Relevance of dynamic studies with magnetic resonance enterography in Crohn's disease / Relevancia de los estudios dinámicos en Resonancia Entérica en la Enfermedad de Crohn

INTRODUCTION: A proper quantification of the inflammatory activity in Crohn's disease (CD) lesions is needed to establish the appropriate management for each patient. The aim of this study is to evaluate the inflammatory activity of affected segments in small bowel lesions using dynamic studies of magnetic resonance enterography (MRE) in patients undergoing surgery, and their correlation with the level of inflammation and histological fibrosis of the surgical piece. METHODS: A prospective, consecutive, observational, clinical study was conducted that included all the patients with small bowel CD that underwent surgery in this center between March 2011 and September 2013. Diagnosis was established according to Lennard-Jones criteria and the Montreal classification. All the patients underwent MRE within three months before surgery, using a routine protocol involving Liver Acquisition with Volume Acceleration-Extended Volume (LAVA-XV) sequence for the dynamic studies before intravenous administering of gadolinium and 30, 70, 120, and 420s after administering this. The results allowed the designing of graphics with different uptake patterns. The Chiorean classification was used in the histological analysis, as well as a modified version published previously by this study group. RESULTS: A total of 28 patients with 47 lesions were analyzed. There was a significant correlation between both curve patterns, including the modified Chiorean classification (p < 0.0001) as well as the level of inflammation (p < 0.0001) and fibrosis (p < 0.002). Inflammatory patterns of dynamic studies are related to histological findings with 80.9% accuracy (sensitivity=75.7%; specificity=100%). CONCLUSION: There is a high correlation between dynamic enhancement studies and the level of inflammatory activity. MRE is a suitable tool to differentiate between inflammatory and fibrotic lesions, making it useful to decide the appropriate management of each patient

INTRODUCCIÓN: Se necesita una cuantificación adecuada de la actividad inflamatoria en las lesiones de la enfermedad de Crohn (EC) para establecer el tratamiento adecuado para cada paciente. El objetivo de este estudio es evaluar la actividad inflamatoria de los segmentos afectados en las lesiones del intestino delgado mediante estudios dinámicos de enterografía por resonancia magnética (ERM). MÉTODOS: Estudio prospectivo, consecutivo, observacional y clínico, que incluye a todos los pacientes con EC del intestino delgado que se sometieron a cirugía en nuestro centro entre marzo de 2011 y septiembre de 2013. El diagnóstico se estableció de acuerdo con los criterios de Lennard-Jones y la clasificación de Montreal. Todos los pacientes se sometieron a una ERM dentro de los 3 meses previos a la cirugía, aplicando el protocolo de rutina y secuencias preestablecidas. Para el estudio dinámico se empleó la secuencia Adquisición hepática con aceleración de volumen-Volumen extendido (LAVA-XV), antes de la administración intravenosa (IV) de gadolinio, y 30, 70, 120 y 420s después de esta administración. Los resultados permiten diseñar gráficos con diferentes patrones de captación. En el análisis histológico se utilizó la clasificación de Chiorean, así como una versión modificada creada por nuestro grupo de estudio. RESULTADOS: En total se analizaron 28 pacientes con 47 lesiones. Se detectó una correlación significativa entre ambos patrones de curva, incluyendo la clasificación de Chiorean modificada (p < 0,0001), así como el grado inflamatorio (p < 0,0001) y de fibrosis (p < 0,002). Los patrones inflamatorios de los estudios dinámicos se relacionaron con los hallazgos histológicos con una precisión del 80,9% (S=75,7%; E=100%). CONCLUSIÓN: Existe una alta correlación entre los estudios dinámicos y el grado de actividad inflamatoria. La ERM constituye una herramienta adecuada para diferenciar entre lesiones inflamatorias y fibróticas, siendo útil para colaborar en la decisión terapéutica

Relevance of dynamic studies with magnetic resonance enterography in Crohn's disease.

