Chapters Transcript Video IBD Breakout: Role of Intestinal Ultrasound in IBD. What, When and Why IBD Breakout Session: Role of Intestinal Ultrasound in IBD. What, When and Why *Not Eligible for CME Credit Hi, everybody. My name is Philip. I'm a junior faculty here at the I B D Center at Cedar Sinai. And today I have the pleasure of introducing to you guys in test ultrasound I B D. Um It's an exciting application of a old uh technology that we've had for many years and this is a new program that we're, we're starting here at our I B D Center. And the purpose of my talk today is really just to give a really brief, high level overview of the capabilities of intestinal ultrasound I B D and hopefully, it will give you what your appetite for uh to encourage everybody to kind of partake in this uh exciting um new in I B D. OK. So no disclosures. So I wanna start off with a case that uh of a woman that I recently saw. She was 43. She had a history of left side ulcer colitis and she was previously doing well on Standard Dose at AIDA, but she came to us to present for second opinion with flare symptoms. When I saw her, she was telling us that she had 8 to 10 bloody bowel movements a day with severe urgency and incontinence. But she had very limited records when we saw her, she didn't have any recent labs. Uh, no recent colonoscopy. We only had the index colonoscopy at the time of diagnosis, which is about two years ago and there was no fecal calprotectin available. So, symptomatically. Yes, we know she had severe disease activity, but, you know, we always would want objective markers of disease activity. So we're able to do an ultrasound in clinic. And what this showed was that she had a thickened bowel wall of her sigmoid colon. And um when I put on the color Doppler, there was increased vascularity as noted here by the signals and there was evidence inflammatory fat and I'll talk a little bit more about what these features mean a little bit in my um presentation so that we begin to understand how uh we can be applying such ultrasound into um V bowel disease. The other neat feature I want to point out was that, um, you know, we were able to characterize the extent of her colitis. Uh as I said before, she had left side colitis, uh we only had one colonoscopy to really suggest that. But when I was able to do the ultrasound further up in the transverse and a ascending colon, you'll notice there's a huge difference in the bowel wall thickness and then transverse and a ending it was quite thin. So, but based on our symptoms we had to hospitalize her and we did an inpatient flexible sigmoidoscopy that confirmed our ultra ultrasound findings. And so there was mayo colitis up to 50 centimeters from the anal verge and proximate to that was uh mayo zero. So this is the outline of what I'm gonna talk about today. I'm gonna start with why, what is the role of ultrasound and I B D and what's the strength of um using this tool? And what are the tools that we need? And what's the technique to perform a ultrasound exam for I B D patient? And finally, I'm gonna finish up with, you know, what are the applications of ultrasound and Crohn's disease? And what are the applications in ulcer colitis? So let's start with the why as Gil had discussed in his lecture, just re uh just previously, we're all familiar with the stride two consensus. And we all know that our current goals for treating I V D now is to achieve mucosal healing. And to achieve this, we use a treat to target approach where we use objective markers that we routinely assess and reassess to see how close we are to mucosal healing. Our current tools for uh disease monitoring are a colonoscopy or endoscopy, uh imaging with AC T or MRI and blood with the C R P or people count protecting the stool. Now, these are really good markers for disease activity, but they don't quite take the patient into account they can be costly like with imaging or with uh colonoscopies where you have to take time off and they're time intensive and again, back to colonoscopy, it's, it's a two day process with the prep and then the actual procedure and these modalities sometimes put patients in uncomfortable positions in a comfortable I'm sorry, uncomfortable situation. Like with fecal cow protecting, you have to store stool in a refrigerator, which can be a little weird for some patients. And with imaging, you have to consider uh radiation exposure of not doing too many C T S and especially in Children. And MRI S aren't easy for everybody. You know, if you have claustrophobia, it can be really difficult for Children. You know, I I've heard of Children need to be intubated so that they can remain still for the MRI. Another issue is you have to wait for the results. It could be a week or months before you have um information that help you to decide whether you escalate or change therapy for a patient. And one last issue with our current modalities is adherence. This is a recent study that was done at a University of Miami that was published in Crohns and Coli 