Diagnostic Imaging Pathways - Crohn's Disease (Suspected)
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This pathway provides guidance on imaging patients with clinically suspected Crohn’s disease.
Date reviewed: May 2015
Date of next review: 2017/2018
Published: July 2015
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| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
investigations
Investigation of Crohn's Disease
- The investigation of Crohn’s disease employs a variety of investigative modalities to assist in the diagnosis. These include biochemical tests, imaging examinations and endoluminal imaging techniques
- Endoluminal examination are commonly used in the investigation of Crohn’s disease. These are procedures performed by a gastroenterologist and include investigations like push enteroscopy, balloon-assisted enteroscopy (single / double balloon), colonoscopy with ileoscopy and capsule endoscopy 1
- Commonly used endoluminal examinations in suspected Crohn’s disease are colonoscopy with ileoscopy and capsule endoscopy followed by balloon-assisted enteroscopy
- Radiological examinations are an important tool to help assist in diagnosing Crohn’s disease. The main radiological examinations used in suspected Crohn’s disease are ultrasonography, barium small bowel studies (enterography also known as follow through and enteroclysis), CT enterography / enteroclysis and MR enterography / enteroclysis
colon
Colonoscopy with Ileoscopy (Ileo-colonoscopy)
- Ileoscopy is visualising the ileum through a colonoscope inserted rectally with a retrograde approach under expert hands
- Distal 20 cms of the small bowel can be visualized under optimal conditions and biopsies can be performed if necessary 14
ce
Capsule Endoscopy (CE)
- A non-invasive procedure where patient swallows a small (approximately 2 cms length) capsule which contains a miniature camera that wirelessly sends images to a sensor attached to a recording device. Capsule is passed per-rectum by the patient and is disposable 1
- Majority of studies report high sensitivity and diagnostic yield when compared to other investigative modalities like ileo-colonoscopy, small bowel radiography and enteroscopy but lack data on positive predictive value and specificity 15,16
- Conventional procedures, including endoscopic, ultrasonographic and / or radiological procedures are usually performed before using capsule endoscopy 17
- There is a lack of standardised diagnostic criteria for CE to diagnose Crohn's disease and developing a scoring system may improve its specificity for Crohn's disease 15,18
- One prospective study that compared CE, CT enterography (CTE) and small bowel follow through (SBFT) studies reported similar sensitivities for Crohn's disease for both CE (83%), and CTE (82%) but significantly lower specificity for CE (53%) compared to CTE (89%) 19
- Contraindications for CE include a history of GI motility disorder, known strictures or fistulae, history of extensive abdominal surgery and active swallowing disorder. If in doubt, a patency capsule test can be performed in which, the capsule is radio-opaque and disintegrates after several days
- Advantages of CE include
- Non-invasive
- Accepted and well tolerated by patients
- Ability to visualise the entire small bowel
- Disadvantages of CE include
- Technical malfunction of the capsule
- Inability to perform diagnostic or therapeutic manoeuvres, requiring further invasive investigations
- Lack of anatomical details makes it difficult to localise lesions
- Slow GI transit time resulting in part of the small bowel being not visualised
- Strictures may result in capsule retention which may require endoscopic removal
dbe
Double Balloon Enteroscopy (DBE)
- Also known as push-and-pull enteroscopy
- Can visualise the entire small bowel using retrograde and antegrade intubation but a recent systematic review concluded that complete enteroscopy was possible in only 44% of cases even with combined antegrade and retrograde approaches 29
- Advantages of enteroscopy include
- Ability for diagnostic (biopsies) and therapeutic intervention
- Improved visualisation of the small bowel as a result of insufflation of air
- Focused examination of any abnormality visualised
-
Disadvantages / adverse effects of enteroscopy include
- Visceral perforation
- Mucosal bleeding as a result of contact by the enteroscope
- Technically demanding and time consuming
- Limited availability
- Pancreatitis
- Abdominal pain as a result of insufflation of air into the bowel
- Requires sedation
ultra
Ultrasonography
- Ultrasonography (US) can be used as a screening tool to exclude active small bowel Crohn’s disease 3
- Studies have shown that ultrasonography with right expertise can be highly sensitive and specific in inflammatory bowel disease and is comparable to MR and CT examinations. 4,5,6 The sensitivity dropped to 67% when early Crohn's disease was considered
- Due to its advantages, bowel sonography can be used to select the patients for subsequent MRI examination 7
- CEUS involves the intravenous administration of microbubble contrast agents providing the real-time depiction of the small bowel microvasculature and perfusion 8
- High temporal resolution of CEUS allows for the grading of disease activity, the differentiation between small bowel stricture due to inflammation or mural fibrosis, and for the assessment of the response to specific therapy 8,9,10,11
- Colour and power Doppler US with microbubbles have major limitations due to blooming artefacts and signal saturation 8
- Cross-sectional imaging techniques have a high accuracy for evaluation of suspected and established Crohn’s disease, reliably measure disease severity and complications; they may offer the possibility to monitor disease progression. 12 As a result of the lack of radiation, US or MRI should be preferred over CT, particularly in young patients 12,13
- Advantages of ultrasonography include
- Non-invasive
- Easily available
- No ionizing radiation
- Can detect extra-mural abnormalities, masses, gynaecological disorders etc.
