CTE AND MRE: WHO, HOW, WHAT, WHY · CTE vs MRE Siddiki et al. (AJR 2009): – 30 pts with suspected...
Transcript of CTE AND MRE: WHO, HOW, WHAT, WHY · CTE vs MRE Siddiki et al. (AJR 2009): – 30 pts with suspected...
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CTE AND MRE:CTE AND MRE:WHO, HOW, WHAT, WHYWHO, HOW, WHAT, WHY
Joel F. Platt, M.D.University of Michigan
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OBJECTIVESOBJECTIVES
Review basics of performing CTE and MRE
Identify key imaging findings with CTE and MRE
Discuss factors that may influence choice of CTE vs MRE
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IMAGING OF SMALL BOWELIMAGING OF SMALL BOWEL
NeoplasmObstructionIBDIschemiaTrauma
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CTECTEWHAT IS IT?WHAT IS IT?
MDCTSingle or dual phase scanningLow attenuation oral contrastIV contrastAxial and 3DFocus on bowel
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CTECTE
CT exam focused on small bowel
CT exam optimized for small bowel
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CTE ORAL CONTRASTCTE ORAL CONTRASTIMPORTANT CHOICEIMPORTANT CHOICE
IntrinsicWaterLAOCMilk and others
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CTE TECHNIQUE: CTE TECHNIQUE: ORAL CONTRASTORAL CONTRAST
VoLumen administration:– 6 hours fasting prior to scan– 1350 ml 3 bottles of 450 ml over 90 min
• 450 ml 90 min• 450 ml 45 min• 225 ml 20 min• 225 ml 5 min
Young B et al; JCAT 2008Kuehle CA et al; AJR 2006
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MAYO ORAL CONTRASTMAYO ORAL CONTRASTRegimen
Time Contrast0 min 1 bottle Volumen (450 cc)
15 min 1 bottle Volumen (450 cc)30 min 1 bottle Volumen (450 cc)45 min 1 bottle H20 (500 cc)58 min +/- 0.5 mg Glucagon IV60 min - scan
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““SELFSELF”” PREPPED PATIENTPREPPED PATIENT
A new observation with VoLumen not seen with bright oral agentsSeen with active bowel disease Crohns, infections, malabsorption, obstructionGives appearance of good VoLumen prep
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CTE DELAY TIME CTE DELAY TIME
40 sec vs 70 secNo advantage for CTE1 Phase is sufficient70 sec preferred
Vandenbroucke et al, Acta Radiology 2007
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CTECTEOPTIMAL SCAN DELAYOPTIMAL SCAN DELAY
50 sec delay 14 sec after aortic peakEnteric phase better than arterial5 ml/sec injection rate
Schindera et al, Radiology 2007
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RADIATION DOSE IN CTERADIATION DOSE IN CTE
Often young patients
Often need repeat imaging
Low dose CTE vs MRE
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MRE PROTOCOL (1.5 T)MRE PROTOCOL (1.5 T)3-plane localizerAxial and coronal T2W single-shot fast spin-echo SSFSE (HASTE)axial & coronal steady-state free precession FIESTA (B-TFE)Coronal pre and post contrast 3D SPGR-LAVA (THRIVE) with fat-saturationAxial delayed postcontrast 2D SPGR-LAVA (THRIVE) with fat-saturation
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MR PULSE SEQUENCESMR PULSE SEQUENCEST2-weighted (single –shot techniques)– HASTE, SSFSE, SSTSE– Fat suppression? Improves conspicuity of ↑ SI
bowel wall and mesenteric fat, but diminished discrimination of bowel wall
Contrast enhanced 3D gradient echo sequence– FAME, VIBE, THRIVE– Fat suppression: yes
May use balanced GRE– FIESTA, TruFISP, Balanced FFE
Employ parallel imaging
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MRE MRE PedsPeds Protocol Protocol –– PrescanPrescanNPO – only if sedated examPt arrives 90 minutes before exam start timeOral prep:– 2-3 bottles of VoLumen “CT” oral contrast material over 60-90
minutes– 8 oz water immediately prior to scan
• VoLumen & water are both biphasic (T1W hypo- intense & T2W hyperintense)
Glucagon administered as split dose (smooth muscle relaxant) – 0.25-0.5 mg IV immediately prior to localization– 0.25-0.5 mg IV immediately prior to postcontrast imaging
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MRE MRE PedsPeds Protocol Protocol –– SequencesSequencesC.S. Mott Children’s Hospital (1.5T)– 3-plane localizer & parallel imaging reference scans– T2W single-shot fast spin-echo (SSFSE)
• axial & coronal– Balanced steady-state free precession (SSFP)
• axial & coronal– Diffusion-weighted echo-planar (EPI)
• axial– T2W fast spin-echo (FSE) with fat-saturation
• axial– Dynamic postcontrast 3D SPGR (THRIVE) with fat-saturation
• coronal– Delayed postcontrast 3D SPGR (THRIVE) with fat-saturation
• axial & coronal
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MDCT OF IBDMDCT OF IBD
DiagnosisDifferentialActivityComplications
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CTE FOR IBD WHY NOW?CTE FOR IBD WHY NOW?
