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Review
. 2022 Dec;10(10):1167-1178.
doi: 10.1002/ueg2.12326. Epub 2022 Nov 3.

Crohn's disease related strictures in cross-sectional imaging: More than meets the eye?

Joseph Sleiman  1 , Prathyush Chirra  2 , Namita S Gandhi  3 , Mark E Baker  4 , Cathy Lu  5 , Ilyssa O Gordon  6 , Satish E Viswanath  2 , Florian Rieder  7   8 ; Stenosis Therapy and Anti-Fibrotic Research (STAR) Consortium
Affiliations
Review

Crohn's disease related strictures in cross-sectional imaging: More than meets the eye?

Joseph Sleiman et al. United European Gastroenterol J. 2022 Dec.

Abstract

Strictures in Crohn's disease (CD) are a hallmark of long-standing intestinal damage, brought about by inflammatory and non-inflammatory pathways. Understanding the complex pathophysiology related to inflammatory infiltrates, extracellular matrix deposition, as well as muscular hyperplasia is crucial to produce high-quality scoring indices for assessing CD strictures. In addition, cross-sectional imaging modalities are the primary tool for diagnosis and follow-up of strictures, especially with the initiation of anti-fibrotic therapy clinical trials. This in turn requires such modalities to both diagnose strictures with high accuracy, as well as be able to delineate the impact of each histomorphologic component on the individual stricture. We discuss the current knowledge on cross-sectional imaging modalities used for stricturing CD, with an emphasis on histomorphologic correlates, novel imaging parameters which may improve segregation between inflammatory, muscular, and fibrotic stricture components, as well as a future outlook on the role of artificial intelligence in this field of gastroenterology.

Keywords: Crohn's disease; computer tomography enterography; cross-sectional imaging; fibrosis; intestinal ultrasound; magnetic resonance enterography; radiomics; strictures.

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Conflict of interest statement

Florian Rieder is consultant to Agomab. Allergan, AbbVie, Boehringer Ingelheim, Celgene, Cowen, Falk Pharma, Genentech, Gilead, Gossamer, Guidepoint, Helmsley, Index Pharma, Jannsen, Koutif, Mestag, Metacrine, Morphic, Origo, Pfizer, Pliant, Prometheus, Receptos, RedX, Roche, Samsung, Takeda, Techlab, Theravance, Thetis, UCB and received funding from the National Institute of Health, Helmsley Charitable Trust, Crohn's and Colitis Foundation, Rainin Foundation, UCB, Boehringer‐Ingelheim, Pliant, Morphic, BMS, 89Bio. Joseph Sleiman receives funding from Pfizer. Prathyush Chirra does not receive funding in conflict with this project. Satish E Viswanath receives funding from Pfizer. Ilyssa O Gordon does not receive and direct funding, but the Cleveland Clinic receives funding on her behalf from Celgene, UCB, GB004, Pliant, Morphic Therapeutics, and Helmsley Charitable Trust. Namita S Gandhi receives funding from Pfizer. Cathy Lu has received consultant/speaker fees from Abbvie, Janssen, Ferring, Takeda, and Fresenius Kabi. Mark E Baker Receives salary support to the Institution from Pfizer and Helmsley Charitable Trust.

Figures

FIGURE 1
FIGURE 1
Representative computed tomography (CT) enterography imaging of a Crohn's disease stricture. (a) Neo‐terminal ileum (terminal ileum (TI)) Stricture. Axial, post contrast enhanced CT enterography of a neo‐TI stricture (arrow) demonstrates stratified mural hyperenhancement, wall thickening and luminal narrowing. (b) Neo‐TI Stricture. Coronal, post contrast enhanced CT enterography of a neo‐TI stricture (arrow) demonstrates stratified mural hyperenhancement, wall thickening and luminal narrowing. (c) Upstream Dilation Proximal to Neo‐TI Stricture. Coronal, post contrast enhanced CT enterography proximal to neo‐TI stricture demonstrates upstream dilation to 4.1 cm (arrowhead).
FIGURE 2
FIGURE 2
Representative magnetic resonance imaging (MR) enterography imaging of a Crohn's disease stricture. (a) Naïve terminal ileum (TI) Stricture. Coronal half‐Fourier single‐shot turbo spin‐echo sequence of a naïve TI stricture (horizontal arrow) demonstrates wall thickening and lumen narrowing. Ulcers are also present (vertical arrow). (b) Naïve TI Stricture. Axial half‐Fourier single‐shot turbo spin‐echo sequence of a naïve TI stricture (arrow) demonstrates wall thickening and luminal narrowing. (c) Naïve TI Stricture. Axial, fat saturation, half‐Fourier single‐shot turbo spin‐echo sequence of a naïve TI stricture (arrow) demonstrates wall thickening, luminal narrowing and increased signal in the wall indicating edema from active inflammation. (d) Naïve TI Stricture. Axial volumetric interpolated breath‐hold examination sequence of a naïve TI stricture (arrow) in the enteric phase post contrast enhancement demonstrates stratified mural hyperenhancement, wall thickening and luminal narrowing. (e) Naïve TI Stricture. Coronal volumetric interpolated breath‐hold examination sequence of a naïve TI stricture (arrow) in the enteric phase post contrast enhancement demonstrates a more uniform but still stratified mural hyperenhancement, wall thickening and luminal narrowing. (f) Upstream Dilation Proximal to Naïve TI Stricture. Axial volumetric interpolated breath‐hold examination sequence proximal to a naïve TI stricture in the enteric phase post contrast demonstrates upstream dilation to 3.4 cm (arrowhead). (g) Naïve TI Stricture. Coronal volumetric interpolated breath‐hold examination sequence of a naïve TI stricture (arrow) in the delayed phase (7 min) post contrast enhancement demonstrates a more uniform but still stratified mural hyperenhancement, wall thickening and luminal narrowing. One investigation suggests that delayed phase enhancement indicates fibrosis predominance. (h) Naïve TI Stricture. Axial high B value (B = 800 s/mm2) diffusion weighted sequence of a naïve TI stricture (arrow) demonstrates a high signal stratified pattern indicating restricted diffusion from active inflammation.
FIGURE 3
FIGURE 3
Representative fibrostenotic Disease on Intestinal Ultrasound using a naïve Crohn's disease stricture at terminal ileum (TI) prior to resection. (a) Longitudinal view of stricture with thickened bowel wall measuring 7.3 mm, narrowed lumen along the entire length of the stricture (arrow), and surrounding inflammatory fat. (b) Pre‐stenotic dilation measured at 3.9 cm with dysfunctional peristalsis.
FIGURE 4
FIGURE 4
Overall experimental workflow for developing Crohn's disease stricturing characterization model. First, an expert radiologist identifies a region of stricturing disease. Quantitative radiomic features are then extracted on a per‐pixel basis withing the region of interest (green). A subset of features that strongly discriminate between low and high fibrosis, inflammation, etc. are selected. Meanwhile, an expert pathologist evaluates pathology sections taken from the same stricturing regions and provides scoring to characterize the disease based on pre‐determined standardized criterion. Finally, radiomic and pathology features are correlated and used to train an artificial intelligence (AI) model to predict extent of each pathology within the stricturing region.
FIGURE 5
FIGURE 5
A experts' decision tree regarding the use of cross‐sectional imaging for diagnosing and following up fibrostenotic disease in CD. The above algorithm reflects the opinion of the author team.
See this image and copyright information in PMC

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