Four intestinal ultrasound scores and bowel wall thickness alone correlated well with pediatric ulcerative colitis disease activity.

OBJECTIVES: Intestinal ultrasound (IUS) is a noninvasive tool in ulcerative colitis (UC), but scoring systems have mostly been developed for adults, Crohn's disease, and flaring UC. Our aim was to evaluate the performance of bowel wall thickness (BWT) and four IUS scores in pediatric patients with newly diagnosed UC. METHODS: Patients <18 years old with suspected UC were prospectively enrolled. Baseline IUS was done, and ulcerative colitis intestinal ultrasound score (UC-IUS), Milan criteria, simple pediatric activity ultrasound score (SPAUSS), and Civatelli index were calculated. Mayo endoscopic segment subscore, pediatric ulcerative colitis activity index (PUCAI), and biomarkers were correlated with IUS using nonparametric and receiver operating characteristic analyses. RESULTS: Fifty-two patients (56% male, median age 13.9 years, interquartile range [IQR] 11.2-16.3) with 206 colon segments were included. Patients who needed hospitalization (n = 27/52) had significantly worse IUS (BWT and all scores) compared to those not hospitalized. For all patients, IUS scores and BWT significantly correlated with baseline endoscopic, clinical, and biochemical disease activity (rho = 0.32-0.67, p < 0.05). BWT (τb = 0.53), UC-IUS (τb = 0.55), and Milan (τb = 0.52) had the strongest endoscopic correlations. For differentiating between endoscopic disease severity, BWT, UC-IUS, and Milan, had the highest areas under the curve (0.89-0.93). Using BWT alone, a thinner cut-off had improved sensitivity while maintaining high specificity: ≥2.5 mm for moderate/severe endoscopic inflammation (sensitivity 66%; specificity 94%) and ≥3.5 mm for severe endoscopic inflammation (sensitivity 92%; specificity 86%). CONCLUSIONS: BWT and all four IUS scores correlated well with endoscopic, clinical, and biochemical disease activity, and was another useful marker of severity in identifying patients needing hospitalization. Pediatric patients needed a thinner BWT cut-off, which should be accounted for when developing pediatric-specific scores. BWT alone may be just as clinically useful as composite US scores.

Gastrointestinal Ultrasound in Infectious Diseases: A Comprehensive Review.

Infectious diseases affecting the gastrointestinal tract often present diagnostic challenges due to the variability in clinical manifestations and overlapping symptoms. Ultrasound imaging has emerged as a valuable tool in the assessment of gastrointestinal pathologies, offering non-invasive and real-time visualization of anatomical structures. This review aims to explore the role of ultrasound in the diagnosis and management of infectious diseases involving the gastrointestinal tract. We discuss the imaging features of various infectious etiologies, such as bacterial, viral, and parasitic infections, highlighting characteristic findings on ultrasound scans. Additionally, we provide insights into the utility of ultrasound for the assessment of treatment response. Through a comprehensive analysis of existing literature and clinical case studies, this review underscores the significance of ultrasound imaging as a frontline modality in the diagnosis and management of infectious diseases affecting the gastrointestinal tract.

Noninvasive Assessment of Postoperative Disease Recurrence in Crohn's Disease: A Multicenter, Prospective Cohort Study on Behalf of the Italian Group for Inflammatory Bowel Disease.