- Negative ultrasound with low clinical probability has high negative predictive value
- Disadvantages of ultrasonography include
- Cannot visualise entire small bowel and bowel gas may preclude proper examination
- Early lesions can be missed
bar
Barium Small Bowel Studies
- For a small bowel follow-through (enterography), patient drinks contract medium prior to the study and enteroclysis requires a naso-jejunal tube through which contrast is delivered directly into the small bowel
- Follow through is non-invasive but has sub-optimal luminal distension compared with enteroclysis
- Both studies give very limited information regarding extramural disease and so have largely been replaced by cross-sectional imaging like CT and MR 1
- Barium enteroclysis is reported to be more sensitive than MR / CT enteroclysis for mild abnormalities of early Crohn's disease 20,21
ct
Computed Tomography Enteroclysis / Enterography
- CT enterography and enteroclysis are CT techniques used to provide better images of the small bowel lumen and wall than conventional CT
- CT enterography involves rapid oral ingestion of 2 litres of contrast media before CT scanning
- The contrast used is usually neutral (water density) or diluted positive contrast. CT may be performed in several phases (e.g. non-contrast, post-contrast arterial, portal venous phase or delayed phase), or combined with CT angiography. Limitations include inability of some patients to consume a large amount of fluid in a short period of time, achieving appropriate timing of the scan to obtain good bowel distension and radiation dose
- CT enteroclysis involves passing a naso-jejunal catheter under fluoroscopic guidance
- Neutral or dilute positive contrast is instilled through the tube allowing rapid filling and distension of the intestine. Images are obtained as for a CT enterography. Limitations of this technique include more invasive nature (compared to enterography), achieving correct timing of scan (less problematic than enterography) and the radiation dose. Enteroclysis has been shown to provide superior bowel distension than enterography, 22 however it is uncertain whether this translates into better diagnostic outcomes. There are a few comparisons in the literature. Two studies found similar accuracy between the two techniques 22,23
- Advantageous effects of computed tomography enteroclysis / enterography include
- Excellent spatial resolution
- Widely available
- Better inter-observer agreement
- Cross-sectional imaging – can diagnose other abdominal abnormalities, extra-mural disease, etc.
- Disadvantageous effects of enteroclysis / enterography include
- Ionizing radiation relatively high especially in young patients with Crohn's disease who may require repeated imaging
- Patients may not be able to drink 2 litres of contrast for enterography
- Needs invasive naso-jejunal tube for enteroclysis
mri
Magnetic Resonance Enteroclysis / Enterography
- Similar procedural details as CT enterography / enteroclysis
- Major advantage of MR over CT is the lack of any ionizing radiation
- Major disadvantages include lesser spatial resolution, higher chance of motion artefacts, higher costs involved and lesser availability than CT
mrct
MR or CT? Enteroclysis or Enterography?
