Intestinal ultrasonography in adults with Crohn's disease: a 2020 update.

In the last years intestinal ultrasonography (IUS) has increased its role in the management of inflammatory bowel diseases (IBD), that include Crohn's disease (CD) and ulcerative colitis. This is due to the fact that IUS is a non-invasive, inexpensive, and well-tolerated examination technique. Furthermore, it allows a real-time diagnosis with no radiation exposure. Usually, convex and linear probes with frequency between 3.5 and 12 MHz are used, also with the Color- Power Doppler. Focusing on CD, the IUS images of clinical interest are: bowel wall thickening (greater than 3 mm), pseudostratification and the wall vascularization. Moreover, IUS demonstrates inflammatory mass, loss of colonic haustration and the complications of the disease, such as stenosis, abscesses, and fistulas as well as other extraintestinal manifestations, such as lymph node enlargement and changes in the appearance of the mesenteric adipose tissue (creeping fat). Oral and intravenous contrast are used to obtain a better visualization of the bowel wall and to increase the diagnostic accuracy of IUS. In particular, intravenous contrast, administered during the procedure, allows to differentiate between active disease (bowel wall enhancement) and the fibrostenotic complications. Contrast-enhanced ultrasonography (CEUS) was proven to be useful in the follow-up and the disease recurrence detection. Beyond the support in the initial diagnosis, IUS has an important role in the follow-up of patients with CD, to monitor the response to the medical therapy and to detect possible complications. Furthermore, it can predict the recurrences after surgery, with more accuracy if Color-Doppler is used.

Power Doppler sonography to predict the risk of surgical recurrence of Crohn's disease.

PURPOSE: The aim of this work is to investigate the role of power Doppler sonography as an additional predictor of surgical recurrence in Crohn's disease. METHODS: A sample of 33 patients, with ileal or ileocolonic Crohn's disease, that had underwent intestinal resection, were retrospectively enrolled. All patients had bowel ultrasonography 7-16 months after resection. Power Doppler sonography of the preanastomotic ileum was evaluated as a possible prognostication tool to assess the risk of long-term need for reoperation. RESULTS: The absolute incidence of surgical recurrence in those who had a positive power Doppler was 42 %, while that of those who had a negative power Doppler was 28.6 %. Combining the power Doppler with bowel wall thickness, the surgical recurrence risk grew from 41.2 % of those with a positive power Doppler and thickness >3 mm to 55.6 % of those with a positive power Doppler and thickness >6 mm. CONCLUSIONS: Power Doppler look to be another useful prediction tool for the personalization of patient's care. It could be useful to perform power Doppler in all patients with a wall thickness >5 mm: for those who have a positive power Doppler it may be indicated as a more aggressive prophylactic therapy.

Role of bowel ultrasound as a predictor of surgical recurrence of Crohn's disease.

BACKGROUND: In Crohn's disease natural history, about 80% of the patients require surgery, which is not curative: unfortunately, the disease recurs in many patients. OBJECTIVE: To investigate the role of intestinal ultrasound to predict the risk of post-operative surgical recurrence in Crohn's disease. MATERIAL AND METHODS: A total of 196 patients, with ileal or ileocolonic Crohn's disease, undergoing intestinal resection, were retrospectively enrolled. All patients underwent bowel ultrasonography 6-15 months after resection. Wall thickness at the anastomosis level was measured, and thickening >3 mm was evaluated as risk factor of long-term need for reoperation. RESULTS: Patients who have a bowel wall thickness >3 mm have an risk ratio (RR) of surgical recurrence = 2.1 [95% confidence interval (CI) = 1.12-3.74] higher than those with a thickness of ≤3 mm. The absolute incidence of new surgical intervention is 13% in patients with thickness of 3 mm, 28% in patients with thickness >3 mm, 29,1% with thickness >4 mm, 34% with thickness >5 mm, and 40% with thickness >6 mm. CONCLUSIONS: Bowel wall thickness >3 mm at ultrasound may be a non-invasive predictor of early surgical recurrence after ileo-colonic resection.

Can single use negative pressure wound therapy be an alternative method to manage keloid scarring? A preliminary report of a clinical and ultrasound/colour-power-doppler study.

