Diagnostic imaging and radiation exposure in inflammatory bowel disease

Diagnostic imaging plays a key role in the diagnosis and management of inflammatory bowel disease(IBD). However due to the relapsing nature of IBD, there is growing concern that IBD patients may be exposed to potentially harmful cumulative levels of ionising radiation in their lifetime, increasing malignant potential in a population already at risk. In this review we explore the proportion of IBD patients exposed to high cumulative radiation doses, the risk factors associated with higher radiation exposures, and we compare conventional diagnostic imaging with newer radiation-free imaging techniques used in the evaluation of patients with IBD. While computed tomography(CT) performs well as an imaging modality for IBD, the effective radiation dose is considerably higher than other abdominal imaging modalities. It is increasingly recognised that CT imaging remains responsible for the majority of diagnostic medical radiation to which IBD patients are exposed. Magnetic resonance imaging(MRI) and small intestine contrast enhanced ultrasonography(SICUS) have now emerged as suitable radiation-free alternatives to CT imaging, with comparable diagnostic accuracy. The routine use of MRI and SICUS for the clinical evaluation of patients with known or suspected small bowel Crohn’s disease is to be encouraged wherever possible. More provision is needed for out-of-hours radiation-free imaging modalities to reduce the need for CT.     

Structural brain lesions in inflammatory bowel disease

Central nervous system (CNS) complications or manifestations of inflammatory bowel disease deserve particular attention because symptomatic conditions can require early diagnosis and treatment, whereas unexplained manifestations might be linked with pathogenic mechanisms. This review focuses on both symptomatic and asymptomatic brain lesions detectable on imaging studies, as well as their frequency and potential mechanisms. A direct causal relationship between inflammatory bowel disease (IBD) and asymptomatic structural brain changes has not been demonstrated, but several possible explanations, including vasculitis, thromboembolism and malnutrition, have been proposed. IBD is associated with a tendency for thromboembolisms; therefore, cerebrovascular thromboembolism represents the most frequent and grave CNS complication. Vasculitis, demyelinating conditions and CNS infections are among the other CNS manifestations of the disease. Biological agents also represent a risk factor, particularly for demyelination. Identification of the nature and potential mechanisms of brain lesions detectable on imaging studies would shed further light on the disease process and could improve patient care through early diagnosis and treatment.     

Magnetic resonance imaging of the perineum in pediatric patients with inflammatory bowel disease

Magnetic resonance imaging (MRI) has profoundly changed and improved the investigation of abdominal and pelvic inflammatory bowel disease (IBD) in pediatrics. Using an imaging modality without ionizing radiation is of particular advantage because the pediatric IBD population is young and often requires repeat evaluation. MRI of the pelvis has become the imaging gold standard for detecting and monitoring perianal disease while bowel-directed imaging techniques (eg, enterography, enteroclysis and colonography) can accurately evaluate bowel inflammation in IBD. With recent technological innovations leading to faster and higher resolution, the role of MRI in IBD will likely continue to expand. The present article focuses on MRI of the perineum in pediatric IBD.     

Evaluation of the small bowel in inflammatory bowel disease

Crohn’s disease is a chronic inflammatory bowel disease (IBD) that can affect the entire GI tract, and adequate visualization of the small bowel is imperative for both diagnosis and management. Magnetic resonance and computed tomography enterography have gradually replaced barium-based studies. Magnetic resonance enterography has the distinct advantage of avoiding ionizing radiation to which many patients with IBD are overexposed. Endoscopy-based techniques, including capsule endoscopy and device-assisted enteroscopy, allow direct visualization of the small bowel mucosa. Deep enteroscopy has the additional benefit of allowing sampling of the mucosa for histological analysis. Small intestine contrast ultrasound is rapidly gaining credence as an excellent, radiation-free imaging technique, but is not available in all countries. Other imaging modalities, such as positron emission tomography and leucocyte scintigraphy, continue to be studied and may have a role in specific circumstances. This review summarizes the evidence for the various techniques for evaluating the small bowel in IBD.     