- Although there are limitations to the literature available, it appears that CT and MR enterography are similar in their diagnostic yield for Crohn's disease 4,24,25
- One study reported higher specificity and better distension of proximal small bowel with CT enteroclysis compared to CT enterography but the final arbiters were endoscopy and barium small bowel studies in this study 22
- Studies comparing MR enterography and enteroclysis show mixed results where two out of three studies 26,27 report similar accuracies while one study 28 reported better detection rate of superficial lesions for MR enteroclysis
- MR enteroclysis provides functional information that is lacking with MR enterography and CT studies
- MR however has a major advantage over CT that it lacks ionizing radiation which is an important factor for younger patients with Crohn's disease who are likely to have repeated imaging tests
References
References
Date of literature search: May 2015
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- B. Hamm and P. Ros (eds.). Abdominal Imaging. Springer-Verlag Berlin Heidelberg 2012. (Review)
- Panes J, Bouhnik Y, Reinisch W, Stoker J, Taylor SA, Baumgart DC, et al. Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines. J Crohns Colitis. 2013;7(7):556-85. (Guideline). View the reference
- Dong J, Wang H, Zhao J, Zhu W, Zhang L, Gong J, et al. Ultrasound as a diagnostic tool in detecting active Crohn's disease: a meta-analysis of prospective studies. Eur Radiol. 2014;24(1):26-33. (Level II evidence). View the reference
- Horsthuis K, Bipat S, Bennink RJ, Stoker J. Inflammatory bowel disease diagnosed with US,MR, scintigraphy, and CT: meta-analysis of prospective studies. Radiology. 2008;247:64–79. (Level II evidence). View the reference
- Sheridan MB, Nicholson DA, Martin DF. Transabdominal ultra-sonography as the primary investigation in patients with suspected Crohn’s disease or recurrence: a prospective study. Clin Radiol. 1993;48:402–4. (Level II/III evidence). View the reference
- Tarjan Z, Toth G, Gyorke T, Mester A, Karlinger K, Mako EK. Ultrasound in Crohn’s disease of the small bowel. Eur J Radiol. 2000;35:176–82. (Level II evidence). View the reference
- Castiglione F, Mainenti PP, De Palma GD, Testa A, Bucci L, Pesce G, et al. Noninvasive diagnosis of small bowel Crohn's disease: direct comparison of bowel sonography and magnetic resonance enterography. Inflamm Bowel Dis. 2013;19(5):991-8. (Level III evidence). View the reference
- Quaia E. Contrast-enhanced ultrasound of the small bowel in Crohn's disease. Abdom Imaging. 2013;38(5):1005-13. (Review article). View the reference
- Nylund K, Jirik R, Mezl M, Leh S, Hausken T, Pfeffer F, et al. Quantitative contrast-enhanced ultrasound comparison between inflammatory and fibrotic lesions in patients with Crohn's disease. Ultrasound Med Biol. 2013;39(7):1197-206. (Level III evidence). View the reference
- Calabrese E, Zorzi F, Onali S, Stasi E, Fiori R, Prencipe S, et al. Accuracy of small-intestine contrast ultrasonography, compared with computed tomography enteroclysis, in characterizing lesions in patients with Crohn's disease. Clin Gastroenterol Hepatol. 2013;11(8):950-5. (Level IV evidence). View the reference
- Magalhaes J, Leite S, Cotter J. Contrast-enhanced ultrasonography for assessment of activity of Crohn's disease: the future? J Crohns Colitis. 2013;7(11):e607. (Level IV/V evidence). View the reference
- Panes J, Bouzas R, Chaparro M, Garcia-Sanchez V, Gisbert JP, Martinez de Guerenu B, et al. Systematic review: the use of ultrasonography, computed tomography and magnetic resonance imaging for the diagnosis, assessment of activity and abdominal complications of Crohn's disease. Aliment Pharmacol Ther. 2011;34(2):125-45. (Level II evidence). View the reference
- Onali S, Calabrese E, Petruzziello C, Zorzi F, Sica G, Fiori R, et al. Small intestine contrast ultrasonography vs computed tomography enteroclysis for assessing ileal Crohn's disease. World J Gastroenterol. 2012;18(42):6088-95. (Level III/IV evidence). View the reference
