Published online Sep 7, 2015. doi: 10.3748/wjg.v21.i33.9785
Peer-review started: November 30, 2014
First decision: January 8, 2015
Revised: February 6, 2015
Accepted: March 31, 2015
Article in press: March 31, 2015
Published online: September 7, 2015
AIM: To evaluate the accuracy of diffusion-weighted imaging (DWI) without bowel preparation, the optimal b value and the changes in apparent diffusion coefficient (ADC) in detecting ulcerative colitis (UC).
METHODS: A total of 20 patients who underwent 3T magnetic resonance imaging (MRI) without bowel preparation and colonoscopy within 24 h were recruited. Biochemical indexes, including C-reactive protein (CRP), erythrocyte sedimentation rate, hemoglobin, leucocytes, platelets, serum iron and albumin, were determined. Biochemical examinations were then performed within 24 h before or after MR colonography was conducted. DWI was performed at various b values (b = 0, 400, 600, 800, and 1000 s/mm2). Two radiologists independently and blindly reviewed conventional- and contrast-enhanced MR images, DWI and ADC maps; these radiologists also determined ADC in each intestinal segment (rectum, sigmoid, left colon, transverse colon, and right colon). Receiver operating characteristic (ROC) analysis was performed to assess the diagnostic performance of DWI hyperintensity from various b factors, ADC values and different radiological signs to detect endoscopic inflammation in the corresponding bowel segment. Optimal ADC threshold was estimated by maximizing the combination of sensitivity and specificity. MR findings were correlated with endoscopic results and clinical markers; these findings were then estimated by ROC analysis.
RESULTS: A total of 100 segments (71 with endoscopic colonic inflammation; 29 normal) were included. The proposed total magnetic resonance score (MR-score-T) was correlated with the total modified Baron score (Baron-T; r = 0.875, P < 0.0001); the segmental MR score (MR-score-S) was correlated with the segmental modified Baron score (Baron-S; r = 0.761, P < 0.0001). MR-score-T was correlated with clinical and biological markers of disease activity (r = 0.445 to 0.831, P < 0.05). MR-score-S > 1 corresponded to endoscopic colonic inflammation with a sensitivity of 85.9%, a specificity of 82.8% and an area under the curve (AUC) of 0.929 (P < 0.0001). The accuracy of DWI hyperintensity was significantly greater at b = 800 than at b = 400, 600, or 1000 s/mm2 (P < 0.05) when endoscopic colonic inflammation was detected. DWI hyperintensity at b = 800 s/mm2 indicated endoscopic colonic inflammation with a sensitivity of 93.0%, a specificity of 79.3% and an AUC of 0.867 (P < 0.0001). Quantitative analysis results revealed that ADC values at b = 800 s/mm2 differed significantly between endoscopic inflamed segment and normal intestinal segment (1.56 ± 0.58 mm2/s vs 2.63 ± 0.46 mm2/s, P < 0.001). The AUC of ADC values was 0.932 (95% confidence interval: 0.881-0.983) when endoscopic inflammation was detected. The threshold ADC value of 2.18 × 10-3 mm2/s indicated that endoscopic inflammation differed from normal intestinal segment with a sensitivity of 89.7% and a specificity of 80.3%.
CONCLUSION: DWI combined with conventional MRI without bowel preparation provides a quantitative strategy to differentiate actively inflamed intestinal segments from the normal mucosa to detect UC.
Core tip: Our results indicated that diffusion-weighted imaging (DWI) provides qualitative and quantitative information when this technique is combined with conventional magnetic resonance imaging without bowel preparation; the combined technique demonstrates a good diagnostic performance to detect colonic inflammation in ulcerative colitis. This technique is completely non-invasive, does not apply ionizing radiation or contrast material injection, does not require any bowel preparation and does not cause discomfort to patients. The optimal b value is 800 s/mm2. DWI hyperintensity at b = 800 s/mm2 detected endoscopic colonic inflammation with a sensitivity of 93.0% and a specificity of 79.3%.