Inflammatory bowel disease in the Hubei Province of China

AIM: To analyze clinical features and response to treatment in inflammatory bowel disease (IBD) patients from the Hubei Province of China.METHODS: Clinical data was collected retrospectively from 74 patients with IBD [66 with ulcerative colitis (UC) and 8 with Crohn’s disease (CD)] admitted to The Second Hospital, Hubei Medical University from 1986 to 1995.RESULTS: The most common symptoms in IBD patients were abdominal pain, diarrhea, blood and mucus in stool, and constipation. Extraintestinal manifestations of IBD were not common. In these patients, inflammation was predominantly located in the sigmoid and left colon in UC cases, and in the ileum and colon in CD cases. Treatment with sulphasalazine and corticosteroids was effective in 95% of UC cases; However, about 42% of UC patients showed disease recurrence during the follow-up period of 1.11 years. Five out of eight CD patients had part of their intestine removed, whereas three were treated with anti-tuberculosis drugs or the antibiotic metronidazole. Out of four patients we followed up for 1-8 years, one died of severe complications after surgery, two experienced recurrence while in treatment with drugs, and one remained in remission under sulphasalazine treatment after surgery.CONCLUSION: Five percent of the patients reported a family history of IBD. About 34% of the patients were smokers and 32% of the patients were alcoholic. Epidemiological studies are urgently needed in the Hubei Province of China to assess the role that genetics and environmental factors play in the pathogenesis of inflammatory bowel diseases.     

Multipotent role of platelets in inflammatory bowel diseases:A clinical approach

There is evidence that inflammatory bowel diseases(IBD)combine both inflammation and coagulation in their pathogenesis and clinical manifestations.Although platelets(PLT)are well known for their role in hemo stasis,there are a rising number of studies supporting their considerable role as inflammatory amplifiers in chronic inflammatory conditions.IBD are associated with several alterations of PLT,including number shape,and function,and these abnormalities are main ly attributed to the highly activated state of circulating PLT in IBD patients.When PLT activate,they increase in size,release a great variety of bio-active inflamma tory and procoagulant molecules/particles,and express a variety of inflammatory receptors.These inflamma tory products may represent a part of the missing link between coagulation and inflammation,and can be considered as possible IBD pathogenesis instigators.In clinical practice,thrombocytosis is associated both with disease activity and iron deficiency anemia.Controlling inflammation and iron replacement in anemic patient usually leads to a normalization of PLT count.The aim of this review is to update the role of PLT in IBD and present recent data revealing the possible therapeutic implications of anti-PLT agents in future IBD remedies.     

Fecal microbial transplant for the treatment of pediatric inflammatory bowel disease

The role of fecal microbial transplant(FMT) in the treatment of pediatric gastrointestinal disease has become increasingly popular among pediatric practitioners, patients, and parents. The success of FMT for the treatment of recurrent Clostridium difficile infection(RCDI) has bolstered interest in its potential application to other disease states, such as inflammatory bowel disease(IBD). FMT has particular interest in pediatrics, given the concerns of patients and parents about rates of adverse events with existing therapeutic options, and the greater cumulative medication burden associated with childhoodonset disease. Published literature on the use of FMT in pediatrics is sparse. Only 45 pediatric patients treated for RCDI have been reported, and only 27 pediatric patients with pediatric IBD. The pediatric microbiome may uniquely respond to microbial-based therapies. This review will provide a comprehensive overview of fecal microbial transplant and its potential role in the treatment of pediatric inflammatory bowel disease. We will discuss the microbiome in pediatric inflammatory bowel disease, existing adult and pediatric literature on the use of FMT in IBD treatment, and pediatric FMT trials that are currently recruiting patients. This review will also discuss features of the microbiome that may be associated with host response in fecal transplant, and potential challenges and opportunities for the future of FMT in pediatric IBD treatment.     

Update on nutritional status,body composition and growth in paediatric inflammatory bowel disease

Growth and nutritional status are important issues in paediatric inflammatory bowel disease(IBD).While linear growth is easy to assess,nutritional status is more complicated,with reports often compromised by the use of simple measures,such as weight and the body mass index,to assess nutritional status rather than more appropriate and sophisticated techniques to measure body composition.This review is an update on what is currently known about nutritional status as determined by body composition in paediatric IBD.Further,this review will focus on the impact of biologics on growth in paediatric IBD.Significant lean mass deficits have been reported in children with IBD compared with controls,and there is evidence these deficits persist over time.Furthermore,data imply that gender differences exist in body composition,both at diagnosis and in response to treatment.With respect to growth improvements following treatment with biologics,there are conflicting data.While some studies report enhancement of growth,others do not.The relationship between disease severity,impaired growth and the requirement for biologics needs to be considered when interpreting these data.However,key features associated with improvements in growth appear to be successful clinical response to treatment,patients in early stages of puberty,and the presence of growth failure at the onset of treatment.     

