Gastrointestinal ImagingFree Access

Invited Commentary on “Small Bowel Crohn Disease at CT and MR Enterography,” with Response from Dr Guglielmo et al

Published Online:https://doi.org/10.1148/rg.2020190213

The prevalence of Crohn disease in developed Western countries has increased over the past decades. Currently, approximately 800 000 patients in the United States and 1 million patients in Europe have been diagnosed with Crohn disease. The incidence of the disease is also increasing in developing countries in Eastern Europe, Asia, South America, and Africa. While the disease cannot be cured, several treatments exist that are able to modify the disease and enable long-term remission. However, owing to complications, surgery might be the only option for some patients. Therefore, it is important to identify and monitor the extent of activity and involvement of the disease as well as the presence of complications noninvasively (1,2). Moreover, monitoring disease progression as well as evaluating the response to medical treatment needs to be achieved noninvasively.

Cross-sectional imaging of the small bowel in patients with suspected Crohn disease using CT enterography or MR enterography has become the standard to identify the extent, activity, and involvement of the disease, as well as its complications (1,2). Therefore, several subspecialty societies, including the Society of Abdominal Radiology, the American Gastroenterological Association, and the Society of Pediatric Radiology, have established recommendations for interpreting and reporting imaging findings in patients with Crohn disease and emphasize the importance of standardized nomenclature. This consensus statement was recently published (3,4).

In the article by Guglielmo et al (5) in this issue of RadioGraphics, the authors provide examples that illustrate the recommendations of this consensus statement. The authors outline how the standard nomenclature should be used in specific clinical settings and how imaging findings should be reported. Moreover, they provide guidelines for how these examinations should be interpreted. This is a major additional benefit for the reader, as the original consensus statement had limited space for illustrations. Therefore, the authors provide the reader with an extended image database that will help the reporting radiologist reference the findings. The recommended standardized nomenclature presented here can be used to generate radiologic report dictations. These standardized reports will help guide medical and surgical management in patients with small bowel Crohn disease.

The major strength of this article is that it provides a practice guideline for the practicing abdominal radiologist. It provides detailed descriptions on how to interpret and report bowel imaging findings, signs of penetrating Crohn disease, and mesenteric imaging findings. For each finding, example images are provided and standardized nomenclature that can be used to report them is recommended. The individual radiologist or radiology department can use this to generate a template for structured reports. In addition, the authors recommend how to report impression statements for inflammation, strictures, penetrating Crohn disease, perianal Crohn disease, and other complications. They also provide terms that should not be used in radiology reports and recommend phrases that should replace these terms. This is also an important aspect of this article, as it emphasizes the standardization of the radiology report language.

A weakness of this article is that it does not provide guidelines or recommendations on how to best perform MR enterography or CT enterography. As a good radiology report can only be generated if the images obtained are of good quality, it is mandatory to provide guidelines on how these images should be obtained. As this is likely beyond the scope of this article, the authors could have provided references on this topic. There are several articles that provide such recommendations (69). The reader needs recommendations for imaging parameters, including type of sequence, contrast agent administration, and timing. Moreover, instructions are needed on bowel distention, patient preparation, and other guidelines that help to generate the best images possible. The reader also needs to know how to evaluate the accuracy of the technique as well as image quality.

The article by Guglielmo et al (5) in this issue of RadioGraphics is an excellent extension of the consensus recommendations for evaluation, interpretation, and utilization of cross-sectional imaging enterography in patients with small bowel Crohn disease (3). Radiologists should be aware of these findings and their importance as they interpret and report CT and MR enterography examinations to identify the extent, activity, and involvement of the disease, as well as its complications.

Disclosures of Conflicts of Interest.—J.T.H.Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: institutional grants from Siemens Heathineers, Guerbet, Bayer Healthcare, and Bracco Imaging Spa. Other activities: disclosed no relevant relationships.

