Procedural and anthropometric factors associated with musculoskeletal injuries among gastroenterology endoscopists.

BACKGROUND AND AIMS: Musculoskeletal (MSK) injuries among gastroenterologists are common. Our study describes risk factors and consequences of injury by comparing provider-specific anthropometric and objective procedural data to self-reported injury patterns. METHODS: A validated MSK symptom survey was sent to gastroenterologists to gauge prevalence, distribution, and severity of active injury. Respondents' procedural activities over 7 years were collected via an endoscopic database. RESULTS: 64 surveys were completed. 54 respondents had active pain; 53.1% reported activity-limiting injury. Activity-limiting injuries lead to longer colonoscopy times (25.3 vs. 22.1 min, P = 0.03) and lower procedural volumes (532 vs. 807, P = 0.01). Hand/wrist injuries yielded longer colonoscopy insertion times (9.35 vs. 8.21 min, P = 0.03) and less hands-on scope hours (81.2 vs. 111.7 h, P = 0.04). Higher esophagogastroduodenoscopy volume corelated with shoulder injury (336.5 vs. 243.1 EGDs/year, P = 0.04). Females had more foot injuries (P = 0.04). CONCLUSION: Activity-limiting MSK symptoms/injuries affect over 50% of endoscopists with negative impact on procedural volume and efficiency.

Colorectal Cancer and Polyp Detection Using a New Preparation-Free, Colon-Scan Capsule: A Pilot Study of Safety and Patient Satisfaction.

BACKGROUND: Current strategies to prevent colorectal cancer (CRC) vary considerably regarding safety, invasiveness, and patient satisfaction. A known deterrent for patients is the required bowel cleansing for colonoscopy. A new colon-scan capsule system is a unique preparation-free approach that provides structural information on colonic mucosa intended for detection of colorectal polyps and masses. AIMS: The aim of this study was to determine safety and patient satisfaction with the colon-scan capsule. METHODS: Prospective single-arm pilot study conducted at two tertiary care centers. Patients with a pre-scheduled colonoscopy for CRC screening or surveillance were included. Patients participating in this study underwent the colon-scan capsule and colonoscopy. Safety was defined by the occurrence of procedure or device-related adverse events. Satisfaction was based on survey questionnaires using a scoring system 1 (strongly disagree) to 5 (strongly agree). Patient satisfaction with the colon-scan capsule was compared to colonoscopy. RESULTS: Forty patients were included (52.9 [5.7] years; 64.1% females). There were no serious adverse events and no occurrences of capsule retention. The most common (12.5%) complaint was self-limiting abdominal cramping. Satisfaction questionnaires were completed by more than 87% of patients, with patients likely to recommend the capsule (score 4.1 [1.03]) compared to colonoscopy (score 2.8 [1.2]), p = 0.001. CONCLUSIONS: The new prepless colon-scan capsule system is an innovative, minimally invasive technology with demonstrated safety and high patient satisfaction. A multicenter pivotal study is planned to validate the performance, safety, and accuracy of polyp detection using the capsule system in comparison with colonoscopy.

The utility of a dual-phase, dual-energy CT protocol in patients presenting with overt gastrointestinal bleeding.

BACKGROUND: Due to their easy accessibility, CT scans have been increasingly used for investigation of gastrointestinal (GI) bleeding. PURPOSE: To estimate the performance of a dual-phase, dual-energy (DE) GI bleed CT protocol in patients with overt GI bleeding in clinical practice and examine the added value of portal phase and DE images. MATERIALS AND METHODS: Consecutive patients with GI bleeding underwent a two-phase DE GI bleed CT protocol. Two gastroenterologists established the reference standard. Performance was estimated using clinical CT reports. Three GI radiologists rated confidence in GI bleeding in a subset of 62 examinations, evaluating first mixed kV arterial images, then after examining additional portal venous phase images, and finally after additional DE images (virtual non-contrast and virtual monoenergetic 50 keV images). RESULTS: 52 of 176 patients (29.5%) had GI bleeding by the reference standard. The overall sensitivity, specificity, and positive and negative predictive values of the CT GI bleed protocol for detecting GI bleeding were 65.4%, 89.5%, 72.3%, and 86.0%, respectively. In patients with GI bleeding, diagnostic confidence of readers increased after adding portal phase images to arterial phase images (p = 0.002), without additional benefit from dual energy images. In patients without GI bleeding, confidence in luminal extravasation appropriately decreased after adding portal phase, and subsequently DE images (p = 0.006, p = 0.018). CONCLUSION: A two-phase DE GI bleed CT protocol had high specificity and negative predictive value in clinical practice. Portal venous phase images improved diagnostic confidence in comparison to arterial phase images alone. Dual-energy images further improved radiologist confidence in the absence of bleeding.