BACKGROUND & AIMS: Colonoscopy (CS) is the gold standard to assess postoperative recurrence (POR) in Crohn's disease (CD). However, CS is invasive and may be poorly tolerated by patients. The aim of this study was to prospectively assess the diagnostic accuracy of a noninvasive approach in detecting POR, using the endoscopic Rutgeerts' score (RS) as the reference standard. METHODS: Consecutive patients with CD who underwent ileo-cecal resection were prospectively enrolled in 3 referral Italian centers. Patients underwent CS and bowel ultrasound within 1 year of surgery. Uni- and multivariable analyses were used to assess the correlation between noninvasive parameters and endoscopic recurrence, defined by a RS ≥2. RESULTS: Ninety-one patients were enrolled. Sixty patients (66%) experienced endoscopic POR. The multivariable analysis identified bowel wall thickness (BWT) per 1-mm increase (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.21-4.89; P = .012), the presence of mesenteric lymph nodes (OR, 15.63; 95% CI, 1.48-164.54; P = .022), and fecal calprotectin (FC) values ≥50 mcg/g (OR, 8.58; 95% CI, 2.45-29.99; P < .001) as independent predictors for endoscopic recurrence. The presence of lymph nodes or the combination of BWT ≥3 mm and FC values ≥50 mcg/g correctly classified 56% and 75% of patients, with less than 5% of patients falsely classified as having endoscopic recurrence. Conversely, the combination of BWT <3 mm and FC <50 mcg/g correctly classified 74% of patients with only 4.5% of patients falsely classified as not having endoscopic recurrence. CONCLUSIONS: A noninvasive approach combining bowel ultrasound and FC can be used with confidence for detecting POR in patients with CD without the requirement for CS.

Small Bowel Imaging in Celiac Disease: Is there a role for Small Bowel Ultrasound?

PURPOSE OF REVIEW: The incidence of celiac disease (CD) has increased over the last decades in part due to better disease awareness. Small bowel ultrasound (sb US) enables dynamic assessment of the bowel; although this topic has been addressed, the use of sb US in the diagnosis and in the follow-up of CD patients is limited to a few specialized tertiary referral centers. Herein, we aimed at summarizing the available literature on this topic to better define the potential clinical implications of sb US in CD, also through a comparison with other available diagnostic techniques. RECENT FINDINGS: According to available data, sb US can be of help in confirming or excluding CD in patients with clinical suspicion; specifically, the finding of increased gall bladder volume, free abdominal fluid and enlargement of mesenteric lymph nodes reliably and accurately predicts the diagnosis of CD, whereas the absence of bowel dilatation and increased peristalsis may exclude the diagnosis. However, the place of intestinal US in the diagnostic algorithm of CD is likely to vary depending on the probability of the disease in a given population. There are only a few studies on the role of sb US in complicated CD, even if recent reports suggest a possible clinical role. There is a lack of data on follow-up of CD patients, particularly with the aim of detecting a poor diet adherence. According to current data sb US parameters have been shown to be of value in confirming and excluding the diagnosis of CD. Prospective studies with large sample size are warranted to determine whether to include sb US in the available guidelines for CD diagnosis and monitoring.

Factors associated with diagnostic ultrasound for midgut volvulus and relevance of the non-diagnostic examination.

BACKGROUND: Few reports explore the frequency and factors associated with diagnostic ultrasound (US) for midgut volvulus. OBJECTIVE: To evaluate predictive factors for diagnostic US for midgut volvulus and clinical outcomes of patients with non-diagnostic US. MATERIALS AND METHODS: This retrospective study included infants imaged for midgut volvulus with US. Exams were rated as diagnostic (midgut volvulus present or absent) or non-diagnostic by a pediatric radiologist, and in cases of disagreement with the original report, an additional pediatric radiologist was the tie-breaker. For each exam, the following were recorded: age, weight, respiratory support, exam indication, sonographer experience, and gaseous dilated bowel loops on radiography. Logistic regression models with "stepwise" variable selection were used to investigate the association of diagnostic US for midgut volvulus with each of the independent variables. RESULTS: One hundred nineteen patients were imaged. US was diagnostic in 74% (88/119) of patients. In subsets of patients presenting with bilious emesis or age <28 days, US was diagnostic in 92% (22/24) and 90% (53/59), respectively. Logistic regression suggested that symptom type (bilious vs other) was the best predictor of diagnostic US (type 3 P=0.02). Out of 26 patients with available radiographs, US was diagnostic in 92% (12/13) of patients without bowel dilation on radiographs compared to 62% (8/13) of patients with bowel dilation (P=0.16). Weight, respiratory support, and sonographer experience did not differ between groups. Two sick neonates, ages 2 days and 30 days, in whom the primary clinical concern was dropping hematocrit and sepsis, respectively, had non-diagnostic ultrasounds in the setting of bowel dilation on radiography. Both were found to have midgut volvulus at surgery and both expired. CONCLUSION: US was most frequently diagnostic in patients with bilious emesis or age less than 28 days. Non-diagnostic US for midgut volvulus must prompt a predetermined follow-up strategy, such as an additional imaging study (e.g., upper GI series), particularly in a sick child, as non-diagnostic US may miss midgut volvulus.