16 slice or beyond MDCT
Water/Volumen for oral contrast
Volume visualization/workstation
Aggressive medical therapy for IBD
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CTECTEGOOD QUESTIONSGOOD QUESTIONS
Known IBD, ? disease activityKnown stricture,? medical vs surgical treatment
Complications from IBD
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CROHNCROHN’’S STRICTURES STRICTUREMANAGEMENTMANAGEMENT
Inflammatory– Medical therapy – steroids, anti-TNFA
agents---- side effects
Fibrotic– Surgical treatment
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CTECTEQUESTIONABLE INDICATIONQUESTIONABLE INDICATION
R/O IBDShort term F/U after treatmentDifferentiate types of bowel disease
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MDCT FOR IBDMDCT FOR IBD
Mucosal/wall enhancement
Local vascularity
Extraluminal complications
Anastomotic disease
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CTE OF CROHNS ACTIVECTE OF CROHNS ACTIVE
Mural enhancementMural stratificationThick bowelSTSEngorged vasa rectaObstruction
Paulsen et al, Radiographics 2006
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CTE FEATURES OF ACTIVE CTE FEATURES OF ACTIVE CROHNS DISEASE CROHNS DISEASE
Mural thickening: – > 3 mm in distended bowel
Mural hyperenhancement: – Visual assessment in comparison with adjacent loops
Mural stratification: – Enhancing mucosa and serosa with hypodense
submucosa due to edemaWall thickening associated with hyper-enhancement is the most sensitive sign of active disease*
*Booya F et al; Radiology 2006
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CTE OF ACTIVE IBDCTE OF ACTIVE IBD
Mesenteric changes:– Mesenteric fat stranding– Prominence and engorgement of vasa
recta “comb sign”Mesenteric changes are the most specificCT finding for active CD and correlate with levels of C reactive protein*
*Colombel JF et al; Gut 2006
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CTE IN CROHNS DISEASECTE IN CROHNS DISEASECTE has reported sensitivity of 80 – 90% for detection of active Crohn disease1
Higher specificity as compared to capsule endoscopy (89% vs 53%)2
CTE can identify intramural inflammation in 24% of patients with normal appearing mucosa on ileoscopy3
CTE changed gastroenterologist’s impression of steroid benefit in 61% of patients4
Booya A et al; Abdominal Imaging 2008 2. Solem CA et al; Gastrointest Endosc 2008 3. Siddiki H et al RSNA 2008 4. Higgins PD et al Inflamm Bowel Dis 2008
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CTE CTE MONITOR CROHNMONITOR CROHN’’S STATUSS STATUS
40 exams (20 patients)CTE correlated with symptoms in 80%Symptoms could get worse with stable/improved CTERadiation/MRE
Haara et al, AJR 2008
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CTE vs SURGICAL PROOFCTE vs SURGICAL PROOF
36 patientsStricture, Fistula, AbscessCTE highly accurate compared to proofSearch for multiple fistula and strictures
Vogel et al, Dis Colon Rectum 2007
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MRE ADVANTAGESMRE ADVANTAGESNo ionizing radiation– Young patients– Life long disease– Life long imaging
Complete evaluation– Bowel– Extraenteric
Superior contrast resolution
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MRE DISADVANTAGESMRE DISADVANTAGES
Scanner timeLabor intensiveExpenseWorse spatial resolution than CTMore unpredictable
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CTE vs MRECTE vs MRE
26 patients CTE = MRE for more advanced dzMRE better for milder dzComplications seen by both
Low, JMRI 2000
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CTE vs MRECTE vs MREIppolito et al. (Abdom Imaging 2009):– Compared MRE vs. CTE agreement in 29 pts
• wall thickening (kappa=1)• mucosal hyperenhancement (kappa=1)• CTE superior to MRE for detection of mesenteric fibrofatty proliferation &
lymphadenopathy (p<0.05)• MRE superior in visualization of fistulae
–– CONCLUSION:CONCLUSION: MRE is accurate in monitoring activity of CD compared to CTE and may be considered an alternative to CTE in assessing degree of CD and evaluating therapeutic effectiveness
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CTE vs MRECTE vs MRESiddiki et al. (AJR 2009):– 30 pts with suspected Crohn evaluated with CTE, MRE, and
ileoscopy– MRE & CTE sensitivities for detection of small bowel Crohn disease
similar (90.5% vs 95.2%; p=0.32)– MRE & CTE both identified 8 cases active small bowel inflammation
in which endoscopy was normal
–– CONCLUSIONS:CONCLUSIONS:• MRE & CTE have similar sensitivities for detecting active small bowel
inflammation• Cross-sectional enterography provides added information to endoscopy
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CTE vs MRECTE vs MRELee et al. (Radiology 2009):– 31 pts with suspected Crohn evaluated with CTE, MRE, SBFT, and
ileoscopy– No differences in ability to detect active terminal ileitis between
modalities (p>0.017)– Sensitivity for detection of extra-enteric complications were higher for
CTE / MRE (100% for both, p<0.001)
–– CONCLUSION:CONCLUSION: Because MRE has a diagnostic effectiveness comparable to CTE, this technique has potential to be used as a radiation-free alternative for evaluation of patients with CD
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CTE vs MRECTE vs MRE
Learning curveTechniqueResolutionCostRadiationAvailability
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CTE/MRE SMALL BOWELCTE/MRE SMALL BOWELSUMMARYSUMMARY
With proper technique CTE/MRE can provide comprehensive evaluation of small bowelIncreasing role of imaging for obstruction, ischemia and IBD