3 60 where out of 3000 I V patients who were ordered to people calprotectin, only 50% completed it. That's huge and that's a lot of missed opportunities to optimize and tightly control someone's Crohn's disease or ulcer colitis for optimal outcome. So this is where in testa ultrasound comes in. This is its strength. It's a point of care exam that you can do at the bedside. It doesn't require patients to do any bowel preparation before no fasting is really required, no radiation risk and you do at bedside and you get real time answers to make real time decisions. It al it's also really uh great for special populations like in pediatrics. It's much more tolerable and accepted to the kids and in pregnancy too where you don't want to do excess imaging or uh endoscopy. And so, you know, it's a great modality that is safe for the baby and you can get the answers you need in terms of disease activity. Now let's dive into what is required and what is involved in the test ultrasound and I B D and I'm gonna talk about what the basic equipment is and what's the basic technique uh to do an ultrasound exam. So obviously, you need an ultrasound machine. I would recommend having a formal ultrasound machine rather than a portable one. Uh We personally have a GE logic E 10 at nine. Some other programs have a Samsung uh with this machine, you want at least two probes. One is a carbo linear probe, the carer linear probe has lower frequency. So there's lower resolution of it uh of structures, but you do get deeper penetration. So generally, this is our workhorse that identifies structures. Um and it's also useful in patients with larger body body habit is is when there is a more subcutaneous tissue to penetrate. The other probe that we use is the linear probe. It has higher frequency. And what this brings is high resolution, but it's downside, there's there's limited penetration. So what we use the linear probe for is detail exam structures, for example, the bell wall layers. And um again, I'll get into that in a little bit about what we're looking specifically in the bell walls. And so the exam is pretty similar to what we do for a colonoscopy. We start our exam at the rectum and then we move on to the sigmoid and D sinning colon, swing over to the transverse colon down the aying colon. And then we take a look at the terminal ilium. After we've completed that, we do what I like to call the lawnmower exam where, you know, we exam all four quadrants of the abdomen. And what you're looking for here is any other abnormal loops of intestines, uh strictures or complications of like, you know, abscesses, such Crohn's disease that you may have missed on your initial um exam when you're looking at the colon and terminal alien. And after you've done that you've completed your exam, um you know, uh people perform this at an expert level, it, they say it takes about 10 minutes. Obviously, for us, newer uh uh ultrasonographer, it could take a little bit longer. But as it's like when you're trained for your colonoscopy and in fellowship, the more you do, the faster you get. And these are the key features that we're looking for on ultrasound for I B D. The two biggest features that we make sure we characterize is the bowel wall thickness and the vascularization as measured by the color Doppler. Other features that we can uh detect are small bowel motility. And uh this is an example in stricturing Crohn's disease where the motility will be impaired. Um And you can actually appreciate this on ultrasound. Other things we can detect are strictures and fistula, um inflammatory fat and both cro disease and actually in ulcer, which is interesting um to know because, you know, we're traditionally taught, there's no really creeping fat in uh uh and then also we can look at me as well. So this is what we're looking for for bow wall thickness. Um So the, the bowel wall has five different layers and what we look for where we start a measurement is at the interface of the mucosa and the muscular mucosa. And then we measure all the way up to the muscular propria and CSA and and thicken bow wall is uh correlates really strongly with inflammation. So generally, when it's you're looking for that black, white, black pattern. And again, this is the strongest indicator of inflammation and generally from the descending colon to a small bowel, the upper limit of normal for the bowel wall thickness is three millimeters above three millimeters. It is 88% sensitive and 93% specific for detecting active disease from the rectum to the sigmoid. There's debate that actually the upper limit of normal should be four millimeters. And right here in the bottom right corner, I have an example of what a normal sigmoid colon would look like under um ultrasound. Uh As you see here, the hyper uh enhancing area that's the uh mucosa and slash the dark layer right here is the muscular muscular mucosa and we measure it up including the submucosa which is the hyper dense uh layer in the middle. Uh this is the muscular appropriate. And then