Correlation between endoscopy and intestinal ultrasound for the evaluation of postoperative recurrence of Crohn's disease. / Correlación entre la endoscopia y la ecografía intestinal para la evaluación de la recurrencia posquirúrgica de la enfermedad de Crohn.

OBJECTIVE: Intestinal ultrasound is considered to be a valid alternative for the evaluation of post-operative recurrence (POR) of Crohn's disease. The aim of this study is to assess the correlation between ultrasound and endoscopic findings. METHODS: Patients with Crohn's disease were retrospectively recruited who had undergone ileocecal resection, and for whom a colonoscopy and intestinal ultrasound had been performed for the detection of POR. Recurrence was assessed using the Rutgeerts score (RS). The ultrasound findings analysed were bowel wall thickness (BWT), parietal hyperaemia using power Doppler, loss of layer pattern and mesenteric fat hypertrophy. RESULTS: A total of 31 patients were included, of which 15 (48.4%) had no POR (RS<2b) and 16 (51.6%) had POR (RS≥2b). A statistically significant association was identified between BWT and the presence of endoscopic recurrence (a mean of 2.75mm vs. 5.68mm, P>0.001). There was also a statistically significant difference in hyperaemia between the 2groups (P=0.03). For wall thickness, an area under the ROC curve (AUC) of 92.9% was obtained, and with a cut-off point of 3.4mm, a sensitivity of 100% and specificity of 86.6%. When comparing with the most frequent biomarkers (fecal calprotectin and serum CRP), a higher AUC was obtained for wall thickness (72.3% and 72.3% vs. 92.9%). CONCLUSIONS: In our experience, ultrasound has high diagnostic efficacy in the detection of POR and can be considered a valid non-invasive alternative to endoscopy.

Use of Cross-Sectional Imaging for Tight Monitoring of Inflammatory Bowel Diseases.

A treat-to-target strategy with close monitoring of intestinal inflammation is recommended in inflammatory bowel disease (IBD). Ileocolonoscopy remains the gold standard for assessing disease activity in IBD but is a relatively invasive procedure and is impossible to repeat in the context of tight monitoring strategies. In addition to biomarkers, cross-sectional imaging increasingly is used in these patients. Computed tomography is limited by the use of radiation, while the use of magnetic resonance enterography (MRE) is limited by its cost and access. There is growing interest in bowel ultrasound that represents a cost-effective, noninvasive, and well-tolerated modality in clinical practice, but it is operator dependent. Compared with ileocolonoscopy and MRE, bowel US has been shown to have the same level of accuracy in assessing and monitoring disease activity for both CD and UC and thus can be considered a point-of-care test. Diffusion-weighted imaging (DWI) is a MR imaging technique that increasingly is used in both IBD and non-IBD conditions and has been shown to be a valuable and accurate tool for assessing and monitoring IBD activity. Compared with conventional MRE, DWI is quicker, less time consuming, may not require intravenous contrast agent, fasting, bowel cleansing, oral preparation, or rectal preparation. This review discusses the role of these cross-sectional imaging techniques for the management of patients with IBD. In the near future, the value of DWI and ultrasound in assessing IBD will require further investigation in the era of transmural healing in CD and complete mucosal healing, including histologic remission, in ulcerative colitis.