MRI-detected extramural venous invasion of rectal cancer: Multimodality performance and implications at baseline imaging and after neoadjuvant therapy.

MRI is routinely used for rectal cancer staging to evaluate tumor extent and to inform decision-making regarding surgical planning and the need for neoadjuvant and adjuvant therapy. Extramural venous invasion (EMVI), which is intravenous tumor extension beyond the rectal wall on histopathology, is a predictor for worse prognosis. T2-weighted images (T2WI) demonstrate EMVI as a nodular-, bead-, or worm-shaped structure of intermediate T2 signal with irregular margins that arises from the primary tumor. Correlative diffusion-weighted images demonstrate intermediate to high signal corresponding to EMVI, and contrast enhanced T1-weighted images demonstrate tumor signal intensity in or around vessels. Diffusion-weighted and post contrast images may increase diagnostic performance but decrease inter-observer agreement. CT may also demonstrate obvious EMVI and is potentially useful in patients with a contraindication for MRI. This article aims to review the spectrum of imaging findings of EMVI of rectal cancer on MRI and CT, to summarize the diagnostic accuracy and inter-observer agreement of imaging modalities for its presence, to review other rectal neoplasms that may cause EMVI, and to discuss the clinical significance and role of MRI-detected EMVI in staging and restaging clinical scenarios.

Evaluating a combined bowel preparation for small-bowel capsule endoscopy: a prospective randomized-controlled study.

BACKGROUND: Capsule endoscopy (CE) is frequently hindered by intra-luminal debris. Our aim was to determine whether a combination bowel preparation would improve small-bowel visualization, diagnostic yield, and the completion rate of CE. METHODS: Single-blind, prospective randomized-controlled study of outpatients scheduled for CE. Bowel-preparation subjects ingested 2 L of polyethylene glycol solution the night prior to CE, 5 mL simethicone and 5 mg metoclopramide 20 minutes prior to CE and laid in the right lateral position 30 minutes after swallowing CE. Controls had no solid food after 7 p.m. the night prior to CE and no liquids 4 hours prior to CE. Participants completed a satisfaction survey. Capsule readers completed a small-bowel-visualization assessment. RESULTS: Fifty patients were prospectively enrolled (56% female) with a median age of 54.4 years and 44 completed the study (23 patients in the control group and 21 in the preparation group). There was no significant difference between groups on quartile-based small-bowel visualization (all P > 0.05). There was no significant difference between groups in diagnostic yield (P = 0.69), mean gastric (P = 0.10) or small-bowel transit time (P = 0.89). The small-bowel completion rate was significantly higher in the preparation group (100% vs 78%; P = 0.02). Bowel-preparation subjects reported significantly more discomfort than controls (62% vs 17%; P = 0.01). CONCLUSIONS: Combined bowel preparation did not improve small-bowel visualization but did significantly increase patient discomfort. The CE completion rate improved in the preparation group but the diagnostic yield was unaffected. Based on our findings, a bowel preparation prior to CE does not appear to improve CE performance and results in decreased patient satisfaction (ClinicalTrials.gov, No. NCT01243736).

An Imaging Stewardship Initiative to Reduce Low-Value Positron Emission Tomography-Computed Tomography Use in Hospitalized Patients.

This quality improvement initiative was aimed at reducing low-value Positron emission tomography-computed tomography (PET-CT) studies performed on hospital inpatients. Requests for PET-CT with a predetermined low-value indication triggered a requirement for the ordering provider to call the Nuclear Medicine radiologist to discuss the case for approval of the testing. A retrospective review of inpatient PET-CT approximately 2 years immediately before and after the implementation revealed a 20.6% decrease in scans for low-value indications after the intervention, from 0.397 to 0.315 studies per day (p < .05; CI -0.158 to -0.005). The overall daily rate of PET-CT was reduced by 23%. Of the 12 low-value indications, 7 had reduced volumes (aggregate 43 fewer scans), 1 was unchanged, and 4 showed an increase in volumes (aggregate of 10 additional scans). Several common indications for inpatient PET-CT that were not targeted for reduction by this intervention also demonstrated large decreases in volumes during the intervention.