INTRODUCTION: A proper quantification of the inflammatory activity in Crohn's disease (CD) lesions is needed to establish the appropriate management for each patient. The aim of this study is to evaluate the inflammatory activity of affected segments in small bowel lesions using dynamic studies of magnetic resonance enterography (MRE) in patients undergoing surgery, and their correlation with the level of inflammation and histological fibrosis of the surgical piece. METHODS: A prospective, consecutive, observational, clinical study was conducted that included all the patients with small bowel CD that underwent surgery in this center between March 2011 and September 2013. Diagnosis was established according to Lennard-Jones criteria and the Montreal classification. All the patients underwent MRE within three months before surgery, using a routine protocol involving Liver Acquisition with Volume Acceleration-Extended Volume (LAVA-XV) sequence for the dynamic studies before intravenous administering of gadolinium and 30, 70, 120, and 420s after administering this. The results allowed the designing of graphics with different uptake patterns. The Chiorean classification was used in the histological analysis, as well as a modified version published previously by this study group. RESULTS: A total of 28 patients with 47 lesions were analyzed. There was a significant correlation between both curve patterns, including the modified Chiorean classification (P<0.0001) as well as the level of inflammation (P<0.0001) and fibrosis (P<0.002). Inflammatory patterns of dynamic studies are related to histological findings with 80.9% accuracy (sensitivity=75.7%; specificity=100%). CONCLUSION: There is a high correlation between dynamic enhancement studies and the level of inflammatory activity. MRE is a suitable tool to differentiate between inflammatory and fibrotic lesions, making it useful to decide the appropriate management of each patient.

A Nomogram Combining Fecal Calprotectin Levels and Plasma Cytokine Profiles for Individual Prediction of Postoperative Crohn's Disease Recurrence.

BACKGROUND: The aims of this study were to characterize the immune response profile in patients with Crohn's disease (CD) and early postoperative recurrence (POR), to identify predictive biomarkers, and to develop a noninvasive predictive tool for individual estimation of POR risk. METHODS: Sixty-one patients who had undergone ileocolonic resection for CD were prospectively included and followed up for 24 months. Fecal calprotectin (FC), analytical parameters, and plasma cytokines were obtained before surgery and at various time points during postoperative follow-up. Morphological recurrence was assessed by ileocolonoscopy or magnetic resonance enterography within 6-12 months after surgery. Clinical activity was scored using the Harvey-Bradshaw Index. RESULTS: Twenty-seven patients (44.3%) had morphological recurrence during follow-up. Fecal calprotectin values were significantly associated with POR risk over time. The receiver operating characteristic curve for FC provided an area under the curve (AUC) of 0.88 (95% confidence interval, 0.75-0.96), and morphological recurrence was best predicted by FC ≥160 µg/g at 6 months after surgery (85% sensitivity, 70% specificity, 26% predictive positive value, 98% negative predictive value [NPV]). The plasma cytokine profile showed higher presurgery interleukin (IL)-13 plasma levels and higher IL-6 and interferon (IFN)-γ levels at 6 months after surgery in patients with POR compared with patients without recurrence. The combination of FC, IL-6, and IFN-γ values at 6 months gave an AUC of 0.90 for predicting an early recurrence. CONCLUSIONS: FC values <160 µg/g at 6 months have a high NPV to rule out early lesions. Combined values of FC, IL-6, and IFN-γ levels at 6 months postsurgery constitute a prognostic index with a high predictive capacity to assess the risk of early POR.

How to reduce the superior mesenteric vein bleeding risk during laparoscopic right hemicolectomy.

PURPOSE: The superior right colic vein (SRCV) has been proposed as the main cause of superior mesenteric vein bleeding by avulsion during laparoscopic right hemicolectomy. Our objective is to identify the main vessel causing transverse mesocolic tension during the extraction of the surgical specimen or extracorporeal anastomosis and to perform an anatomical description of the SRCV. METHODS: In this cadaveric study, we performed a simulation of right hemicolectomy and anatomical description of the surgical area of the gastrocolic trunk of Henle (SAGCTH), the gastrocolic trunk of Henle (GCTH), and SRCV. The length of the exteriorization of the anastomotic transverse colon (ATC) was measured before and after sectioning the vascular vessel causing the exteriorization tension. RESULTS: Five fresh cadavers and 12 formalin were dissected. In 100% of the specimens, the SRCV was present and drained in 95% into the GCTH and in 5% directly into the superior mesenteric vein (SMV). In 100% of the specimens, the SRCV caused the tension when extracting the ATC. The mean length of exteriorization of the ATC before and after SRCV section was 7.2 and 10.4 cm in formalin cadavers, meaning a 44% of increment in the length of exteriorization. In fresh cadavers, the mean length of exteriorization increased to 2.7 cm, meaning a 28% of the initial length of exteriorization. CONCLUSIONS: The SRCV is the main cause of tension in the extraction of the surgical specimen after right hemicolectomy. Its high tie increases the length of the ATC exteriorization, in about 3 cm, and could reduce the risk of SMV bleeding during laparoscopic right hemicolectomy and facilitate an extracorporeal anastomosis free of tension.