Technology Insight: new techniques for imaging the gut in patients with IBD

Advances in techniques for imaging the gut continue to drive the rapid development of modalities for diagnosing and assessing the activity of IBD. Abdominal ultrasound and magnetic resonance enterography have shown great potential for the diagnosis of IBD and assessment of its distribution, with the benefit of avoiding radiation exposure and serving as a safe option for pregnant patients. CT enterography or CT enteroclysis, with neutral or negative contrast, seems to be a sensitive and specific modality for detecting disease in the small bowel. The role of CT or magnetic resonance colonography in patients with IBD remains uncertain and these modalities are now best reserved for patients who decline or cannot undergo standard endoscopic evaluations. Capsule endoscopy might be the most sensitive modality for the detection of mucosal small bowel disease, but its specificity remains in question. Double-balloon endoscopy is an exciting new tool that has the distinct advantage of enabling biopsy or treatment of lesions detected during the procedure. All these techniques are at the forefront of the rapidly evolving field of imaging the gut in patients with IBD.     

Oral pathology in inflammatory bowel disease

The incidence of inflammatory bowel diseases(IBD)-Crohn's disease(CD) and ulcerative colitis(UC)- has been increasing on a global scale, and progressively, more gastroenterologists will be included in the diagnosis and treatment of IBD. Although IBD primarily affects the intestinal tract, extraintestinal manifestations of the disease are often apparent, including in the oral cavity, especially in CD. Specific oral manifestations in patients with CD are as follows: indurate mucosal tags, cobblestoning and mucogingivitis, deep linear ulcerations and lip swelling with vertical fissures. The most common non-specific manifestations, such as aphthous stomatitis and angular cheilitis, occur in both diseases, while pyostomatitis vegetans is more pronounced in patients with UC. Non-specific lesions in the oral cavity can also be the result of malnutrition and drugs. Malnutrition, followed by anemia and mineral and vitamin deficiency, affects the oral cavity and teeth. Furthermore, all of the drug classes that are applied to the treatment of inflammatory bowel diseases can lead to alterations in the oral cavity due to the direct toxic effects of the drugs on oral tissues, as well as indirect immunosuppressive effects with a risk of developing opportunistic infections or bone marrow suppression. There is a higher occurrence of malignant diseases in patients with IBD, which is related to the disease itself and to the IBD-related therapy with a possible oral pathology. Treatment of oral lesions includes treatment of the alterations in the oral cavity according to the etiology together with treatment of the primary intestinal disease, which requires adequate knowledge and a strong cooperation between gastroenterologists and specialists in oral medicine.     

Pulmonary manifestations of inflammatory bowel disease

Extraintestinal manifestations of inflammatory bowel disease(IBD) are a systemic illness that may affect up to half of all patients. Among the extraintestinal manifestations of IBD, those involving the lungs are relatively rare and often overlooked. However, there is a wide array of such manifestations, spanning from airway disease to lung parenchymal disease, thromboembolic disease, pleural disease, enteric-pulmonary fistulas, pulmonary function test abnormalities, and adverse drug reactions. The spectrum of IBD manifestations in the chest is broad, and the manifestations may mimic other diseases. Although infrequent, physicians dealing with IBD must be aware of these conditions, which are sometimes life-threatening, to avoid further health impairment of the patients and to alleviate their symptoms by prompt recognition and treatment. Knowledge of these manifestations in conjunction with pertinent clinical data is essential for establishing the correct diagnosis and treatment. The treatment of IBD-related respiratory disorders depends on the specific pattern of involvement, and in most patients, steroids are required in the initial management. Corticosteroids, both systemic and aerosolized, are the mainstay therapeutic approach, while antibiotics must also be administered inthe case of infectious and suppurative processes, whose sequelae sometimes require surgical intervention.     