References

  • 1. Amzallag-Bellenger E, Oudjit A, Ruiz A, Cadiot G, Soyer PA, Hoeffel CC. Effectiveness of MR enterography for the assessment of small-bowel diseases beyond Crohn disease. RadioGraphics 2012;32(5):1423–1444.
  • 2. Kaushal P, Somwaru AS, Charabaty A, Levy AD. MR enterography of inflammatory bowel disease with endoscopic correlation. RadioGraphics 2017;37(1):116–131.
  • 3. Bruining DH, Zimmermann EM, Loftus EV Jr, et al. Consensus Recommendations for Evaluation, Interpretation, and Utilization of Computed Tomography and Magnetic Resonance Enterography in Patients With Small Bowel Crohn’s Disease. Radiology 2018;286(3):776–799.
  • 4. Bruining DH, Zimmermann EM, Loftus EV Jr, et al. Consensus recommendations for evaluation, interpretation, and utilization of computed tomography and magnetic resonance enterography in patients with small bowel Crohn’s disease. Gastroenterology 2018;154(4):1172–1194.
  • 5. Guglielmo FF, Anupindi SA, Fletcher JG, et al. Small bowel Crohn disease at CT enterography and MR enterography: imaging atlas and glossary. RadioGraphics 2020;40(2):354–375.
  • 6. Baker ME, Hara AK, Platt JF, Maglinte DD, Fletcher JG. CT enterography for Crohn’s disease: optimal technique and imaging issues. Abdom Imaging 2015;40(5):938–952.
  • 7. Grand DJ, Guglielmo FF, Al-Hawary MM. MR enterography in Crohn’s disease: current consensus on optimal imaging technique and future advances from the SAR Crohn’s disease-focused panel. Abdom Imaging 2015;40(5):953–964.
  • 8. American College of Radiology. ACR-SAR-SPR practice parameter for the performance of CT enterography. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CT-Entero.pdf. Published 2015. Accessed December 5, 2019.
  • 9. Elsayes KM, Al-Hawary MM, Jagdish J, Ganesh HS, Platt JF. CT enterography: principles, trends, and interpretation of findings. RadioGraphics 2010;30(7):1955–1970.

References

  • 1. Guglielmo FF, Anupindi SA, Fletcher JG, et al. Small Bowel Crohn Disease at CT and MR Enterography: Imaging Atlas and Glossary of Terms. Radiographics 2020;40(2):354–375.
  • 2. Bruining DH, Zimmermann EM, Loftus Jr EV, et al. Consensus Recommendations for Evaluation, Interpretation, and Utilization of Computed Tomography and Magnetic Resonance Enterography in Patients With Small Bowel Crohn’s Disease. Radiology 2018;286(3):776–799.
  • 3. Bruining DH, Zimmermann EM, Loftus Jr EV, et al. Consensus recommendations for evaluation, interpretation, and utilization of computed tomography and magnetic resonance enterography in patients with small bowel Crohn’s disease. Gastroenterology 2018;154(4):1172–1194.
  • 4. Grand DJ, Guglielmo FF, Al-Hawary MM. MR enterography in Crohn’s disease: current consensus on optimal imaging technique and future advances from the SAR Crohn’s disease-focused panel. Abdom Imaging 2015;40(5):953–964.
  • 5. Baker ME, Hara AK, Platt JF, Maglinte DD, Fletcher JG. CT enterography for Crohn’s disease: optimal technique and imaging issues. Abdom Imaging 2015;40(5):938–952.
  • 6. Guglielmo FF, Roth CG, Mitchell DG. MR and CT Imaging Techniques of the Bowel. In: Cross-Sectional Imaging in Crohn’s Disease: Springer, 2019; 49–75.
  • 7. Wnorowski AM, Guglielmo FF, Mitchell DG. How to perform and interpret cine MR enterography. Journal of Magnetic Resonance Imaging 2015;42(5):1180–1189.
  • 8. Taylor S, Avni F, Cronin C, et al. The first joint ESGAR/ESPR consensus statement on the technical performance of cross-sectional small bowel and colonic imaging. Eur Radiol 2017;27(6):2570–2582.

References

1. Amzallag-Bellenger E, Oudjit A, Ruiz A, Cadiot G, Soyer PA, Hoeffel CC. Effectiveness of MR enterography for the assessment of small-bowel diseases beyond Crohn disease. RadioGraphics 2012;32(5):14231444. LinkGoogle Scholar
2. Kaushal P, Somwaru AS, Charabaty A, Levy AD. MR enterography of inflammatory bowel disease with endoscopic correlation. RadioGraphics 2017;37(1):116131. LinkGoogle Scholar
3. Bruining DH, Zimmermann EM, Loftus EV Jr, et al. Consensus Recommendations for Evaluation, Interpretation, and Utilization of Computed Tomography and Magnetic Resonance Enterography in Patients With Small Bowel Crohn’s Disease. Radiology 2018;286(3):776799. LinkGoogle Scholar
4. Bruining DH, Zimmermann EM, Loftus EV Jr, et al. Consensus recommendations for evaluation, interpretation, and utilization of computed tomography and magnetic resonance enterography in patients with small bowel Crohn’s disease. Gastroenterology 2018;154(4):11721194. Crossref MedlineGoogle Scholar
5. Guglielmo FF, Anupindi SA, Fletcher JG, et al. Small bowel Crohn disease at CT enterography and MR enterography: imaging atlas and glossary. RadioGraphics 2020;40(2):354375. LinkGoogle Scholar
6. Baker ME, Hara AK, Platt JF, Maglinte DD, Fletcher JG. CT enterography for Crohn’s disease: optimal technique and imaging issues. Abdom Imaging 2015;40(5):938952. Crossref MedlineGoogle Scholar
7. Grand DJ, Guglielmo FF, Al-Hawary MM. MR enterography in Crohn’s disease: current consensus on optimal imaging technique and future advances from the SAR Crohn’s disease-focused panel. Abdom Imaging 2015;40(5):953964. Crossref MedlineGoogle Scholar
8. American College of Radiology. ACR-SAR-SPR practice parameter for the performance of CT enterography. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CT-Entero.pdf. Published 2015. Accessed December 5, 2019. Google Scholar
9. Elsayes KM, Al-Hawary MM, Jagdish J, Ganesh HS, Platt JF. CT enterography: principles, trends, and interpretation of findings. RadioGraphics 2010;30(7):19551970. LinkGoogle Scholar