Imaging Findings of Ileal Inflammation at Computed Tomography and Magnetic Resonance Enterography: What do They Mean When Ileoscopy and Biopsy are Negative?

BACKGROUND AND AIMS: Our goal was to determine the importance of ileal inflammation at computed tomography or magnetic resonance enterography in Crohn's disease patients with normal ileoscopy. METHODS: Patients with negative ileoscopy and biopsy within 30 days of CT or MR enterography showing ileal inflammation were included. The severity [0-3 scale] and length of inflammation within the distal 20 cm of the terminal ileum were assessed on enterography. Subsequent medical records were reviewed for ensuing surgery, ulceration at ileoscopy, histological inflammation, or new or worsening ileal inflammation or stricture on enterography. Imaging findings were classified as: Confirmed Progression [subsequent surgery or radiological worsening, new ulcers at ileoscopy or positive histology]; Radiologic Response [decreased inflammation with medical therapy]; or Unlikely/Unconfirmed Inflammation. RESULTS: Of 1471 patients undergoing enterography and ileoscopy, 112 [8%] had imaging findings of inflammation with negative ileoscopy, and 88 [6%] had negative ileoscopy and ileal biopsy. Half [50%; 44/88] with negative biopsy had moderate/severe inflammation at enterography, with 45%, 32% and 11% having proximal small bowel inflammation, stricture or fistulas, respectively. Two-thirds with negative biopsy [67%; 59/88] had Confirmed Progression, with 68%, 70% and 61% having subsequent surgical resection, radiological worsening or ulcers at subsequent ileoscopy, respectively. Mean length and severity of ileal inflammation in these patients was 10 cm and 1.6. Thirteen [15%] patients had Radiologic Response, and 16 [18%] had Unlikely/Unconfirmed Inflammation. CONCLUSION: Crohn's disease patients with unequivocal imaging findings of ileal inflammation at enterography despite negative ileoscopy and biopsy are likely to have active inflammatory Crohn's disease. Disease detected by imaging may worsen over time or respond to medical therapy.

The evolving role of imaging for small bowel neuroendocrine neoplasms: estimated impact of imaging and disease-free survival in a retrospective observational study.

PURPOSE: To determine how small bowel neuroendocrine neoplasms (SBNEN's) are diagnosed and examine the effect of CT enterography (CTE) on diagnosis and rates of disease-free survival. METHODS: Histopathologically-confirmed SBNEN's diagnosed at our institution between 1996 and 2016 were identified. Clinical presentation, radiology, endoscopy, surgery, and pathology reports were reviewed and compared between consecutive 5-year periods. RESULTS: Of the 178 SBNEN initially diagnosed at our institution, the incidence increased 12-fold from 9 (during 1996-2000) to 114 (during 2011-2016). Comparing the first 5 to the last 5 years, GI bleeding and abdominal pain increased significantly as indications (with both increasing from 0 to > 25%, p ≤ 0.023). Initial diagnosis by radiology increased 2-fold [from 33% (n = 3) to 66% (n = 75); p = 0.263]. Detection of a small bowel mass and the suggestion that SBNEN was present varied significantly between imaging modalities (p < 0.0001; CTE - 95% (52/55) and 91% (50/55) vs. abdominal CT 45% (37/85) and 35% (29/85), respectively). Recurrence rates increased with SBNEN size (p = 0.012; e.g., of SBNEN diagnosed by endoscopy, 18% of SBNEN measuring 0.6 ± 0.3 cm recurred vs. 75% measuring 3.7 ± 1.0 cm). Rates of disease-free survival, and the incidence of local and liver metastases were decreased when tumors were first identified by CTE rather than other CT/MR imaging modalities (p = 0.0034, 0.0475, and 0.0032, respectively). CONCLUSION: There has been a dramatic increase in SBNENs detected by CTE and endoscopy over the last 20 years. SBNEN's detected by CTE and small tumors detected at endoscopy have longer disease-free survival after surgical resection.

Prospective multicenter study to evaluate capsule endoscopy competency using a validated assessment tool.