Utility of MR enterography and ultrasound for the investigation of small bowel Crohn's disease.

Cross sectional Imaging plays an increasingly important role the diagnosis and management of Crohn's disease. Particular emphasis is placed on MRI and Ultrasound as they do not impart ionising radiation. Both modalities have reported high sensitivity for disease detection, activity assessment and evaluation of extra-luminal complications, and have positive effects on clinical decision making. International Guidelines now recommend MRI and Ultrasound in the routine management of Crohn's disease patients. This article reviews the current evidence base supporting both modalities with an emphasis on the key clinical questions. We describe current protocols, basic imaging findings and highlight areas in need of further research. LEVEL OF EVIDENCE: 5 Technical Efficacy: Stage 4 J. MAGN. RESON. IMAGING 2017;45:1573-1588.

Bowel Sonography and MR Enterography in Children.

OBJECTIVE: The objective of this study was to assess the diagnostic agreement between bowel sonography and MR enterography in children with suspected or confirmed inflammatory bowel disease (IBD). SUBJECTS AND METHODS: We prospectively studied 33 children undergoing clinically indicated MR enterography. Bowel sonography was performed within 2 hours before MR enterography. The reliability of each modality was assessed by computing the interreader kappa agreement on nine inflammatory markers in eight bowel segments and the interreader intraclass correlation coefficients (ICC) in each bowel segment. The agreement between both modalities in each bowel segment was also calculated using the Kendall coefficient of concordance (KCC) in addition to the sensitivity and specificity of sonography using those of MR enterography as the reference standard. RESULTS: Sonographic readings are substantially reliable in the colon and terminal and distal ileum (ICC = 0.79-0.88) but are highly unreliable in the mid and proximal small bowel. MR enterography has moderate to almost perfect reliability for all bowel segments (ICC = 0.43-0.96). Sonography was in substantial agreement with MR enterography in most of the large bowel (KCC = 0.67-0.83) and terminal and distal ileum (KCC = 0.75) and in moderate agreement in the remaining bowel segments (KCC = 0.45-0.48). Sonographic findings are specific for disease using MR enterography as the reference standard in all bowel segments (0.83-1.00), but sensitivity markedly varies according to disease location. CONCLUSION: Sonography is highly specific and shows substantial agreement with MR enterography in detecting inflammatory and damage changes in the colon and terminal and distal ileum, the segments most likely to be affected by IBD. Therefore, sonography can be a good complement to MR enterography in evaluations of patients with known or suspected IBD, particularly if MR enterography access is limited.

Diagnostic accuracy of bowel ultrasonography in patients with inflammatory bowel disease: a systematic review and meta-analysis.

Background: Bowel ultrasonography (BUS) is emerging as a promising noninvasive tool for assessing disease activity in inflammatory bowel disease (IBD) patients. We evaluated the diagnostic accuracy of BUS in IBD patients against the gold standard diagnostic method, standard colonoscopy. Methods: Major databases were searched from inception to May 2023 for studies on BUS diagnostic accuracy in IBD. Outcomes of interest were pooled sensitivity, specificity, positive (PPV), and negative (NPV) predictive values. Endoscopic confirmation served as ground truth. Standard meta-analysis methods with a random-effects model and I2 statistics were applied. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Results: Twenty studies (1094 patients) were included in the final analysis. The majority (75%) of studies considered bowel wall thickness >3 mm as abnormal. Endoscopic evaluation was performed between days 3 and 180. The pooled diagnostic accuracy of BUS in IBD was 66% (95% confidence interval [CI] 58-72%; I2=78%), sensitivity was 88.6% (95%CI 85-91%; I2=77%), and specificity 86% (95%CI 81-90%; I2=95%). PPV and NPV were 94% (95%CI 93-96%; I2=25%) and 74% (95%CI 66-80%; I2=95%), respectively. On subgroup analysis, small-intestine contrast-enhanced ultrasonography (SICUS) demonstrated high sensitivity (97%, 95%CI 91-99%; I2=83%), whereas BUS exhibited high specificity (94%, 95%CI 92-96%; I2=0%) and NPV (76%, 95%CI 68-83%; I2=80.9%). Meta-regression revealed a significant relation between side-to-side anastomosis and BUS specificity (P=0.02) and NPV (P=0.004). Conclusion: The high diagnostic accuracy of BUS in detecting bowel wall inflammation suggests utilizing regular BUS as the primary modality, with subsequent consideration of SICUS if clinically warranted.