    Dr Guglielmo et al respond:

    We thank Dr Heverhagen for his insightful comments about our article, “Small Bowel Crohn Disease at CT and MR Enterography: Imaging Atlas and Glossary of Terms” (1). The purpose of this article, authored by 21 members of the Society of Abdominal Radiology Crohn’s Disease–Focused Panel, was to illustrate many of the CT enterography and MR enterography imaging findings and the recommended standardized radiology report impression statements to use when reporting these examinations in patients with small bowel Crohn disease, based on the consensus recommendations provided in a special report published jointly in the journals Radiology and Gastroenterology in 2018 (2, 3). We also included additional interpretation guidelines for reporting these examinations. The goal of the original consensus recommendations article and this subsequent imaging atlas and glossary of terms article was to create, and then to further illustrate, the agreed-on standardized nomenclature to use when reporting CT enterography and MR enterography examinations for patients with small bowel Crohn disease to help guide medical and surgical management.

    We agree with Dr Heverhagen that providing high-quality radiology reports begins with interpreting high-quality CT enterography and MR enterography images, which requires optimal imaging technique. However, providing an acceptable discussion about the proper technique for performing CT enterography and MR enterography was beyond the scope and objective of this article. Also, a number of prior publications have provided in-depth reviews of this topic, including several authored by Society of Abdominal Radiology Crohn’s Disease–Focused Panel members, all of which are included in the reference section of this article for the reader (48). Finally, members of the Society of Abdominal Radiology Crohn’s Disease–Focused Panel have completed a survey of CT enterography and MR enterography imaging protocols collected from 16 Society of Abdominal Radiology Crohn’s Disease–Focused Panel institutions, which highlights state-of-the-art CT enterography and MR enterography protocols along with the variability between institutions. The results of this survey may help to optimize and standardize CT enterography and MR enterography imaging protocols. We expect that this data will be published in Abdominal Radiology later this year.

    References

    1. Guglielmo FF, Anupindi SA, Fletcher JG, et al. Small Bowel Crohn Disease at CT and MR Enterography: Imaging Atlas and Glossary of Terms. Radiographics 2020;40(2):354375. LinkGoogle Scholar
    2. Bruining DH, Zimmermann EM, Loftus Jr EV, et al. Consensus Recommendations for Evaluation, Interpretation, and Utilization of Computed Tomography and Magnetic Resonance Enterography in Patients With Small Bowel Crohn’s Disease. Radiology 2018;286(3):776799. LinkGoogle Scholar
    3. Bruining DH, Zimmermann EM, Loftus Jr EV, et al. Consensus recommendations for evaluation, interpretation, and utilization of computed tomography and magnetic resonance enterography in patients with small bowel Crohn’s disease. Gastroenterology 2018;154(4):11721194. Crossref MedlineGoogle Scholar
    4. Grand DJ, Guglielmo FF, Al-Hawary MM. MR enterography in Crohn’s disease: current consensus on optimal imaging technique and future advances from the SAR Crohn’s disease-focused panel. Abdom Imaging 2015;40(5):953964. Crossref MedlineGoogle Scholar
    5. Baker ME, Hara AK, Platt JF, Maglinte DD, Fletcher JG. CT enterography for Crohn’s disease: optimal technique and imaging issues. Abdom Imaging 2015;40(5):938952. Crossref MedlineGoogle Scholar
    6. Guglielmo FF, Roth CG, Mitchell DG. MR and CT Imaging Techniques of the Bowel. In: Cross-Sectional Imaging in Crohn’s Disease: Springer, 2019; 4975. CrossrefGoogle Scholar
    7. Wnorowski AM, Guglielmo FF, Mitchell DG. How to perform and interpret cine MR enterography. Journal of Magnetic Resonance Imaging 2015;42(5):11801189. Crossref MedlineGoogle Scholar
    8. Taylor S, Avni F, Cronin C, et al. The first joint ESGAR/ESPR consensus statement on the technical performance of cross-sectional small bowel and colonic imaging. Eur Radiol 2017;27(6):25702582. Crossref MedlineGoogle Scholar

    Article History

    Published online: Mar 03 2020
    Published in print: Mar 2020