we measure up to the where the interfaces with the um with the. So this is about three, it just a little under three millimeters. And so it was normal. Again, I just want to show a side by side comparison of ultrasound findings with endoscopy findings just to really hammer in the home uh on the point that you know, the ultrasound findings really do correlate well with endos endoscopy findings. So this was from our case earlier, this woman had a uh increased bowel wall thickness of it measured about 7.3 millimeters. And then we noted that she had mao three colitis on her inpatient flexible. Now, how do we apply this to Crohn's Disease and ulcer? So, starting with Crohn's disease tests, ultrasound is sensitive for detecting Crohn's disease. And this was highlighted in the metrics study. This was a multi sound prospective study in the UK, which recruited almost 300 Crohn's patients and using a reference standard model. They wanted to compare M R toy to tests ultrasound for detecting small bow Crohns disease. And what they found is that both are very sensitive. So the M R E had about 97% sensitivity and ultrasound had 92% sensitivity. Now, previously, there was a lot of um argument against ultrasound thing. There's a lot of inter operator uh variability, but studies have shown that tests, ultrasound has excellent Interra rel sorry inter reliability with inter class correlation of 0.8 to 0.96. And so again, when we're assessing disease activity and Crohn's disease, we're looking at bowel thickness or hyper with the color alert, echos, application, inflammatory centric fat and uh meric lymph nodes. Now because we've talked about bow wall thickness and in the interest of time, I'm just gonna briefly touch upon the hyper because this is also high yield for detecting disease activity. So studies have shown that there's a strong correlation with his logic and and endoscopic disease activity. Oh sorry. Um And again, there's also high inter class uh correlation of 0.6 to 0.93. And the way it's measured is once you put on the color Doppler, it's scored on a scale of 0 to 30 being absolutely normal. You don't get any Doppler signal um, within the bowel wall. As you see in panel A uh, and panel B, this is a, we call number score one, you see speckles of uh Doppler signal. And then as you move on to limb two, you start seeing protracted stretches of vascularity and then the most severe stage, Limra three. Now, not only do you see a Doppler signal within the bowel wall, you actually see it extra luminary and this is presumably intra uh inflammatory fat that's um having increased vascularity. Another use for tests, ultrasound and Crohns disease is to detect post-op occurrence. Um There was a recent meta analysis of 10 studies that found that tests ultrasound is 94% sensitive and 84% specific for detecting post-op recurrence. And the cutoffs are generally the same as um in non posts occurrence patients where three millimeters is the upper limit and normal. And in this meta analysis, what they found was that the cut-off of 5.5 millimeters of the bell wall um was generally reflected a severe recurrence of roots I three. And in the panel here on the right, this is an example of what post-op occurrence might look like under intestinal ultrasound. Um So just kind of identifying the structures on the right here where my arrow is, that's the neo terminal ilium uh at the I Amos and this is the colonic side on the left side of the uh iis. And when you see these little bright dots down that make a nice line, that's the stable line from the prior surgery. So this is a patient that I saw recently too for um mild symptoms and we didn't know whether they had recurrences or not. Uh We did ultrasound and found that his neo aum measured about 5.1 millimeters and I follow up a week later with the fecal cop protecting it confirmed recurrence uh because it's elevated at 500. So it also not being able to detect disease. We also wanna be able to use it to assess how patients are responding to treatment. So the eco consensus guidelines recommend you using a threshold of a reduction in bowel thickness about 25% or two millimeters or one millimeter plus one color Doppler signal reduction. Um as a outcome for a reduction in bowel wall thickness in terms of timing of when you want to uh perform an ultra ultrasound exam after starting new therapy, uh you wanna do week zero when you start it and then week 14, 16 and then weeks 26 to 50 52. And of course, you can use it as a uh on an as needed basis as well based on biochemical markers or flare symptoms. And one thing here I do want to emphasize is that the intest ultrasound isn't meant to replace the colonoscopy. You still need to do a colonoscopy around 6 to 12 months after starting therapy to confirm cause of healing. But like uh you know, eco co protect N and C R P, it's a really good adjunct um modality for disease assessment. So now what about ultrasound and ulcer colitis? This has a kind of a uh interesting history to it. So, you know, in medical school, we're