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. 2016 Oct;41(10):1918-30.
doi: 10.1007/s00261-016-0802-z.

MRI characteristics of proctitis in Crohn's disease on perianal MRI

Charlotte J Tutein Nolthenius  1   2 , Shandra Bipat  3 , Banafsche Mearadji  3 , Anje M Spijkerboer  3 , Cyriel Y Ponsioen  4 , Alexander D Montauban van Swijndregt  5 , Jaap Stoker  3
Affiliations

MRI characteristics of proctitis in Crohn's disease on perianal MRI

Charlotte J Tutein Nolthenius et al. Abdom Radiol (NY). 2016 Oct.

Abstract

Purpose: Multiple features have been described for assessing inflammation in Crohn's disease (CD) in MR enterography, but have not been validated in perianal magnetic resonance imaging (MRI). Retrospectively, we studied which MRI features are valuable in assessing proctitis.

Materials and methods: CD patients (≥18 years) who underwent colonoscopy (reference standard) and perianal fistula MRI within 8 weeks were included. Seventeen MRI features were blindly scored by three observers and correlated to endoscopy (regression analysis). Reproducibility (multirater kappa, intraclass correlation coefficient) was determined for all three observer pairs. MRI features were considered relevant when significantly correlated to endoscopy for ≥2 observers, and reproducibility was ≥0.40 for ≥2 observer pairs.

Results: Perianal MRI of 58 CD patients were included. Wall thickness, rectal mural fat, creeping fat, and size of mesorectal lymph nodes showed a significant correlation with endoscopy for ≥2 observers (p = 0.000-0.023, p = 0.011-0.172, p = 0.007-0.011 and p = 0.000-0.005, respectively) with a kappa/intraclass correlation coefficient of ≥0.60 for ≥2 observer pairs. Perimural T2 signal and perimural enhancement significantly correlated to endoscopy (all p values ≤0.05) for all three observers and the reproducibility was ≥0.40 for ≥2 observer pairs. Mural T2 signal and degree and pattern of T1 enhancement showed significant correlation to endoscopy for two observers, but with poor to moderate reproducibility.

Conclusion: Wall thickness, mural fat, and mesorectal features (perimural T2 signal, perimural enhancement, creeping fat, and size of mesorectal lymph nodes) had significant correlation to endoscopy and were reproducible in diagnosing proctitis. Some established luminal features in MRE were considered not useful.

Keywords: Crohn disease; Inflammatory bowel disease; Magnetic resonance imaging; Proctitis; Rectum.

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Conflict of interest statement

Compliance with ethical standards Funding This study received no funding. For none of the authors of this manuscript any financial interest is applicable. Disclosures Professor J. Stoker is a consultant for Robarts. Dr.C.Y. Ponsioen has received unconditional grants from Takeda, served as a consultant for Takeda and Abbvie, and received speaker’s fees from Takeda, MSD, Ferring, Dr. Falk, and Abbvie. All other authors, C.J. Tutein Nolthenius, S. Bipat, B. Mearadji, S. Spijkerboer, and A.D. Montauban van Swijndregt, have nothing to disclose. Informed consent The requirement for review by the Medical Ethical Committee or informed consent was waived because of the retrospective nature of this study with pre-existing data.

Figures

Fig. 1
Fig. 1
Axial oblique fat-saturated post-contrast T1-weighted images of four different patients with Crohn’s disease with different degrees of perimural enhancement. A Equivalent to normal fat tissue. B Minor enhancement. There is blurred demarcation of the bowel wall with or without mild increase of perimural fat tissue signal. C Moderate enhancement. Increase of perimural fat tissue signal but less than nearby vascular structures. D Marked enhancement. Perimural fat tissue signal approaches that of nearby vascular structures. Mesorectal fascia enhancement can be noted
Fig. 2
Fig. 2
Flow chart of search in hospitals’ patient database
Fig. 3
Fig. 3
Sagittal T2-weighted image of two different patients with Crohn’s disease. A A 25-year-old female with ulcerative proctitis at endoscopy. The image shows increased amount of mesorectal fat tissue (creeping fat) and a subtle increase of perimural vascularity (‘comb sign’) in addition to rectal wall thickening. B A 24-year-old female with no signs of proctitis at endoscopy. There is no increased amount of mesorectal fat tissue and the rectum shows no abnormal MRI features
Fig. 4
Fig. 4
A 53-year-old female with Crohn’s disease and ulcerative proctitis at endoscopy. A Axial oblique T2-weighted image shows high mural signal intensity and B low signal intensity on axial oblique fat-saturated T2-weighted image corresponding to mural fat (arrow). C Axial oblique fat-saturated post-contrast T1-weighted images shows moderate enhancement of the rectal wall and perimural fat tissue. In addition, wall thickening and multiple mesorectal lymph nodes are present
Fig. 5
Fig. 5
A 49-year-old female with Crohn’s disease. A Axial oblique T2-weighted image and B axial oblique fat-saturated T2-weighted image show rectal wall thickening, a marked increase of T2 signal intensity and a perimural large fluid rim (>2 mm). C Axial oblique fat-saturated post-contrast T1-weighted images obtained at the same level shows a moderate enhancement of the rectal wall and the perimural fat tissue. In addition, there is creeping fat and a supralevatoric abscess left anterolateral of the rectum on all three images. D Endoscopy showed ulcerative proctitis
Fig. 6
Fig. 6
A 45-year-old male with Crohn’s disease and no signs of proctitis at endoscopy. A Axial oblique T2-weighted image and B axial oblique fat-saturated T2-weighted image obtained at the same level shows a moderate increase of T2 signal intensity of the rectal wall
Fig. 7
Fig. 7
A 43-year-old male with Crohn’s disease and ulcerative proctitis at endoscopy. Sagittal T2-weighted image shows the increased perimural vascularity perpendicular to the rectum (‘comb sign’) in addition to the wall thickening of the entire rectum
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