Fecal Calprotectin in Ileal Crohn's Disease: Relationship with Magnetic Resonance Enterography and a Pathology Score.

BACKGROUND: Magnetic resonance enterography (MRE) is an effective method of assessing small bowel Crohn's disease (CD). Fecal calprotectin (FC) correlates well with endoscopic disease activity. We aimed to evaluate the correlation between FC and disease activity according to MRE and surgical pathology in small bowel CD. METHODS: One hundred twenty consecutive patients with ileal CD who underwent MRE assessment were included. Clinical data, C-reactive protein and FC, radiological and histological variables were obtained. Clinical activity was evaluated by the Harvey-Bradshaw Index and FC by enzyme-linked immunosorbent assay. MRE activity was assessed by means of the Magnetic Resonance Index of Activity score. Chiorean's score was used to grade pathological inflammation in surgical specimens. RESULTS: Seventy-five patients (62.5%) were in clinical remission (Harvey-Bradshaw Index < 5) and 45 (37.5%) had active disease (Harvey-Bradshaw Index ≥ 5). The Magnetic Resonance Index of Activity score was significantly associated with FC levels (P < 0.01), with a moderate overall correlation (Spearman's r = 0.56, P < 0.001). FC reflected MRE inflammatory activity with an area under the receiver operating characteristic curve of 0.914 (confidence interval, 0.849-0.958; P < 0.001). A cutoff value of 166.50 µg/g had 90% sensitivity, 74% specificity, 89% positive predictive value, and 76% negative predictive value for diagnosis of inflammation. Twenty-eight of 120 patients were operated. Surgical pathology showed a good agreement with FC for moderate (P = 0.03) and severe (P = 0.01) Chiorean's index. No relationship was detected for C-reactive protein. CONCLUSIONS: FC correlates with the degree of MRE inflammatory activity and with surgical pathology damage in ileal CD. Thus, FC could be a surrogate marker of disease control used to select patients for MRE assessment and therapeutic adjustment.

Las malformaciones uterinas congénitas como causa importante de esterilidad e infertilidad. Papel de la histerosalpingografía en su diagnóstico / Congenital uterine malformations, an important cause of sterility and infertility: the role of hysterosalpingography in diagnosis

Objetivos: Valorar la importancia de las malformaciones uterinas en pacientes infértiles y estériles y comprobar si la histerosalpingografía (HSG) es suficiente para diferenciar entre un útero septo y un útero bicorne o si hacen falta exploraciones complementarias. Material y métodos: Se valoraron las HSG realizadas en 622 mujeres infértiles o estériles. A 10 mujeres se las estudió además con laparoscopia e histeroscopia. En estos casos se comparó el resultado entre la HSG y las otras técnicas comentadas. Resultados: Se detectaron malformaciones uterinas en el 8,8% de las pacientes exploradas. En estas pacientes, el útero arcuato (56,4%) constituía la malformación más frecuente, seguido del útero subsepto (16,4%), del bicorne unicollis (12,7%), del bicorne bicollis (1,8%), del septado (7,3%) y del unicorne (3,6%). En las 10 pacientes que se comparó el resultado de la HSG con la histeroscopia y la laparascopia, se vio que la HSG había emitido el diagnóstico correcto del tipo de malformación uterina en seis de los casos. Conclusiones: Según los datos obtenidos en la búsqueda bibliográfica, se confirma que el útero arcuato es la malformación más frecuente. Dado que el tratamiento del útero septo es muy distinto al del bicorne, se desprende la importancia que supone un diagnóstico correcto entre estas dos patologías. El tratamiento del útero septo es la metroplastia y el del bicorne es la intervención abdominal. Si la HSG y la ecografía transvaginal no son concluyentes en la diferenciación de estas dos malformaciones, recomendamos completar el estudio con una resonancia magnética