BACKGROUND AND AIMS: Capsule endoscopy (CE) is an established, noninvasive modality for examining the small bowel. Minimum training requirements are based primarily on guidelines and expert opinion. A validated tool to assess the competence of CE is lacking. In this prospective, multicenter study, we determined the minimum number of CE procedures required to achieve competence during gastroenterology fellowship; validated a capsule competency test (CapCT); and evaluated any correlation between CE competence and endoscopy experience. METHODS: We included second- and third-year gastroenterology fellows from 3 institutions between 2013 and 2018 in a structured CE training program with supervised CE interpretation. Fellows completed the CapCT with a maximal score of 100. For comparison, expert faculty completed the same CapCT. Trainee competence was defined as a score ≥90% compared with the mean expert score. Fellows were tested after 15, 25, and 35 supervised CE interpretations. CapCT was validated using expert consensus and item analysis. Data were collected on the number of previous endoscopies. RESULTS: A total of 68 trainees completed 102 CapCTs. Fourteen CE experts completed the CapCT with a mean score of 94. Mean scores for fellows after 15, 25, and 35 cases were 83, 86, and 87, respectively. Fellows with at least 25 interpretations achieved a mean score ≥84 in all 3 institutions. CapCT item analysis showed high interobserver agreement among expert faculty (k = 0.85). There was no correlation between the scores and the number of endoscopies performed. CONCLUSION: After a structured CE training program, gastroenterology fellows should complete a minimum of 25 supervised CE interpretations before assessing competence using the validated CapCT, regardless of endoscopy experience.

Patient-oriented education and visual-aid intervention are inadequate to identify patients with potential capsule retention: a prospective randomized study.

Background/aims: The key procedure-related risk with video capsule endoscopy (VCE) is capsule retention, which should be suspected in patients who have not reported capsule passage. The study aims were to determine the frequency of capsule passage visualization and the difference in self-reporting of capsule passage between patients who receive patient-oriented education (POE) and patients who receive POE and a visual aid intervention in the form of a wrist band (WB). Methods: This was a prospective randomized study that enrolled patients undergoing VCE. Patients were randomly assigned to a POE group versus a POE and WB group. POE consisted of verbal education and an information booklet. Both groups received instructions to notify the study team regarding capsule passage. Results: Sixty patients (mean age 57 ± 18 years; 61% female) were included. A total of 57 patients were included in the analysis (3 lost to follow-up; 28 in POE group; 29 in WB group). Capsule passage status was reported by 68% without significant difference between POE and WB groups (72% vs. 64%; p = .51). Capsule passage status was obtained from all 57 patients with the addition of a proactive follow-up. Only 56% (n = 32) reported visualizing capsule passage. Of the remaining patients who did not visualize capsule passage, 60% (n = 15) reported on this without significant difference between the POE and WB groups (p = .23). Conclusions: Lack of visualization of capsule passage is a poor indicator of retention. Self-reporting of VCE passage status is suboptimal and the addition of a visual aid did not improve this parameter.

Multiphase Computed Tomographic Enterography: Diagnostic Yield and Efficacy in Patients With Suspected Small Bowel Bleeding.

OBJECTIVE: To estimate the diagnostic yield and efficacy of multiphase computed tomographic enterography (mpCTE) for suspected small bowel bleeding in routine clinical practice. PATIENTS AND METHODS: All mpCTEs performed between January 1, 2006, and December 31, 2014, for suspected small bowel bleeding were included and classified by a gastroenterologist and an abdominal radiologist. The reference standard for a definitive diagnosis was balloon-assisted enteroscopic, angiographic, surgical, or pathologic results. Overall and lesion-specific diagnostic yield (DY), sensitivity, and positive predictive value were calculated. The relationship of mpCTE diagnosis and continued bleeding or iron supplementation was examined using logistic regression in patients with at least 1 year of follow-up. RESULTS: We identified 1087 patients who had an initial mpCTE indication of small bowel bleeding. The overall DY was 31.6% (344 of 1087 patients; 95% CI, 29.0%-35.0%), higher for an indication of small bowel bleeding that was overt or occult with heme-positive stool vs occult with only iron-deficiency anemia (DY, 35.0% [170 of 486] and 35.3% [66 of 187] vs 26.1% [108 of 414]; P=.004 and P=.02, respectively). The highest sensitivity and positive predictive value were for small bowel masses (90.2% [55 of 61] and 98.2% [55 of 56], respectively). Higher risk of future bleeding and iron supplementation was seen with a negative result on mpCTE (odds ratio [OR], 1.91; 95% CI, 1.28-2.86), lack of surgical intervention (OR, 4.37; 95% CI, 2.31-8.29), or discrepant balloon-assisted enteroscopic findings (OR, 2.50; 95% CI, 1.03-6.09). CONCLUSION: Multiphase computed tomographic enterography has a higher rate of detection in patients with overt bleeding or heme-positive stool. The procedure provides actionable targets for further intervention and leads to substantially reduced rates of rebleeding in long-term follow-up.