Efficacy of bowel ultrasound to diagnose necrotizing enterocolitis in extremely low birthweight infants.

BACKGROUND: Bowel ultrasound (US) is one of the methods used to enhance diagnostic accuracy of necrotizing enterocolitis (NEC) and its associated complications in premature newborns. AIM: To explore the diagnostic accuracy of bowel US in extremely low birth weight (ELBW) infants with NEC. METHODS: A single-center retrospective case-control study included 84 extremely low birth weight (ELBW) infants. The infants were divided into three groups: Group 1 -infants with NEC (n = 26); Group 2 -infants with feeding problems (n = 28); Group 3 -control group (n = 30). RESULTS: The specific bowel US findings in premature newborns with NEC (stage 3) included bowel wall thinning, complex (echogenic) ascites, and pneumoperitoneum, p < 0.05. The diagnostic effectiveness of these sonographic signs was 96.8% (sensitivity 75.0% and specificity 97.6%), p < 0.05. These findings with high specificity were associated with the need for surgical intervention, poor outcomes, or increased mortality. Stage 2 NEC which did not require surgery showed impaired differentiation of the bowel wall layers, absent or decreased bowel peristalsis, pneumatosis intestinalis, portal venous gas, or simple ascites, with a diagnostic accuracy of 82.9% (sensitivity 55.6%, specificity 91.4%, p < 0.05). CONCLUSIONS: Bowel US can be used as an adjunct to abdominal radiography to aid in the diagnosis of infants with suspected NEC by providing more detailed evaluation of the intestine.

Ultrasound remission after biologic induction and long-term endoscopic remission in Crohn's disease: a prospective cohort study.

Background: The Bowel Ultrasound Score (BUSS) accurately detects therapy-related changes by using the Simple Endoscopic Score for Crohn's disease (SES-CD) as the reference standard. We aimed to evaluate ultrasound remission as a treatment target and its prediction for long-term endoscopic remission. Methods: This single-centre prospective observational study, based at a tertiary referral centre in Milan, Italy, enrolled, between March 1, 2018, and January 31, 2021, adult patients with active CD (SES-CD >2) who were starting biologics. Colonoscopy and IUS was performed at baseline and at 12 months (mean 12.8 ± 4.2). The primary outcome was the predictive value of ultrasound remission at week 12 (BUSS ≤3.52) for long-term endoscopic remission at 12 months. The International Bowel Ultrasound Segmental Activity Score (IBUS-SAS) was also calculated and optimal cut-point to detect endoscopic remission was identified through ROC analysis. Findings: 93 patients with CD were included. Of these, 22 patients (24%) achieved endoscopic remission. Week 12 ultrasound remission predicted endoscopic remission (59% compared with 41% of the patients who were not in ultrasound remission; OR 9.93, 95% CI 3.10-31.80; p < 0.001), while week 12 calprotectin values (<50, <100, <250 µg/g) did not. Week 12 ultrasound activity was associated with failure to achieve long-term endoscopic remission (NPV 87%, PPV 54%). IBUS-SAS cut-off to discriminate endoscopic remission was 22.8 (AUC 0.906). ROC curve comparison showed no-significant difference between BUSS and IBUS-SAS (p = 0.46) for detecting endoscopic remission. Interpretation: Early ultrasound remission predicts long-term endoscopic remission, making it a valuable early treatment target for clinical practice and in clinical trials. Larger multicentre validation studies are warranted to confirm these findings. Funding: None.

