Korean J Radiol.  2017 Feb;18(1):162-172. 10.3348/kjr.2017.18.1.162.

Diffusion-Weighted MR Enterography to Monitor Bowel Inflammation after Medical Therapy in Crohn's Disease: A Prospective Longitudinal Study

• Huh J
• Kim KJ
• Park SH
• Park SH
• Yang SK
• Ye BD
• Park SH
• Han K
• Kim AY

• KMID: 2468130
• DOI: http://doi.org/10.3348/kjr.2017.18.1.162

Abstract

OBJECTIVE
To prospectively evaluate the performance of diffusion-weighted imaging (DWI) to monitor bowel inflammation after medical therapy for Crohn's disease (CD).
MATERIALS AND METHODS
Before and following 1-2 years of medical therapy, between October 2012 and May 2015, 18 randomly selected adult CD patients (male:female, 13:5; mean age ± SD, 25.8 ± 7.9 years at the time of enrollment) prospectively underwent MR enterography (MRE) including DWI (b = 900 s/mm²) and ileocolonoscopy. Thirty-seven prospectively defined index lesions (one contiguous endoscopy-confirmed inflamed area chosen from each inflamed anatomical bowel segment; 1-4 index lesions per patient; median, 2 lesions) were assessed on pre- and post-treatment MRE and endoscopy. Visual assessment of treatment responses on DWI in 4 categories including complete remission and reduced, unchanged or increased inflammation, and measurements of changes in apparent diffusion coefficient (ΔADC), i.e., pre-treatment-post-treatment, were performed by 2 independent readers. Endoscopic findings and CD MRI activity index (CDMI) obtained using conventional MRE served as reference standards.
RESULTS
ΔADC significantly differed between improved (i.e., complete remission and reduced inflammation) and unimproved (i.e., unchanged or increased inflammation) lesions: mean ± SD (× 10⁻³ mm²/s) of -0.65 ± 0.58 vs. 0.06 ± 0.15 for reader 1 (p = 0.022) and -0.68 ± 0.56 vs. 0.10 ± 0.26 for reader 2 (p = 0.025). DWI accuracy for diagnosing complete remission or improved inflammation ranged from 76% (28/37) to 84% (31/37). A significant negative correlation was noted between ΔADC and ΔCDMI for both readers with correlation coefficients of -0.438 and -0.461, respectively (p < 0.05).
CONCLUSION
DWI is potentially a feasible tool to monitor quantitatively and qualitatively bowel inflammation of CD after medical treatment.

Keyword

Crohn; Crohn's; Diffusion; Diffusion-weighted; Magnetic resonance; Magnetic resonance enterography; Longitudinal; Follow-up; Monitoring

MeSH Terms

Adolescent
Adult
Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
Crohn Disease/diagnostic imaging/drug therapy/*pathology
*Diffusion Magnetic Resonance Imaging
Endoscopy, Gastrointestinal
Female
Humans
Immunosuppressive Agents/therapeutic use
Inflammation/diagnostic imaging/pathology
Infliximab/therapeutic use
Intestine, Large/diagnostic imaging/pathology
Longitudinal Studies
Male
Prospective Studies
Treatment Outcome
Young Adult
Anti-Inflammatory Agents, Non-Steroidal
Immunosuppressive Agents
Infliximab

Figure

• 

  Fig. 1 Flow diagram of study subjects. DWI = diffusion-weighted imaging, MRE = MR enterography

• 

  Fig. 2 Box plots comparing ΔADC between improved (white; left-side plot for each reader) and unimproved (gray; right-side plot for each reader) lesions according to reference standard after medical therapy. ADC = apparent diffusion coefficient

• 

  Fig. 3 20-year-old man (at diagnosis) with CD who showed complete remission of terminal ileal lesion on endoscopy after 2 years of therapy. A. Pre- and post-treatment DWI images (b = 900 s/mm2) indicate that restricted diffusion, which appears as hyperintensity in terminal ileum before treatment (left arrow), had completely disappeared at time of complete remission after treatment (right arrow). B. Colonoscopic images of terminal ileum shows complete resolution of multiple ulcers and mucosal swelling after treatment. CD = Crohn's disease, DWI = diffusion-weighted imaging

• 

  Fig. 4 21-year-old man (at diagnosis) with CD shows reduced inflammation in descending colon on endoscopy after 1 year of therapy. A. Pre- and post-treatment DWI images (b = 900 s/mm2) show that restricted diffusion, which appears as hyperintensity in distal descending colon, before treatment (left arrow) was remarkably reduced after treatment (right arrow). B. Colonoscopic images of corresponding area show large deep longitudinal ulcers before treatment (left), and reduced inflammation after treatment, presented as scattered small superficial ulcers and aphthoid lesions (right). CD = Crohn's disease, DWI = diffusion-weighted imaging

• 

  Fig. 5 25-year-old man (at diagnosis) with CD who showed unchanged inflammation in descending colon on endoscopy after 2 years of therapy. A. Pre- and post-treatment DWI images (b = 900 s/mm2) reveal similar restricted diffusion that appears as hyperintensity in descending colon (arrows). B. Colonoscopic images of corresponding area reveal persistent extensive inflammation with multiple large ulcers before treatment and on follow-up without remarkable improvement. CD = Crohn's disease, DWI = diffusion-weighted imaging

• 

  Fig. 6 Scatter plots show negative correlation between ΔADC and ΔCDMI (reference standard). CDMI = Crohn's disease MRI activity index

• 

  Fig. 7 Bland-Altman plot shows inter-reader agreement in ΔADC (× 10-3 mm2/s). ADC = apparent diffusion coefficient

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