imaging in crohns disease: mr enterography...– mr enterography new opportunities: distinguish...
TRANSCRIPT
![Page 1: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/1.jpg)
Imaging in Crohns Disease: MR Enterography
Imaging in Crohns Disease: MR Enterography
SCBT/MRMarch 2009
Scott B. Reeder, MD, PhD
SCBT/MRMarch 2009
Scott B. Reeder, MD, PhDDepartment of RadiologyUniversity of Wisconsin
Madison, WI
![Page 2: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/2.jpg)
Disclosure
• Advisory boards of Bayer, GE Healthcare• UW receives support from GE and Bracco• Spouse is an employee of GE
![Page 3: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/3.jpg)
Off-Label Uses of Gadolinium
• Off-label uses of Gadolinium contrast• Investigational Pulse Sequences
![Page 4: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/4.jpg)
Outline• Need for cross sectional imaging of small
bowel– Challenges in the diagnosis & treatment monitoring
of Crohns disease
• Increasing concerns over radiation• CT vs MR Enterography• MR Enterography Protocol at UW• Examples
![Page 5: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/5.jpg)
Crohn’s Disease• Inflammatory bowel disease (autoimmune)• 700,000 Americans afflicted• Young adults (20’s and 30’s)• Any part of GI tract, esp. distal ileum
– Complete small bowel coverage needed– Colon and esophagus accessible by other means
• Features– Transmural inflammation– Strictures– Fistulas, abscesses, etc
• Key question: active vs quiescent disease
![Page 6: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/6.jpg)
Crohns Disease• Active disease treated with “biologics”
– eg. infliximab (remicade)– Effective– Very expensive– Serious side effects, including lymphoma
• Burned out disease with strictures: surgery• Imaging plays a central role
– Small bowel follow through– CT enterography– MR enterography
New opportunities: distinguish active from chronic disease
![Page 7: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/7.jpg)
952,420 non-elderly adults followed for three years655,613 underwent one or more imaging procedures2.4 ± 6.0mSv (3mSv = background dose)82% from outpatient facilities (CT, nuclear scintigraphy)
![Page 8: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/8.jpg)
2.5 year old boy for neck CT scan after falling off bedInadvertent exposure to 151x normal dose
![Page 9: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/9.jpg)
CTE Enterography: Findings of Active Disease
• Bowel wall thickening– > 3mm– Asymmetric involvement
• mesenteric > antimesenteric
• Perienteric stranding• Engorged vasa recta
• “comb” sign
• Perienteric fibrofatty proliferation• Remains present in clinically quiescent disease
![Page 10: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/10.jpg)
MRE Enterography: Findings of Active Disease
• Bowel wall thickening– > 3mm– Asymmetric involvement
• mesenteric > antimesenteric
• Perienteric stranding• Engorged vasa recta
• “comb” sign
• Perienteric fibrofatty proliferation• Remains present in clinically quiescent disease
• High signal on T2 weighted imaging
• Decreased peristalsis on “real-time” imaging
![Page 11: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/11.jpg)
MR vs CT Enterography
In 2010, MRE and CTE have equivalent performance
![Page 12: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/12.jpg)
Accuracy of MRI
Accurate markers of acute inflammation: • increasing mural thickness• high signal on T2• mural enhancement NOT a feature• layered enhancement
![Page 13: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/13.jpg)
Complications
• Fistula– Enteroenteric– Enterocystic– Enterocutaneous (perianal fistulas common)– Enterovaginal
• Abscess• Strictures (fibrostenosis)• Small bowel obstruction
![Page 14: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/14.jpg)
Protocol: Patient Preparation
• Drink• Prone position
– minimize respiratory motion– Better co-localization between sequences– Splay out loops of small bowel
• Spasmolytic– Buscopan (Europe)– Glucagon (IM or IV)
![Page 15: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/15.jpg)
Drink• Goal: distend small bowel, terminal ileum• Variability in the literature• Hyperosmolar agent to distend bowel
– Mannitol– Locus bean gum– Sorbitol + Barium (Volumen)
• Volume– 1000-1500ml
• UW protocol– 900-1250ml Volumen in 2-3 boluses over 30-
60minutes– 300 ml of water on table
![Page 16: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/16.jpg)
Glucagon: IM or IV?• 1mg IM
– Onset 1-3 min, 10-20 min duration– Efficacy is good but variable
• 0.3-0.5mg IV– Immediate onset, 5-7 minutes duration– Reliable cessation of peristalsis– Occasional nausea: push slowly
No glucagon 1 minute after glucagon
![Page 17: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/17.jpg)
Protocol: Overview• Position prone on table• Drink 300cc water on table• Localizers• Real time 2D-SSFP before Glucagon• 0.3-0.5mg IV Glucagon• Axial T2-SSFSE with fat-sat• Coronal T2-SSFSE without fat-sat• 3D-SSFP• 0.3-0.5mg IV Glucagon• T1W 3D-SPGR with fat-suppression
– Pre-contrast (can perform before 2nd dose of glucagon)– Inject 0.1mmol/kg GBCA at 2.0ml/s, 25-50ml saline flush– 40 seconds (later arterial)– 2 minutes