Intestinal ultrasound in inflammatory bowel disease: New kid on the block.

Intestinal ultrasound is an emerging technique for diagnosing and monitoring patients with inflammatory bowel disease (IBD). It is a simple, non-invasive, inexpensive, safe and reliable tool for monitoring patients with IBD. This technique has good diagnostic accuracy in the assessment of the extent and severity of IBD and its complications. The most commonly used parameters are bowel wall thickness, color Doppler flow, bowel wall stratification and peri-bowel inflammation. Various scoring systems have been developed utilizing the above parameters to monitor patients with IBD. It is a good tool to monitor response to therapy and follow-up for post-operative recurrence. Early response on intestinal ultrasound (IUS) predicts long-term clinical remission and mucosal healing in patients with Crohn's disease. In patients with ulcerative colitis (UC), the response to IUS can be assessed as early as two weeks. Recent data has emerged to predict the response to corticosteroids and colectomy in patients with acute severe UC. Point of care IUS in the outpatient clinic is an excellent tool to follow-up patients and guide clinical decision-making and has good acceptability among patients. It is an underutilized technique in spite of its appeal and the availability of evidence. Underutilization can be attributed to the lack of awareness, expertise and training centres. This review discusses the technical details and the evidence to support the use of IUS in IBD. We aim to increase awareness and use of intestinal ultrasound and build local expertise and data.

The learning curve for using intestinal ultrasonography.

BACKGROUND AND AIMS: Intestinal ultrasonography (IUS) is challenging to learn. This prospective study examined how the accuracy of IUS increases with operator experience ("learning curve") and if prior abdominal ultrasound experience facilitates the learning process. METHODS: The study included two trainees with limited abdominal ultrasound experience (< 50 exams) and two with extensive experience (> 500 exams). Each trainee performed 99 examinations and reported four IUS findings. An expert sonographer repeated the exam, and concordance (k) between the expert and trainees was assessed in three consecutive testing periods of 33 exams each. RESULTS: A progressive improvement in concordance was observed for all IUS findings from Period 1 to Period 3, overall and for both groups of trainees, although those with experience in abdominal ultrasound had faster learning curves. The minimum number of examinations required to achieve concordance with the expert operator for detecting increased bowel wall thickness was 84 and detecting bowel dilatation was 79. However, a minimum of 97 examinations was necessary to achieve concordance for detecting intra-abdominal complications, considered an advanced IUS competence. CONCLUSION: Basic competence in IUS can be acquired with relatively few examinations, while advanced competence requires more extensive training, particularly for gastroenterologists without abdominal ultrasound experience.

Return of the Living Dead Gut - A Case Report of Ischemic Colitis Identified on Point of Care Ultrasound.

Ischemic colitis is the most common form of gastrointestinal ischemia 1. The diagnosis of ischemic colitis is made by clinical data and computed tomography (CT) imaging of the abdomen and pelvis 1. While colonoscopy is considered the gold standard for diagnosis, this is not performed in the emergency department (ED) 2. Few studies have been performed to describe the sonographic findings of ischemic colitis using point of care ultrasound (POCUS). We report a case that highlights the sonographic findings of ischemic colitis in a patient who had two separate visits to the ED, showcasing the utility of POCUS in making this diagnosis. POCUS can be used as a diagnostic tool for early detection of ischemic colitis leading to prompt treatment with antibiotics, CT imaging, and surgical consultation.

Current Developments and Role of Intestinal Ultrasound including the Advent of AI.

