Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 21, 2020; 26(39): 6057-6073
Published online Oct 21, 2020. doi: 10.3748/wjg.v26.i39.6057
Dynamic contrast-enhanced magnetic resonance imaging and diffusion-weighted imaging in the activity staging of terminal ileum Crohn's disease
Yin-Chen Wu, Ze-Bin Xiao, Xue-Hua Lin, Xian-Ying Zheng, Dai-Rong Cao, Zhong-Shuai Zhang
Yin-Chen Wu, Xue-Hua Lin, Xian-Ying Zheng, Dai-Rong Cao, Department of Radiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, Fujian Province, China
Ze-Bin Xiao, Department of Biomedical Sciences, University of Pennsylvania, Philadelphia, PA 19104, United States
Zhong-Shuai Zhang, Department of Diagnosis Imaging, Siemens Healthcare Ltd, Shanghai 201318, China
Author contributions: Wu YC made substantial contributions to the conception and design of the study, performing the study, acquisition of data and drafting the manuscript; Xiao ZB carried out the statistical analyses and image post-processing; Lin XH performed the scanning sequences; Zhang ZS was responsible for sequence optimization; Cao DR participated in the design and helped in drafting the manuscript; Zheng XY conceived the study idea, participated in its design, and helped in drafting the manuscript; all authors have read and approved the final manuscript.
Supported by Medical Innovation Program of Fujian Province, No. 2018-CX-30; and Startup Fund for Scientific Research of Fujian Medical University, No. 2018QH1054.
Institutional review board statement: The study was reviewed and approved by the Branch for Medical Research and Clinical Technology Application, Ethics Committee of First Affiliated Hospital of Fujian Medical University.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Xian-Ying Zheng, MD, Professor, Department of Radiology, The First Affiliated Hospital of Fujian Medical University, No. 20 Chazhong Road, Fuzhou 350005, Fujian Province, China.
Received: June 19, 2020
Peer-review started: June 19, 2020
First decision: July 28, 2020
Revised: August 6, 2020
Accepted: September 12, 2020
Article in press: September 12, 2020
Published online: October 21, 2020
Research background

Crohn’s disease (CD) is a chronic inflammatory bowel disease which usually involves the terminal ileum. Clinically, it is important to evaluate accurately and noninvasively the activity of terminal ileum CD in order to make a precise treatment plan. However, current evaluation methods have their inherent disadvantages. Specifically, the Crohn’s Disease Activity Index (CDAI) is subjective, Crohn’s Disease Endoscopic Index of Severity (CDEIS) is invasive, and Magnetic Resonance Index of Activity (MaRIA) is complex.

The activity of terminal ileum CD is associated with the microcirculation of involved bowel walls. During the process of CD, blood perfusion and permeability increase and water diffusion will be restricted. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and diffusion-weighted imaging (DWI) can reflect perfusion and permeability of bowel walls by providing microcirculation information. As such, we hypothesize that DCE-MRI and DWI parameters can assess terminal ileum CD, thereby providing an opportunity to stage CD activity.

Research motivation

The parameters of DCE-MRI, based on the two-compartment Tofts model (TCM), and apparent diffusion coefficient (ADC), based on DWI, allow for the evaluation of perfusion and permeability in bowel walls. Few studies have analyzed the diagnostic performance of the combination of DCE-MRI and DWI in staging CD activity.

Research objectives

The purpose of this study was to investigate the performance of DCE-MRI and DWI as non-invasive methods in staging CD activity with CDAI and CDEIS as references.

Research methods

Forty-eight patients with CD were analyzed retrospectively. According to the CDAI and CDEIS values, the patients were divided into the remission group (CDAI < 151, CDEIS < 3), mild group (CDAI 151-219, CDEIS 3-8), and moderate-severe group (CDAI > 219, CDEIS > 8). Ktrans, Kep, and Ve were calculated from DCE-MRI and ADC was obtained from DWI. MaRIA was calculated from magnetic resonance enterography. The parameters were compared between normal ileal loop (NIL) and inflamed terminal ileum (ITI). Correlations between these parameters, MaRIA with CDAI, CDEIS were examined. Receiver operating characteristic curve analyses were used to evaluate the performance of these parameters in staging CD activity.

Research results

In the present study, the results showed that higher Ktrans (0.07 ± 0.04 vs 0.01 ± 0.01), Kep (0.24 ± 0.11 vs 0.15 ± 0.05) and Ve (0.27 ± 0.07 vs 0.08 ± 0.03) but lower ADC (1.41 ± 0.26 vs 2.41 ± 0.30) values were displayed in the ITI than in the NIL (all P < 0.001). The parameters of DCE-MRI and MaRIA increased in CD progression, whereas the ADC decreased. The Ktrans, Kep, Ve and MaRIA showed positive correlations with the CDAI (r = 0.866 for Ktrans, 0.870 for Kep, 0.858 for Ve, 0.890 for MaRIA, all P < 0.001) and CDEIS (r = 0.563 for Ktrans, 0.567 for Kep, 0.571 for Ve, 0.842 for MaRIA, all P < 0.001), while the ADC showed negative correlations with the CDAI (r = -0.857, P < 0.001) and CDEIS (r = -0.536, P < 0.001). The areas under the curve (AUC) for the individual values ranged from 0.68 to 0.91 for differentiating inactive CD (CD remission) from active CD (mild to severe CD) and MaRIA had the higher AUC of 0.91. The AUC when combining the Ktrans, Kep and Ve was 0.80, while the AUC when combining DCE-MRI parameters and ADC was the highest (AUC = 0.95).

Research conclusions

DCE-MRI and DWI are non-invasive methods with good performances in staging the activity of terminal ileum CD. When they were used in combination, the value was greater, which can supplement clinical diagnosis and monitoring.

Research perspectives

DCE-MRI and DWI are valuable tools in staging CD with CDAI and CDEIS as the references. The correlation of the DCE-MRI and DWI parameters between pathological activity status of CD, and the performance of DCE-MRI and DWI in monitoring the treatment effect of CD should be explored in the future.