Objectives: To evaluate the importance of uterine malformations in infertile and sterile patients and to determine whether hysterosalpingographies (HSG) alone can differentiate between septate uterus and bicornuate uterus or whether complementary procedures are necessary. Material and methods: Hysterosalpingograms performed in 622 infertile or sterile women were evaluated. Ten women also underwent laparoscopy and hysteroscopy; in these cases, the results obtained with HSG were compared with those of the other techniques. Results: Uterine malformations were detected in 8.8% of those examined. The most common malformation was arcuate uterus (56.4%), followed by subseptate uterus (16.4%), uterus bicornis unicollis (12.7%), uterus bicornis bicollis (1.8%), septate uterus (7.3%), and uterus unicornis (3.6%). In the 10 patients in whom the HSG results were compared with those of hysteroscopy and laparoscopy, HSG diagnosed the type of malformation correctly in 6 cases. Conclusions: Our findings that arcuate uterus is the most common malformation corroborate those reported in the literature. Given that the treatment for septate uterus is very different from that for bicornuate uterus, we emphasize the importance of distinguishing between these two malformations. The treatment for septate uterus is metroplasty, whereas the treatment for bicornuate uterus is abdominal surgery. If HSG and transvaginal ultrasound are not conclusive in differentiating these two malformations, we recommend magnetic resonance imaging to complete the study

Herniación amigdalina en la malformación de Chiari I en la edad pediátrica: observación y evolución en el tiempo / Tonsillar herniation in children with Chiari type I malformation: observations and changes throughout the disease course

Objetivo: Valorar la existencia de cambios evolutivos en la malformación de Chiari tipo I en la edad pediátrica. Material y métodos: Revisión retrospectiva de los pacientes diagnosticados de malformación de Chiari tipo I, sin intervención quirúrgica, que disponían al menos de un control de imagen con un intervalo mínimo de un año. Se estableció este diagnóstico cuando la ectopia de las amígdalas cerebelosas a través del agujero magno fue mayor de 5 mm en el plano sagital de resonancia magnética (RM). Se recogieron los datos clínicos, el grado de herniación amigdalina y las alteraciones intracraneales y medulares asociadas. Se relacionó el grado de herniación amigdalina con la presencia de síntomas relacionados y de cavitación medular, utilizando el test de la 2 con la prueba exacta de Fisher y el cociente de probabilidad de un test positivo (likelihood ratio+).Resultados: Se analizan 11 pacientes, siete niños y cuatro niñas, con edades comprendidas entre los cuatro meses y los 14 años (media de seis años y medio). El grado de herniación amigdalina al diagnóstico osciló entre 6 y 20 mm. Se consideró incidental en 9/11 casos (81 por ciento), mostrando el resto cefalea y cervicalgia. Los controles se realizaron con un intervalo que varió entre 13 y 79 meses. Se observó estabilidad de la herniación en seis casos (54 por ciento), progresión en tres (27 por ciento), disminución en uno (9 por ciento) y regresión espontánea en un caso (9 por ciento). Dos pacientes estaban afectos de neurofibromatosis tipo 1 con lesiones intracraneales características de la enfermedad. En otro paciente se detectó una heterotopia subcortical focal. Se objetivó cavitación medular en 2/11 casos (18 por ciento) asintomáticos. La relación entre el grado de herniación y la presencia de síntomas y de cavitación medular no fue significativa. Discusión: La malformación de Chiari tipo I en la edad pediátrica constituye frecuentemente un hallazgo incidental. La cavitación medular asociada es menos frecuente que en el adulto, sugiriendo una alteración evolutiva a largo plazo. En casi la mitad de los casos se puede observar una evolución en la herniación amigdalar, siendo posible, aunque excepcional, una regresión espontánea de la malformación (AU)