CT for Evaluation of Acute Gastrointestinal Bleeding.

Acute gastrointestinal (GI) bleeding is common and necessitates rapid diagnosis and treatment. Bleeding can occur anywhere throughout the GI tract and may be caused by many types of disease. The variety of enteric diseases that cause bleeding and the tendency for bleeding to be intermittent may make it difficult to render a diagnosis. The workup of GI bleeding is frequently prolonged and expensive, with examinations commonly needing to be repeated. The use of computed tomography (CT) for evaluation of acute GI bleeding is gaining popularity because it can be used to rapidly diagnose active bleeding and nonbleeding bowel disease. The CT examinations used to evaluate acute GI bleeding include CT angiography and multiphase CT enterography. Understanding the clinical evaluation of acute GI bleeding, including the advantages and limitations of endoscopic evaluation, is necessary for the appropriate selection of patients who may benefit from CT. Multiphase CT enterography is used primarily to evaluate stable patients who have undergone upper and lower endoscopy without identification of a bleeding source. CT angiography is used to examine stable and unstable patients who respond to resuscitation, are believed to be actively bleeding, and are considered unlikely to have an upper GI source of hemorrhage. In the emergent setting, CT may yield critical information regarding the presence, location, and cause of active bleeding-data that can guide the choice of subsequent therapy. Recent developments in the use of and techniques for performing CT angiography have made it a potential first-line tool for evaluating acute GI bleeding. ©RSNA, 2018.

Clinical Benefit of Capsule Endoscopy in Crohn's Disease: Impact on Patient Management and Prevalence of Proximal Small Bowel Involvement.

Background: Ileocolonoscopy and computed tomography (CT) or magnetic resonance (MR) enterography (CTE/MRE) are utilized to evaluate patients with small bowel (SB) Crohn's disease (CD). The purpose of our study was to estimate the impact of capsule endoscopy (CE) on patient management after clinical assessment, ileocolonoscopy, and CTE/MRE. Methods: We prospectively analyzed 50 adult CD patients without strictures at clinically indicated ileocolonoscopy and CTE/MRE exams. Providers completed pre- and post-CE clinical management questionnaires. Pre-CE questionnaire assessed likelihood of active SBCD and management plan using a 5-point level of confidence (LOC) scales. Post-CE questionnaire assessed alteration in management plans and contribution of CE findings to these changes. A change of ≥2 on LOC scale was considered clinically meaningful. Results: Of the 50 patients evaluated (60% females), median age was 38 years, median disease duration was 3 years, and median Crohn's Disease Activity Index (CDAI) score was 238 points. All CTE/MRE studies were negative for proximal disease. CE detected proximal disease in 14 patients (28%) with a median Lewis score of 215 points. CE findings altered management in 17 cases (34%). The most frequent provider-perceived benefits of CE were addition of new medication (29%) and exclusion of active SB mucosal disease (24%). Conclusion: CE is a safe imaging modality that alters clinical management in patients with established SBCD by adding incremental information not available at ileocolonoscopy and cross-sectional enterography.

Predictors of Durability of Radiological Response in Patients With Small Bowel Crohn's Disease.