Pulmonary abnormalities in inflammatory bowel disease

Extraintestinal manifestations of inflammatory bowel disease (IBD) is a common clinical problem affecting up to half of all IBD patients; pulmonary disease, however, ranks among less common extraintestinal manifestations of IBD. Pulmonary disease in patients with IBD is most frequently drug induced due to treatment with sulfasalazine or mesalamine leading to eosinophilic pneumonia and fibrosing alveolitis or due to treatment with methotrexate leading to pneumonitis. Recently, various opportunistic infections have been shown to be a further important cause of pulmonary abnormalities in those IBD patients who are treated with immunosuppressants such as anti TNF- monoclonal antibodies, methotrexate, azathioprine or calcineurin antagonists. In not drug related pulmonary disease a wide spectrum of disease entities ranging from small and large airway dysfunction to obstructive and interstitial lung disorders exist. Patients with lung disorders and inflammatory bowel disease should be evaluated for drug-induced lung disease and opportunistic infections prior to considering pulmonary disease as an extraintestinal manifestation of inflammatory bowel disease.     

New endoscopic imaging techniques in surveillance of inflammatory bowel disease

Endoscopy plays a crucial role in the management of inflammatory bowel disease(IBD). Advancesimaging techniques allow visualization of mucosal details, tissue characteristics and cellular alteration. In particular chromoendoscopy, magnification endoscopy, confocal laser endomicroscopy and endocytoscopy seem to have the possibility to radically modify the approach to surveillance and decision making. Dyebased chromoendoscopy(DBC) and magnification chromoendoscopy improve detection of dysplasia, and evaluation of inflammatory activity and extension of ulcerative colitis and are thus considered the standard of care. Dye-less chromoendoscopy could probably replace conventional DBC for surveillance. Narrow band imaging and i-scan have shown to improve activity and extent assessment in comparison to white-light endoscopy. Confocal laser endomicroscopy(CLE) can detect more dysplastic lesions in surveillance colonoscopy and predict neoplastic and inflammatory changes with high accuracy compared to histology. This technology is best used in conjunction with chromoendoscopy, narrow-band imaging, or autofluorescence because of its minute scanning area. This combination is useful for appropriate tissue classification of mucosal lesions already detected by standard or optically enhanced endoscopy. The best combination for IBD surveillance appear to be chromoendoscopy for identification of areas of suspicion, with further examination with CLE to detect intraepithelial neoplasia. However cost, availability, and experience are still an issue.     

Evolving role of endoscopy in inflammatory bowel disease: Going beyond diagnosis

Inflammatory bowel disease, encompassing Crohn’s disease (CD) and ulcerative colitis, are chronic immune-mediated inflammatory bowel diseases (IBD) that primarily affect the gastrointestinal tract with periods of activity and remission. Large body of evidence exist to strengthen the prognostic role of endoscopic evaluation for both disease activity and severity and it remains the gold standard for the assessment of mucosal healing. Mucosal healing has been associated with improved clinical outcomes with prolonged remission, decreased hospitalization, IBD-related surgeries and colorectal cancer risk. Therefore, endoscopic objectives in IBD have been incorporated as part of standard care. With the known increased risk of colorectal cancer in IBD, although prevention strategies continue to develop, regular surveillance for early detection of neoplasia continue to be paramount in IBD patients’ care. It is thanks to evolving technology and visualization techniques that surveillance strategies are continuously advancing. Therapeutic endoscopic options in IBD have also been expanding, from surgery sparing therapies such as balloon dilation of fibrostenotic strictures in CD to endoscopic mucosal resection of neoplastic lesions. In this review article, we discuss the current evidence on the use of endoscopy as part of standard of care of IBD, its role in surveillance of neoplasia, and the role of interventional endoscopic therapies.     

Liver abnormalities in bowel diseases

Liver abnormalities are often seen in bowel diseases. Whether these represent aspects of two separate diseases, or if one is causing the other, is not always easy to decide. Extraintestinal manifestations of inflammatory bowel disease (IBD) or coeliac disease are frequently observed. Of these extraintestinal manifestations, hepatic disorders are among the most common. Primary sclerosing cholangitis (PSC) and primary biliary cirrhosis are the most frequent hepatic disorders in IBD and coeliac disease, respectively. Genetic studies have lately elucidated the associations between IBD and PSC, but there is still a long way until we have complete understanding of the molecular aetiology and pathophysiology of these conditions. There is no curative treatment available for PSC, besides liver transplantation. Steatosis and cholelithiasis are also common in IBD, as are signs of hepatic injury due to IBD treatment. Less common liver abnormalities include liver abscesses, hepatic thromboembolic events, granulomatous liver disease and hepatic amyloidosis.     