Intestinal ultrasound is a non-invasive, safe, and cost-effective technique to study the small and large intestines. In addition to conventional B-mode and color doppler imaging, new US tools have been developed in more recent years that provide auxiliary data on many GI conditions, improving the diagnosis and assessment of relevant outcomes. We have reviewed the more recent literature (from 2010 onwards) on auxiliary tools in bowel ultrasound such as elastography techniques, CEUS, SICUS, and the potential contribution by artificial intelligence (AI) to overcome current intestinal ultrasound limitations. For this scoping review, we performed an extensive literature search on PubMed and EMBASE to identify studies published until December 2023 and investigating the application of elastography techniques, CEUS, SICUS, and AI in the ultrasonographic assessment of the small and large intestines. Multiparametric intestinal ultrasound shows promising capabilities in Crohn's disease, while less is known about the role in ulcerative colitis. Despite some evidence, the CEUS role as a point-of-care examination tool for rare conditions such as intestinal GvHD and ischemic small bowel disease seems promising, possibly avoiding the need to perform further cross-sectional imaging. The use of AI in intestinal ultrasound is still anecdotical and limited to acute appendicitis.

Ultrasound Elastography in Inflammatory Bowel Diseases: A Systematic Review of Accuracy Compared with Histopathological Assessment.

BACKGROUND AND AIMS: Ultrasound elastography [USE] is an innovative, non-invasive, promptly available, ancillary technique that has been proposed in the evaluation of intestinal fibrosis as a monitorable biomarker, in terms of stiffness. The non-invasive estimate of fibrosis by USE appears appealing for dedicated physicians, in order to optimise the treatments for inflammatory bowel disease [IBD] patients [surgical vs non-surgical]. We aimed to systematically review literature evidence on ultrasound elastography in IBD patients. METHODS: For this qualitative systematic review, we searched PubMed, EMBASE, and Scopus to identify all studies, published until October 2021, investigating the application of USE in IBD patients compared with histopathological assessment. RESULTS: Overall, 12 papers published between 2011 and 2019 were included. A total of 275 IBD patients were included: 272 Crohn's disease [CD] [98.9%] and three ulcerative colitis [UC] [1.1%]. Seven [58.3%] and four [41.6%] studies investigated strain elastography [SE] and shear wave elastography [SWE], respectively; in one study [0.1%] both techniques were addressed. The histological evaluation was largely conducted on surgical specimens and in two studies endoscopic biopsies were also included. The histological assessment was semi-quantitative in all the included studies, except for two where the fibrosis was evaluated only qualitatively. In 10/12 publications USE could accurately distinguish inflammation from fibrosis in the examined bowel tracts. CONCLUSIONS: From the preliminary available data, an overall moderate-to-good accuracy of USE in detecting histological fibrosis [10/12 studies] was found. Point-shear wave elastography has been shown to perform superiorly. Further studies are needed to confirm these evidences.

Complicated appendicitis in an adult patient.

Introduction: Appendicitis is a common cause for emergency operations in the western part of the world, mostly affecting children and young adults. Ultrasound in well-trained hands is an effective imaging tool in making this diagnosis; however, this does not come without its challenges and potential complications. Case report: This is a case of a 19-year-old male with one-day history of severe pain in the right iliac fossa; blood results showed raised inflammatory markers. Ultrasound revealed a large abnormal loop of bowel containing heterogeneously echogenic contents, and two large appendicoliths at the base and fundus, with the presence of free fluid in the right iliac fossa and oedema in the adjacent mesentery. Laparoscopic appendectomy confirmed the presence of severe appendicitis with generalised peritonitis and appendicolith. Histology revealed gangrenous appendicitis with perforation in two places. Discussion: This case demonstrates that making a diagnosis of an inflamed appendix alone on ultrasound is not enough, and conducting a detailed assessment of the inflamed appendix and its surrounding anatomy is essential so that all the associated findings can be reported to aid in the patient management, reduce hospital stay and improve overall diagnosis and prognosis.