• T1W 2D-SPGR with fat-suppression
$$ Money Shot $$
$$ Money Shot $$
$$ Money Shot $$
Total table time is 30 minutes
![Page 18: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/18.jpg)
Protocol: Localizers• 3-plane SSFSE no fat-saturation• Large FOV body phased array• Not critical to cover to dome of liver• It is critical to cover through perineum• Check coil sensitivity after this step• Check bowel distension
![Page 19: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/19.jpg)
Protocol: Real Time bSSFP• Balanced steady-state free precession
(SSFP, FIESTA, trueFISP, BFFE)• Bright fluid• “India-ink” artifact at water-fat interfaces• 10-20 phases at each slice in 2D stack• Free-breathing• Fast, high SNR, available on all systems• Perform before glucagon• Diseased segments have reduced motility
![Page 20: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/20.jpg)
Protocol: Real Time bSSFP
![Page 21: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/21.jpg)
Protocol: T2 weighted imaging
• SSFSE (HASTE): rapid, insensitive to motion• Coronal T2-SSFSE without fat-sat: anatomy• Axial T2-SSFSE with fat-sat: disease activity
![Page 22: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/22.jpg)
Protocol: 3D-bSSFP
• Anatomical overview with high resolution• Isotropic spatial resolution for 3D reformats• Bright fluid• Water-fat interfaces black – etched appearance• Banding artifacts• Single breath-hold
![Page 23: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/23.jpg)
Protocol: Contrast Enhanced Imaging• T1 weighted 3D-SPGR with fat-saturation
(LAVA, VIBE)• 2D parallel imaging (ARC, GRAPPA) essential
– Complete coverage of all small bowel– 1.5 x 1.9 x 2.0mm3 (0.9 x 0.9 x 1.0mm3)
Pre-contrast Late Arterial (40s) Delayed (2 minutes)
![Page 24: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/24.jpg)
2D-ARC: Increased Coverage
LumLum et al JMRI 2009et al JMRI 2009
![Page 25: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/25.jpg)
Protocol: Axial 2D T1W-SPGR
• Second look with contrast• Peri-anal fistulas• Adenopathy
![Page 26: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/26.jpg)
Case: 16yo Girl with Crohns
Coronal T1 Weighted SPGR Coronal T2 Weighted SSFSE
Axial T2 Weighted SSFSE
Axial Reformat T1 Weighted SPGR
![Page 27: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/27.jpg)
Case:9yo M with Crohn Dz
![Page 28: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/28.jpg)
Case: Follow-up 1 year later
New lesions, high T2 signal: Active Disease
SSFSE 3D-SSFP T1W 3D-SPGR
T2W SSFSE with Fat-Sat
T1W 2D-SPGR
Lymphadenopathy
![Page 29: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/29.jpg)
Case: 24y woman with Crohns
CT Enterography T1W 3D-SPGR T2 SSFSE 3D-SSFP
T1W 2D-SPGR T2 SSFSE with fat-sat
![Page 30: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/30.jpg)
Case: 27yo with abdominal pain
SSFSE T1W 3D-SPGR
T1W 3D-SPGR
T1W 2D-SPGR
CT
SSFSE with Fat-Sat
![Page 31: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/31.jpg)
3D Multiplanar Reformats
Axial
ObliqueSagittal
ObliqueCoronal
Pearl: useful for referringsurgeons - surgical planning
![Page 32: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/32.jpg)
Case: 33yo M with known h/o Crohns
Multiple Lesions of Varying Acuity
SSFSE T1W 3D-SPGRT2W SSFSE with Fat-Sat
T2W SSFSE with Fat-Sat
![Page 33: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/33.jpg)
Case: 33yo M with known h/o Crohns
Perianal Fistulas
T2W SSFSE with Fat-Sat
Oblique MPR 3D-SPGR
T1W 2D-SPGR
![Page 34: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/34.jpg)
Case: 30yo F, known Crohns Disease
Active disease with perienteric stranding and fistula formation
![Page 35: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/35.jpg)
Case: 37 yo M with chronic disease and acute abdominal pain
Perienteric fatty proliferation (chronic)Enteroenteric fistula (active disease?)
![Page 36: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/36.jpg)
Case: 69yo F with histology proven Crohns of the rectum
•Active on chronic disease- Bright T2 signal- Perirectal fatty proliferation
•Rectal labial fistula
T2W SSFSE with Fat-Sat
T1W 2D-SPGR
Oblique MPR 3D-SPGR
T1W 3D-SPGR
![Page 37: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/37.jpg)
Case: 40yo M with long history of Crohns, presents with PSBO
SSFSE 3D-SSFP T1W 3D-SPGR
![Page 38: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/38.jpg)
Summary MR Enterography• In 2010, MRE = CTE• Moving target, with improved technology
performance of MRE will exceed CTE• MRE is an excellent modality to assess
disease status and complications• Additional information in the future …
– Assessment of active inflammation– Role for DWI, MT, DCE, BOLD, others?– Advanced real time applications
![Page 39: Imaging in Crohns Disease: MR Enterography...– MR enterography New opportunities: distinguish active from chronic disease. 952,420 non-elderly adults followed for three years 655,613](https://reader034.vdocument.in/reader034/viewer/2022042417/5f33b4a64a9c1a2ba63555ce/html5/thumbnails/39.jpg)
Thank you
• Acknowledgements– Jessica Robbins, MD– Sumona Saha, MD– Mark Reichelderfer, MD– Andy Taylor, MD– Fred Kelcz, MD, PhD