的肠壁厚度、层次结构及周围改变,分析高频超声在IBD中的声像图特点并总结诊断要点。结果 正常儿童及炎症性肠病患儿二者不同部位肠壁厚度均存在显著差异(P <0.05),其肠壁层次结构及周围组织之间也有不同表现。结论 利用高频超声检测肠壁厚度及其周围情况可以为IBD的诊断提供有力参考。