- Pasha SF, Leighton JA. Enteroscopy in the diagnosis and management of Crohn disease. Gastrointest Endosc Clin N Am. 2009;19:427–44. (Review article). View the reference
- Dionisio PM, Gurudu SR, Leighton JA, et al. Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohn’s disease: a metaanalysis. Am J Gastroenterol. 2010;105:1240–8. quiz 1249. (Level II evidence). View the reference
- Triester SL, Leighton JA, Leontiadis GI, et al. A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohn’s disease. Am J Gastroenterol. 2006;101:954–64. (Level II evidence). View the reference
- Petruzziello C, Calabrese E, Onali S, Zuzzi S, Condino G, Ascolani M, et al. Small bowel capsule endoscopy vs conventional techniques in patients with symptoms highly compatible with Crohn's disease. J Crohns Colitis. 2011;5(2):139-47. (Level III evidence). View the reference
- Bourreille A, Ignjatovic A, Aabakken L, et al. Role of small-bowel endoscopy in the management of patients with inflammatory bowel disease: an international OMEDECCO consensus. Endoscopy. 2009;41:618–37. (Guideline). View the reference
- Solem CA, Loftus Jr EV, Fletcher JG, et al. Small-bowel imaging in Crohn’s disease: a prospective, blinded, 4-way comparison trial. Gastrointest Endosc. 2008;68:255–66. (Level III evidence). View the reference
- Gourtsoyiannis NC, Grammatikakis J, Papamastorakis G, et al. Imaging of small intestinal Crohn’s disease: comparison between MR enteroclysis and conventional enteroclysis. Eur Radiol. 2006;16:1915–25. (Level II evidence). View the reference
- Minordi LM, Vecchioli A, Guidi L, Mirk P, Fiorentini L, Bonomo L. Multidetector CT enteroclysis versus barium enteroclysis with methylcellulose in patients with suspected small bowel disease. Eur Radiol. 2006;16:1527–36. (Level III evidence). View the reference
- Minordi LM, Vecchioli A, Mirk P, Bonomo L. CT enterography with polyethylene glycol solution vs CT enteroclysis in small bowel disease. Br J Radiol. 2011;84:112–9. (Level III evidence). View the reference
- Wold PB, Fletcher JG, Johnson CD, Sandborn WJ. Assessment of small bowel Crohn disease: noninvasive peroral CT enterography compared with other imaging methods and endoscopy– feasibility study. Radiology. 2003;229:275–81. (Level III evidence). View the reference
- Siddiki HA, Fidler JL, Fletcher JG, et al. Prospective comparison of state-of-the-art MR enterography and CT enterography in small-bowel Crohn’s disease. AJR Am J Roentgenol. 2009;193:113–21. (Level II evidence). View the reference
- Jensen MD, Ormstrup T, Vagn-Hansen C, Ostergaard L, Rafaelsen SR. Interobserver and intermodality agreement for detection of small bowel Crohn’s disease with MR enterography and CT enterography. Inflamm Bowel Dis. 2011;17:1081–8. (Level II/III evidence). View the reference
- Schreyer AG, Geissler A, Albrich H, et al. Abdominal MRI after enteroclysis or with oral contrast in patients with suspected or proven Crohn’s disease. Clin Gastroenterol Hepatol. 2004;2:491–7. (Level II/III evidence). View the reference
- Negaard A, Paulsen V, Sandvik L, et al. A prospective randomized comparison between two MRI studies of the small bowel in Crohn’s disease, the oral contrast method and MR enteroclysis. Eur Radiol. 2007;17:2294–301. (Level III evidence). View the reference
- Masselli G, Casciani E, Polettini E, Gualdi G. Comparison of MR enteroclysis with MR enterography and conventional enteroclysis in patients with Crohn’s disease. Eur Radiol. 2008;18:438–47. (Level II evidence). View the reference
- Xin L, Liao Z, Jiang YP, Li ZS. Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic double-balloon endoscopy: a systematic review of data over the first decade of use. Gastrointest Endosc. 2011;74:563–70. (Level II evidence). View the reference
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