Keloid scarring represents a pathological healing where primary healing phenomenon is deviated from normal. Pico is a single use negative pressure wound therapy system originally introduced to manage open or just closed wounds. Pico dressing is made of silicone, and distributes an 80 mmHg negative pressure across wound bed. Combination of silicon layer and continuous compression could be a valid method to manage keloid scarring. Since November 2011, three patients were enrolled and evaluated before negative pressure treatment, at end of treatment (1 month) and 2 months later, through Vancouver Scar Scale (VSS), Visual Analog Scale (VAS) and a scoring system for itching. Ultrasound (US) and colour-power-doppler (CPD) examination was performed to evaluate thickness and vascularisation of the scar. One patient was discharged from study after 1 week. In last two patients, VSS, VAS and itching significantly improved after 1 month therapy and the results were stable after 2 months without any therapy. At end of therapy, the 'appearance of palisade vessels' disappeared in both cases at CPD exam; US showed a thickness reduction (average 43·8%). We propose a well-tolerated, non invasive treatment to manage keloid scarring. Prospective studies are necessary to investigate whether these preliminary observations are confirmed.

Negative pressure wound therapy using gauze and foam: histological, immunohistochemical and ultrasonography morphological analysis of the granulation tissue and scar tissue. Preliminary report of a clinical study.

Negative pressure wound therapy (NPWT) is becoming routine for the preparation of wounds prior to grafting for wound closure. We have been using both foam- and gauze-based NPWT to prepare wounds for closure prior to skin grafting and have obtained similar proportions of closed wounds; 7/7 for wounds treated with gauze-based NPWT and 11/11 for wounds treated with foam-based NPWT. In our follow-up consultations we observed that skin grafts on the foam-treated patients were less pliable than those on the gauze-treated patients. To assess what the mechanism of this effect might be, we compared the specific details of the treatments of both 11 foam and 7 gauze patients, including depth, location, patients' age and co-morbidity; biopsies of granulation and scar tissue were taken and stained with haematoxylin-eosin and by Masson's trichrome staining and conducted ultrasound analysis of the closed wounds, to see if there were features which explained those effects. All foam patients were treated at -125 mm Hg for an average of 25·9 days before skin grafts were applied. All gauze patients were treated at -80 mm Hg for an average of 24·7 days before skin grafts were applied. Biopsies of granulation tissue prior to skin grafting from five foam and four gauze-based NPWT patients did not reveal any obvious histological differences between the treatments. Ultrasound analysis of the skin-grafted wounds showed an average depth of scar tissue of 18 mm in the wound beds of the foam-treated wounds and 7 mm in the gauze-treated ones. Biopsies taken on the scar tissue after treatment with the gauze showed a minor tissue thickness and disorganisation and less sclerotic components. The findings of this preliminary analysis suggest that foam-based NPWT may induce a thicker layer of scar tissue beneath skin grafts than gauze-based NPWT which might explain a reduced pliability of the reconstructed bed. At present it is unclear which mechanism might be responsible for the difference in pressure (-125 versus -80 mm Hg), either the length of the time taken to reconstruct the wound bed or the intrinsic nature of the foam or gauze on the tissue surface. Prospective studies are necessary to investigate whether these preliminary observations are confirmed and to investigate what the mechanism might be.

Ultrasonography for the monitoring of subcutaneous damage in Mycobacterium ulcerans infection (Buruli ulcer).

We used ultrasonography to evaluate the nature and the extent of subcutaneous damage provoked by Mycobacterium ulcerans (M. ulcerans) and to investigate the possible involvement of the tributary lymph nodes during the various stages of progression of Buruli ulcer. Nineteen patients affected by M. ulcerans infection in Benin, West Africa, were studied. Ultrasonography was performed on all subjects, except one, at the site of nonulcerated lesions and/or at perilesional site. The tributary lymph nodes were also studied in six patients. Ultrasound (US) evaluation was carried out using a 10 MHz linear probe and all lesions were compared with the homologous unaffected controlateral site. The ultrasonography showed relevant alterations at the dermo-hypodermic level, in agreement with histological specimens. In the active forms of the disease, these alterations are characterized by significant oedematous imbibition of the adipose tissue and necrosis (adiponecrosis) that leads to varying irregularities in the echogenicity of the hypodermis, which is generally thicker. In agreement with the clinical examination, the lymph nodes in six patients evaluated, despite their possible histological involvement with necrotic phenomena described in literature in M. ulcerans infection, did not display significant alterations visible by ultrasonography. The US scanning we have performed is the first use of this technique for M. ulcerans infection. We have shown that it can reveal the subcutaneous depth and the peripheral extent of the pathological process and it is particularly useful for monitoring the efficacy of or resistance to antibiotic treatment, especially in extensive ulcero-oedomatose forms. Such monitoring offers also a useful guide to the surgeon allowing the reduction or postponement of the removal of the large cutaneous areas that were carried out until recently.