A combination of bowel wall thickness and submucosa index is useful for estimating endoscopic improvement in ulcerative colitis: external validation of the Kyorin Ultrasound Criterion.

BACKGROUND: Endoscopic improvement (EI; a Mayo endoscopic subscore of 0 or 1) is considered a therapeutic target in ulcerative colitis (UC) treatment. The potential to estimate EI non-invasively is an advantage of intestinal ultrasound (IUS). In a previous study, we developed a new sonographic parameter, the submucosa index (SMI), calculated as the ratio of the submucosal thickness to bowel wall thickness (BWT), and reported that combining BWT and SMI results in a practical and promising criterion for estimating EI without color Doppler assessment. This study aimed to validate the EI estimation ability of our B mode-based criterion, the 'Kyorin Ultrasound Criterion for UC' (KUC-UC; BWT < 3.8 mm and SMI < 50%), using an external cohort. METHODS: Patients with UC who underwent IUS and colonoscopy within 15 days without a treatment change between examinations were included. IUS findings, including BWT, SMI, and modified Limberg score for vascularity of the colon, were assessed. RESULTS: Forty-four test pairs of IUS and colonoscopy examinations in a total of 122 colonic segments were analyzed. The KUC-UC showed positive predictive value (PPV) of 94.6% and negative predictive value (NPV) of 80.0% for EI. In comparison, PPV and NPV were 85.4% and 79.0%, respectively, for the common criterion BWT of < 3 mm, and 83.0% and 82.7% for the validated Milan Ultrasound Criteria (a score of ≤ 6.2). CONCLUSIONS: External validation showed that the KUC-UC using only B mode findings without complicated calculations is a feasible and accurate sonographic criterion for estimating the EI of UC.

Ratio of submucosal thickness to total bowel wall thickness as a new sonographic parameter to estimate endoscopic remission of ulcerative colitis.

BACKGROUND: The development of feasible, reliable parameters and criteria for intestinal ultrasound (IUS) to estimate endoscopic remission of ulcerative colitis (UC) is a crucial clinical challenge. Such parameters must be simple, objective, and reproducible so that IUS can be widely used in daily practice. We developed a new parameter called the submucosa index (SMI), defined as a percentage of the submucosal thickness (SMT) in the total bowel wall thickness (BWT), and investigated its clinical potential. METHODS: The inclusion criteria were performance of both IUS and endoscopy (sigmoidoscopy or colonoscopy) for UC and a ≤ 15-day time interval between IUS and endoscopy. Loss of stratification was defined as inability to identify the submucosa even with a BWT of > 3 mm. The vascularity of the colon was assessed by the modified Limberg score (mLS) and evaluated as bowel wall flow (BWF) ( -) or ( +) using color Doppler mode. A Mayo endoscopic subscore (MES) of 0 or 1 was defined as endoscopic remission. RESULTS: Seventy-four colonic segments were analyzed. The SMI, mLS, and BWF could distinguish an MES of 1 versus 2 (p < 0.05, p < 0.01, and adjusted p < 0.001, respectively). The criteria using the BWT and SMI and using the BWT and BWF had the same estimating ability for endoscopic remission (sensitivity, 70.0%; specificity, 97.7%; positive predictive value, 95.5%; and negative predictive value, 82.7%). CONCLUSION: The SMI is a practical, quantitative parameter based on the bowel wall structure and may be used to estimate endoscopic remission of UC.

Correlation between the macroscopic severity of Crohn's disease in resected intestine and bowel wall thickness evaluated by water-immersion ultrasonography.

Objectives: Transabdominal ultrasonography is a common and accurate tool for managing Crohn's disease (CD); however, the significance of the resulting data is poorly understood. This study was performed to determine the association between bowel wall thickness evaluated by water-immersion ultrasonography and macroscopic severity, namely, refractory inflammation and subsequent fibrosis in CD surgical specimens.Materials and methods: We retrospectively evaluated 100 segments of colon and small intestine from 27 patients with CD. The resected specimens were placed in saline postoperatively, and bowel wall thickness was measured by water-immersion ultrasonography and compared with macroscopic findings. Correlations between bowel wall thickness and macroscopic findings were assessed using analysis of variance and receiver operating characteristic curves.Results: According to the progression of macroscopic severity, the mean bowel wall thickness was increased as follows: macroscopically intact: 4.1 mm, longitudinal ulcer scars: 5.4 mm, longitudinal open ulcers: 6.0 mm, large ulcers: 6.4 mm, cobblestone-like lesions: 7.1 mm, and fibrotic strictures: 7.4 mm. For all lesions except longitudinal ulcer scars, the bowel wall thickness was significantly thicker than that of macroscopically-intact areas (p < .001). According to receiver operating characteristic curves, bowel wall thickness >4.5 mm was associated with CD lesions, and thickness >5.5 mm was associated with more severe lesions.Conclusions: The bowel wall thickness of CD lesions was evaluated by water-immersion ultrasonography correlated with macroscopic disease severity.