Longitudinal Bowel Behavior Assessed by Bowel Ultrasound to Predict Early Response to Anti-TNF Therapy in Patients With Crohn's Disease: A Pilot Study.

BACKGROUND: Early changes in bowel behavior during anti-tumor necrosis factor (anti-TNF) induction therapy in Crohn's disease (CD) are relatively unknown. We determined (1) the onset of changes in bowel behavior in CD patients receiving anti-TNF therapy by ultrasound and (2) the feasibility of shear wave elastography (SWE) in predicting early response to anti-TNF therapy. METHODS: Consecutive ileal or ileocolonic CD patients programmed to initiate anti-TNF therapy were enrolled. Bowel ultrasound was performed at baseline and at weeks 2, 6, and 14. Changes in bowel wall thickness, Doppler signals of the bowel wall (Limberg score), and SWE values were compared using a linear mixed model. Early response to anti-TNF therapy was based on a composite strategy of clinical and colonoscopy assessment at week 14. RESULTS: Of the 30 patients enrolled in this study, 20 patients achieved a response to anti-TNF therapy at week 14. The bowel wall thickness and SWE value of the response group showed a significant downward trend compared with the nonresponse group (P = .003 and P = .011, respectively). Bowel wall thickness, the Limberg score, and SWE values were significantly reduced as early as week 2 compared with baseline (P < .001, P < .001, and P = .003, respectively) in the response group. Baseline SWE values (21.3 ± 8.7 kPa vs 15.3 ± 4.7 kPa; P = .022) and bowel wall thickness (8.5 ± 2.3 mm vs 6.9 ± 1.5 mm; P = .027) in the nonresponse group were significantly higher than in the response group. CONCLUSIONS: This pilot study suggested that changes in bowel ultrasound behavior could be assessed as early as week 2 after starting anti-TNF therapy. Bowel ultrasound together with elasticity imaging could predict early response to anti-TNF therapy.

This pilot study suggested that changes in bowel ultrasound behavior could be assessed as early as 2 weeks after anti-tumor necrosis factor therapy in patients with Crohn's disease. Bowel ultrasound together with elasticity imaging could predict early response to anti-tumor necrosis factor therapy.

Carcinomas in inflammatory bowel disease: a narrative review on diagnostic imaging techniques.

OBJECTIVE: We aimed, therefore, to review the current evidence on imaging modalities and carcinomas overlapping IBD. BACKGROUND: Patients affected by inflammatory bowel diseases (IBD) are at increased risk for developing both gastrointestinal and extra-intestinal cancers. The subtype of IBD, namely Crohn's disease or ulcerative colitis, the location, the activity, the extent, and the duration of the disease determine this risk. Standardized surveillance programs based on imaging techniques exist only for colorectal cancer, where colonoscopy is the milestone of early detection. Clarification is needed on whether different imaging modalities might be adopted in the algorithms for screening and diagnosis of cancers in IBD patients. METHODS: PubMed was searched up to July 2021 to identify relevant studies investigating the accuracy of imaging techniques in identifying carcinomas in IBD patients. The following text words and corresponding Medical Subject Heading/Entree terms were used: "imaging", "computed tomography", "magnetic resonance imaging", "inflammatory bowel disease", "adenocarcinoma" and "cancer". CONCLUSIONS: Currently dye-chromoendoscopy (DCE) is established as the gold standard diagnostic modality for the detection of dysplasia in IBD, with a demonstrated superiority compared to white-light endoscopy. Two main radiological patterns have been described at cross-sectional imaging for both colorectal cancer and small bowel adenocarcinoma. The first subtype is characterized by a tissue mass, while the second subtype recognizes a circumferential thickening with or without the stricturing of the lumen. The diagnostic sensitivity, specificity, and accuracy of cross-sectional imaging techniques for the detection of carcinomas in the context of IBD are largely unknown and scarcely investigated. The definition of surveillance programs based on different imaging methods is warranted.