Los Angeles Radiological Society SELF ASSESSMENT MODULE - CONTENT

38
th
Annual Spring Diagnostic Ultrasound Conference
June 1-2, 2013 Pasadena Convention Center

Inflammatory Bowel Disease: Evaluation of Classic Features and Complications with Ultrasound
Presented by Stephanie R. Wilson, MD
Clinical Professor of Radiology and Medicine, University of Calgary

Self-Assessment Questions:

Question 1: In a patient with active Crohns Disease on medical therapy, the best predictor of
continued disease remission is:
A. Complete relief of all symptoms.
B. Resolution of all imaging features of disease.
C. Normal inflammatory markers.
D. Complete mucosal healing at ileocolonoscopy.

Question 2: Which statement best describes Crohns Disease
A. Inflammatory markers and symptoms are inconsistent predictors of disease activity.
B. It increases the risk of small bowel lymphoma.
C. Its incidence worldwide is declining.
D. It is caused by atypical mycobacterial infection.

Question 3: Regarding imaging modalities in CD,
A. Small bowel follow through is a highly sensitive modality for detecting complications including
strictures.
B. MRE is superior to CTE in detecting small bowel inflammatory disease.
C. Barium radiography is considered a routine modality to accurately image the colonic mucosa to
characterize IBD.
D. The accuracy of US in detecting inflammatory disease in IBD is equivalent to CT and MR.

Question 4: A threshold thickness for the wall of the terminal ileum above which inflammation is
highly likely to be present is
A. 1 to 2 mm
B. 3 to 4 mm
C. 5 mm
D. Greater than or equal to 6 mm

Question 5: This image of the terminal ileum suggests which of the following complications of CD:
A. Stricture with incomplete mechanical bowel obstruction
B. Enteroenteric fistula
C. Perienteric abscess
D. Phlegmon





Question 6: This image suggests which complication:
Los Angeles Radiological Society SELF ASSESSMENT MODULE - CONTENT
38
th
Annual Spring Diagnostic Ultrasound Conference
June 1-2, 2013 Pasadena Convention Center

A. Stricture
B. Localized perforation of the bowel in Crohn Disease
C. Abscess
D. Incomplete bowel obstruction






Answer Key & References for Additional Study:
Question 1: Correct answer = D - Complete mucosal healing at ileocolonoscopy.
Complete mucosal healing at endoscopy is the best predictor of positive response to therapy.
References:
Pineton de Chambrun G, Peyrin Biroulet L, Lemann M, Colombel JF. Clinical implications of mucosal
healing for the management of IBD. Hepatol 7. 15 29, 2010.
Frslie KF, Jahnsen J, Moum BA, Vatn MH. Mucosal Healing in Inflammatory Bowel Disease: Results
From a Norwegian Population-Based Cohort. Gastroenterology, Volume 133, Issue 2, August 2007,
Pages 412422.

Question 2: Correct answer = A - Inflammatory markers and symptoms are inconsistent predictors of
disease activity.
Neither inflammatory markers nor symptoms are routinely reflective of disease activity. If the CRP, for
example is high, it helps in management. A negative test, however, is uncertain. Therefore imaging
surveillance is highly important in the management of this patient population.
References:
Rodgers AD, Cummins AG. CRP Correlates with Clinical Score in Ulcerative Colitis but Not in Crohns
Disease. Dig Dis Sci 2007; 52: 2063 2068.
Rutgeerts P, Geboes K, Vantrappen G, et al. Predictability of the postoperative course of Crohns
Disease. Gastroenterology 1990; 99: 956 983.

Question 3: Correct answer = D - The accuracy of US in detecting inflammatory disease in IBD is
equivalent to CT and MR.
US is shown in meta-analysis to be equivalent to CT and MR scan for the diagnosis of IBD. In our own
hands, we find US to be highly effective also in surveillance and evaluation at the time of a clinical flare.
Reference: Horthuis K, Bipat S, Bennick RJ, and Stooker J. Inflammatory Bowel disease Diagnosed
with US, MR, Scintigraphy, and CT: Metanalysis of Prospective Studies. Radiology. 2008 Apr; 247(1):64-
79.

Question 4: Correct answer = B - 3 to 4 mm
Los Angeles Radiological Society SELF ASSESSMENT MODULE - CONTENT
38
th
Annual Spring Diagnostic Ultrasound Conference
June 1-2, 2013 Pasadena Convention Center

Different sensitivity and specificity is obtained if 3 mm or 4 mm or greater is selected as the threshold
level.
Reference:
Fraquelli M, Colli A, Casazza G, Paggi S, Colucci A, Massironi S, Duca P, Conte D. Role of US in detection
of Crohn disease: meta-analysis. Radiology. 2005 Jul; 236(1):95-101.
*Extracted from that publication is the following: Sensitivity and specificity of 88% and 93%,
respectively, were achieved when a bowel wall thickness threshold greater than 3 mm was used, and
sensitivity and specificity of 75% and 97%, respectively, were achieved when a threshold greater than 4
mm was used.
Question 5: Correct answer = A - Stricture with incomplete mechanical bowel obstruction
A Stricture with incomplete mechanical bowel obstruction. The bowel is thickened and black on the left
side of the image. The luminal surfaces are in virtual apposition. On the right side of the image, the
bowel is dilated and fluid filled. On real-time evaluation, not shown here, there is hyperperistalsis of
this dilated obstructed segment.
Reference: Neye H, Ensberg D, Rauh P, et al. Impact of high-resolution transabdominal ultrasound in
the diagnosis of complications of Crohns disease. Scandinavian Journal of Gastroenterology.
2010;45(6):690695

Question 6: Correct answer = B - Localized perforation of the bowel in Crohn Disease
Localized perforation of the bowel. There is an air filled echogenic tract running through the entire
bowel wall.
Reference: Neye H, Ensberg D, Rauh P, et al. Impact of high-resolution transabdominal ultrasound in the
diagnosis of complications of Crohns disease. Scandinavian Journal of Gastroenterology. 2010;
45(6):690695