Doppler ultrasound findings correlate with tissue vascularity and inflammation in surgical pathology specimens from patients with small intestinal Crohn's disease.

BACKGROUND: Crohn's disease (CD) is routinely evaluated using clinical symptoms, laboratory variables, and the CD activity index (CDAI). However, clinical parameters are often nonspecific and do not precisely reflect the actual activity of CD small-intestinal lesions. The purposes of this prospective study were to compare color Doppler ultrasound (US) findings with histological findings from surgically resected specimens and confirm the hypothesis that color Doppler US can distinguish tissue inflammation and fibrosis. METHODS: Among 1764 consecutive patients who underwent color Doppler US examinations, 10 patients with CD (12 small-intestinal CD lesions) who underwent US examinations before elective small-intestine resection were evaluated in the present study. Areas of thickened intestinal walls were evaluated in terms of blood flow using color Doppler US imaging. The blood flow was semiquantitatively classified as "hyper-flow" and "hypo-flow" according to the Limberg score. Resected lesions were macroscopically and histopathologically processed. Inflammatory cell infiltration, fibrosis and vascularity were evaluated by myeloperoxidase (granulocytes), CD163 (macrophages), CD79a (B cells), CD3 (T cells), Masson's trichrome (fibrosis), and factor VIII staining (vascular walls). All histopathological images were entered into virtual slide equipment and quantified using a quantitative microscopy integrated system (TissueMorph™). RESULTS: There were no significant differences in disease features or laboratory findings between "hypo-flow" lesions (n = 4) and "hyper-flow" lesions (n = 8). Histopathologically, "hyper-flow" lesions showed significantly greater bowel wall vascularity (factor VIII) (p = 0.047) and inflammatory cell infiltration, including CD163 macrophages (p = 0.008), CD3 T cells, and CD79a B cells (p = 0.043), than did "hypo-flow" lesions. There was no apparent association between the blood flow and CDAI. CONCLUSIONS: In this study, active CD lesions were macroscopically visible in surgical specimens of patients with increased blood flow on preoperative color Doppler US imaging. Additionally, these CD lesions exhibited significantly greater vascularity and numbers of inflammatory leukocytes microscopically. Color Doppler US may predict tissue inflammation and fibrosis in small-intenstinal CD lesions.

Use of color Doppler ultrasonography for evaluating vascularity of small intestinal lesions in Crohn's disease: correlation with endoscopic and surgical macroscopic findings.

OBJECTIVE. Ultrasonography (US) is a simple, inexpensive and minimally invasive method. We evaluated the vascularity of small intestinal lesions in Crohn's disease using color Doppler US (CD-US) and retrospectively compared them with endoscopic and surgical macroscopic findings. MATERIAL AND METHODS. In order to compare CD-US and endoscopic findings, 108 Crohn's disease patients who underwent examination of the terminal ileum by both colonoscopy and CD-US were included in the study. Vascularity was evaluated in CD-US using a semiquantitative method, the Limberg score. We analyzed correlations between Limberg score and simple endoscopic score for Crohn's disease (SES-CD), an index reflecting endoscopic activity. Scores of SES-CD 3 and higher were defined as endoscopically active. For comparison with surgical macroscopic findings, 22 Crohn's disease patients who received CD-US and subsequent iliectomies were included. Lesions with apparent open ulcers were defined as active, and those without as non-active. These findings were compared with the Limberg score. RESULTS. A substantial positive correlation was observed between Limberg scores and SES-CD (ρ = 0.709 [p < 0.001]). Notably, all 27 cases with a Limberg score of 3 or 4 were classified as endoscopically active. Compared to surgical macroscopic activity, Limberg scores of active lesions were significantly higher than those of non-active lesions (p = 0.005). In particular, all 11 cases with a Limberg score of 3 or 4 were classified as active lesions. CONCLUSION. Vascularity of small intestinal lesions of Crohn's disease evaluated by CD-US with Limberg score is well correlated with endoscopic and surgical macroscopic findings.