Background: The long-term significance of radiological transmural response (TR) as a treatment goal at the first follow-up scan in small bowel Crohn's disease (CD) has been previously shown. We examined the durability of a long-term strategy of treating to a target of radiological TR and the influence of baseline predictors on the maintenance of TR. Methods: Small bowel CD patients between January 1, 2002, and December 31, 2014, were identified with serial computed tomography enterography (CTE)/magnetic resonance enterography (MRE) before and after initiation of therapy or on maintenance therapy. Overall TR (inflammatory lesions with/without strictures) w1as characterized by abdominal radiologists in up to 5 small bowel lesions per patient at each serial scan until last follow-up or small bowel resection, as response, partial response, or nonresponse. The rate of conversion between TR states and transition to surgery, including the effect of baseline patient/disease characteristics, was examined using a multistate model (mstate R-package). Results: CD patients (n = 150, 705 CTE/MRE) with a median of 4 CTE/MRE during 4.6 years of follow-up, 49% with ileal-only distribution, had 260 examined bowel segments. Conversion from response to partial response/nonresponse was 37.4% per year of follow-up with no transitions seen directly from response to surgery. Current smoking status (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.1-4.3) and internal penetrating disease at baseline scan (HR, 2.2; 95% CI, 1.2-4.1) were associated with a 2-fold increased risk of transition from partial response/nonresponse to surgery. Conclusions: Achievement and maintenance of radiological response is associated with avoidance of small bowel surgery. Continued follow-up with CTE/MRE is recommended to identify loss of response, especially in current smokers and patients with internal penetrating disease at baseline CTE/MRE.

Reproducible imaging features of biologically aggressive gastrointestinal stromal tumors of the small bowel.

PURPOSE: To identify reproducible CT imaging features of small bowel gastrointestinal stromal tumors (GIST) that are associated with biologic aggressiveness. METHODS: Patients with histologically proven small bowel GISTs and CT enterography or abdominopelvic CT were included. Biologic aggressiveness was established based on initial histologic grading (very low risk to malignant), with "malignant" assigned if recurrence or metastases developed subsequently. CT exams were independently evaluated by three gastrointestinal radiologists for tumor size, growth pattern, enhancement, tumor borders, necrosis, calcification, ulceration, multiplicity, internal air or enteric contrast, nodal metastasis, liver metastasis, peritoneal metastasis, ascites, and draining vein size. Inter-observer variability and imaging features associated with high-grade and malignant small bowel GISTs were determined. RESULTS: Of 78 patients with small bowel GISTs, 10/78 (13%) were high grade and 18/78 (23%) were malignant. There was moderate to substantial inter-observer agreement (Kappa > 0.4) for all findings except tumor border, ulceration, and nodal metastases. Tumor size, irregular or invasive tumor border, necrosis, liver metastasis, ascites, and iso-enhancement were associated with high-grade/malignant small bowel GISTs (p < 0.04). Internal air or enteric contrast and peritoneal metastases additionally predicted malignant behavior (p < 0.03). When imaging features predicting malignant small bowel GISTs were absent and size was ≤ 3 cm, 0% (0/16), 5% (1/19), and 5% (1/17) of patients had high grade, and 0% (0/16, 0/19, and 0/17) had malignant tumors for the three readers, respectively. CONCLUSION: Multiple, reproducibly identified, small bowel GIST imaging features suggest biologic aggressiveness. The absence of these imaging features may identify small tumors that can be followed in asymptomatic or high-risk patients.

Endoscopic and Radiographic Assessment of Crohn's Disease.

Crohn's disease is a chronic inflammatory disorder that can progress to obstructive and penetrating complications. Although clinical symptoms are an important component of therapy, they correlate poorly with objective measures of inflammation. The treatment targets have evolved from clinical improvement only to the addition of more objective measures, such as endoscopic mucosal healing and radiologic response, which have been associated with favorable long-term outcomes, including reduced hospitalizations, surgeries, and need for corticosteroids. There are multiple endoscopic and radiologic scoring systems that can aid in quantifying disease activity and response to therapy. These modalities and scoring tools are discussed in this article.

Crohn's disease diagnosis, treatment approach, and management paradigm: what the radiologist needs to know.

Crohn's disease is one of the major subtypes of idiopathic inflammatory bowel disease and is characterized by chronic transmural intestinal inflammation of the gastrointestinal tract anywhere from mouth to the anus, with a predilection for the small bowel. Cross-sectional imaging with computed tomography and magnetic resonance enterography plays a key role in confirming diagnosis, identifying and managing complications, assessing disease severity, and identifying response to medical therapy. This review will focus on the role of radiologists in the diagnosis and assessment of Crohn's disease. Additionally, a review of current medical therapy approaches, available medications, and side effects will be discussed. The review will also highlight key complications of medical therapy and associated diseases that should be evaluated by the radiologist with cross-sectional imaging.