Learning objectives

Objectives

1. To summarise the indications for radiological imaging in the diagnostic pathway of inflammatory bowel disease (IBD) as recommended in the 2019 ECCO-ESGAR guidelines.

2. To discuss the role for imaging in the initial diagnosis, monitoring of treatment and detection of complications in IBD.

Background

IBD encompasses a group of chronic and often debilitating enteropathic conditions, of which Crohn’s disease (CD) and Ulcerative colitis (UC) are the most common. The diagnosis and monitoring of CD and UC relies on a combination of clinical assessment and serological, stool, endoscopic, radiological and histological investigations. No single modality alone is adequate for diagnosis or assessment of treatment response, and cross sectional Imaging investigations, particularly MR enterography and ultrasound, play an increasingly important role.

Imaging findings OR Procedure findings

The European Crohn’s and Colitis Organisation (ECCO) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) have recently published a joint consensus guideline for diagnosis and management of IBD. The purpose of this educational presentation is to summarise the key recommendations from the guideline, emphasising the role of imaging, particularly intestinal ultrasound, MRI and where appropriate, CT. In addition, the use of newly recommended MRI activity scoring systems as a surrogate marker for disease response will be described.

Conclusion

We aim to summarise the role for imaging in the initial diagnosis, treatment monitoring and detection of complications in IBD. In addition, we will discuss the role of cross-sectional scoring systems and their potential as a surrogate marker for disease response.

Purpose

Dysregulation of iron homeostasis has been associated with fatty liver disease and type 2 diabetes mellitus (T2DM). Serum ferritin levels are positively correlated with elevated liver iron concentration (LIC), but the relationship in patients with non-elevated liver iron concentration (LIC) is not known. Here, we investigate the relationship between serum ferritin levels and non-elevated proton-density fat fraction (PDFF) derived R2* liver iron concentration (LIC) in patients with T2DM undergoing endoscopic Duodenal Mucosal Resurfacing (DMR) in the Revita-2 trial.

Material and methods

Revita-2 is a phase II blinded, sham-controlled international multi-site multi-scanner vendor cross-over trial (NCT02879383). Average LIC measurements were obtained from vendor-derived PDFF R2* maps from seven sites (TR=5-10ms, TE of first echo=1-2ms, number of echoes=6, alpha=3 degrees, 6mm slice thickness, 2-2.5 mm isotropic inplane resolution), with circular regions-of-interest (ROIs) placed in each of the 9 Coinaud liver segments. Baseline and 12-week post-treatment liver MRI scans with paired serum ferritin levels for initial open-label training (n=17), DMR (n=39) and sham (n=23) cohorts were analysed.

Results

At baseline, a modest positive but significant correlation was demonstrated between LIC and serum ferritin (r=0.5313, P<0.0001). Following treatment, change in LIC and serum ferritin were poorly correlated across all three cohorts (training r=0.3683, P=NS; DMR r=0.1075, P=NS; sham r=-0.1319, P=NS).

Conclusion

Even at non-elevated LIC levels, serum ferritin and LIC are positively correlated. Poor post-treatment change in LIC and serum ferritin correlations may reflect mechanistic effects on hepatic iron metabolism as a result of DMR.

Purpose

To investigate the effects of endoscopic Duodenal Mucosal Resurfacing (DMR) in patients with sub-optimally controlled type 2 diabetes mellitus (T2DM) on liver fat fraction (FF) using MRI proton density fat fraction (PDFF).

Material and methods

Revita-2 is a phase II blinded, sham-controlled international multi-site multi-scanner vendor cross-over trial (NCT02879383). Average FF measurements were obtained from vendor-derived PDFF maps from seven sites (TR=5-10ms, TE of first echo=1-2ms, number of echoes=6, alpha=3 degrees, 6mm slice thickness, 2-2.5 mm isotropic inplane resolution), with circular regions-of-interest (ROIs) placed in each of the 9 Coinaud liver segments. Baseline and 12-week post-treatment FF data in patients with baseline hepatic steatosis (average FF>5%), randomised to DMR or sham treatment were analysed. Longitudinal measurement stability was confirmed using custom-built fat-water liquid-emulsion based phantoms.

Results

A total of 108 patients were enrolled (DMR n=56, sham n=52). Prespecified interaction testing revealed non-homogeneity between one country and the remaining patient populations – analyses were therefore stratified. From the remaining patient population, baseline hepatic steatosis (n=60) was prevalent in both cohorts (DMR n=33 (85%) vs sham n=27 (75%), P=0.250), mean liver FF 16.5% (DMR) vs 16.1% (sham, P=0.500). Median change in liver FF from baseline at 12 weeks was -5.4% (DMR) vs -2.4% (sham, P=0.039, absolute difference) and -32.1% (DMR) vs -18.1% (sham, P=0.025, relative difference).

Conclusion

DMR elicits favourable effects on liver PDFF at 12 weeks, in patients with sub-optimally controlled T2DM.

Learning objectives