generally taught that ulcer colitis is a mucosal mucosal disease as opposed to Crohn's disease, which is a uh transmittal disease, which makes sense that we're measuring bowel thickness. And so early on, people weren't really quite thrilled with the application of ultrasound and ulcer colli based on that um principle. But more and more studies have shown that in fact, yes, ultrasound has a really defined role, definite role, I mean in uh ultra in ulcer colitis. And this was really well highlighted in a recent study called the Trust U C study. It was a multi center study uh done in Germany where they recruit about 250 patients with ulcer colitis with active disease. And their primary outcome was to determine the percent of normalization of bowel thickness at week 12. And those with clo clinical response to starting a new therapy. And one of the highlights of the study was that the majority of bowel response was observed at week two. So in this graph here on the left, um as you can see, there's a dramatic decrease in bowel thickness within two weeks of the sigma colon and the descending colon. And there's also a significant decrease in um the color Doppler signal or hyper uh but within two weeks of starting a new therapy. And so, in their primary outcome, what they found was that in those who had bowel wall thickness normalization, there was a higher proportion of patients who had clinical response over 12 compared to those who never, who didn't achieve uh bowel wall thickness normalization. And to illustrate what this looks like in, in, you know, at bedside. Um this was a patient that my colleague, Mike Dollinger had seen a few months ago. Um This was a uh a young woman who presented with, who had left side ulcer colitis had been on influx map for six months and had come in and on pre them. He did an ultrasound at bedside and found that the sigmoid colon was thicken to about five millimeters. And as you can see here, there uh was a limber two uh score for hyper and they start her on to. And within two weeks, you can see that the bowel wall has normalized and there's no more uh vast uh color Doppler signal observed. So this is, you know, this is kind of the pinnacle of tests. Ultrasound. You get real time answers with the diagnosis and you can uh rapidly assess if um the patient is responding to treatment. So this is an emerging uh area uh for tests, ultrasound and ulcer colitis is can we use it to predict outcomes for acute severe U C? So, in this study, uh what they found is that those who responded to steroid therapy had uh were more likely to have bowel wall thickness reduction than those who didn't. And this is still under investigation. But it is a very exciting area that I just want to introduce to have everybody stay tuned for the future. And lastly, I want to touch up on emerging uh in future directions of tesol ultrasound. As you all know, transmittal healing is associated with superior long term outcomes. But there wasn't a great way to really assess that in clinical trials, access for MRI S, which you can be arguably it's not as accessible. So more and more trials are probably gonna start incorporating ultrasound at the study. Uh end point, this was one of the first to do it. This is the Stardust trial and that Gil had touched on before and in, in a sub study, they used um intense ultrasound to see how patients responded from a sonographic standpoint. They found progressive response from weeks 48 4 to 48. Um So really interesting and uh you know, I'm excited to, to see what and how um ultrasound is gonna be incorporated in clinical trials in the future. Now, these are some of the other future directions. Uh There's a lot of room for multi collaboration. People are looking into A I. Uh we still don't understand how we can use ultrasound or predict treatment response. It's a great tool to understand transmittal healing. And there's a lot of room to develop novel uh diagnostic and monitoring techniques with just a simple software update. And I kind of see that like as a Tesla and there's just so much more room to learn how to use and position Te Ultrasound in I B D. So in summary, uh I us is sensitive and specific for detecting ulcer cola and Croon disease and monitoring disease activity. Its point of care exam means you get real time answers and that allows for real time answer. Uh sorry, real time answers to make you can make for real time decisions as well. And it's more acceptable for patients and what bears associated more commonly uh used disease monitoring modalities. If you wanna learn more about te sound, there's the intestinal uh bell ultrasound group and this is the website, they have a formalized curriculum to get people trained in intestinal ultrasound. And if you're, if you want to email me or reach out to me on Twitter at Doctor Phil underscore go, I'd be happy to answer any questions that you may have. Uh I wanna thank everybody for their time and uh and uh have a great day. Created by
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