Diagnosing inflammatory bowel disease and differentiating it from potential mimics

The initial diagnosis of inflammatory bowel disease (IBD) requires multiple diagnostic modalities; however, endoscopic evaluation as a diagnostic test is considered the gold standard. Endoscopic evaluation includes colonoscopy with ileoscopy, esophagogastroduodenoscopy, enteroscopy, and capsule endoscopy. IBD encompasses Crohn’s disease, ulcerative colitis, and IBD unclassified. Colonoscopy with ileoscopy along with biopsy collection is essential in most IBD cases for diagnosis and to rule out alternative findings that may mimic IBD including ischemia, diverticulitis, segmental colitis associated with diverticulosis, neoplasia, radiation enteritis, and drug-induced colitis. Esophagogastroduodenoscopy, enteroscopy, and capsule endoscopy are used in the initial workup of specific groups of patients with IBD. The role of endoluminal diagnostic studies in the initial diagnosis of IBD is discussed in detail in this article.     

Capsule endoscopy in Crohn’s disease: Are we seeing any better?

Crohn’s disease (CD) is a complex, immune-mediated disorder that often requires a multi-modality approach for optimal diagnosis and management. While traditional methods include ileocolonoscopy and radiologic modalities, increasingly, capsule endoscopy (CE) has been incorporated into the algorithm for both the diagnosis and monitoring of CD. Multiple studies have examined the utility of this emerging technology in the management of CD, and have compared it to other available modalities. CE offers a noninvasive approach to evaluate areas of the small bowel that are difficult to reach with traditional endoscopy. Furthermore, CE maybe favored in specific sub segments of patients with inflammatory bowel disease (IBD), such as those with IBD unclassified (IBD-U), pediatric patients and patients with CD who have previously undergone surgery.     

From the surface to the single cell: Novel endoscopic approaches in inflammatory bowel disease

Inflammatory bowel diseases(IBD) comprise the two major entities Crohn's disease and ulcerative colitis and endoscopic imaging of the gastrointestinal tract has always been an integral and central part in the management of IBD patients. Within the recent years,mucosal healing emerged as a key treatment goal in IBD that substantially decides about the clinical outcome of IBD patients,thereby demanding for a precise,timely and detailed endoscopic assessment of the mucosal inflammation associated with IBD. Further,molecular imaging has tremendously expanded the clinical utility and applications of modern endoscopy,now encompassing not only diagnosis,surveillance,and treatment but also the prediction of individual therapy response. Within this review we describe novel endoscopic approaches and advanced endoscopic imaging methods for the diagnosis,treatment and surveillance of IBD patients. We begin by providing an overview over novel and advanced imaging techniques such as magnification endoscopy and dye-based and dye-less chromoendoscopy,endomicroscopy and endocytoscopy. We then describe how these techniques can be utilized for the precise and ultrastructural assessment of mucosal inflammation and dysplasia development associated with IBD and outline how they have enabled the endoscopist to gain insight onto the cellular level in real-time. Finally,we provide an outlook on how molecular imaging has rapidly evolved in the recent past and can be used to make individual predictions about the therapeutic response towards biological treatment.     

Utility of faecal calprotectin analysis in adult inflammatory bowel disease

The inflammatory bowel diseases (IBD), Crohn’s disease and ulcerative colitis, are chronic relapsing, remitting disorders. Diagnosis, along with assessment of disease activity and prognosis present challenges to managing clinicians. Faecal biomarkers, such as faecal calprotectin, are a non-invasive method which can be used to aid these decisions. Calprotectin is a calcium and zinc binding protein found in the cytosol of human neutrophils and macrophages. It is released extracellularly in times of cell stress or damage and can be detected within faeces and thus can be used as a sensitive marker of intestinal inflammation. Faecal calprotectin has been shown to be useful in the diagnosis of IBD, correlates with mucosal disease activity and can help to predict response to treatment or relapse. With growing evidence supporting its use, over the last decade this faecal biomarker has significantly changed the way IBD is managed.     

炎症性肠病眼部表现的研究进展

炎症性肠病(inflammatory bowel disease,IBD)是一种胃肠道的慢性非特异性炎性病症,近年来,我国的发病率逐渐升高,已成为消化科的主要疾病之一.IBD的肠外表现复杂多样,涉及多个系统.眼部表现作为其中的一个类型较少见,可严重影响患者的生活质量,由于发病率低、缺乏特异性表现,在临床工作中常被忽略....