Loading [MathJax]/jax/output/HTML-CSS/jax.js

Role of MR Imaging of Perianal Involvement in Pediatric & Adult Crohn Disease
Anuradha Shenoy-Bhangle1
1Beth Israel Deaconess Medical Center, Boston, MA, United States

Synopsis

Pelvic MRI is the standard of care in imaging perianal fistulae in patients with Crohn disease. Understanding the MR imaging protocol including scan planes and sequences used, is essential for accurate disease mapping. Knowledge of MR anatomy of the anal sphincter; types and classification of fistulae including complications and their imaging appearance at different stages of healing is of utmost importance for optimal patient care. This presentation will focus on the role of MRI in the diagnosis, various MR-classification systems used to describe perianal fistulizing disease, treatment response and prognostication of perianal Crohn disease in pediatric and adult patients.

Body

PerianalinvolvementbyfistulizingdiseaseisaknowndebilitatingmanifestationofCrohndiseaseinadultsandpediatricpatientsalike[1][2].Besidessurgicalmanagement,thecourseofthischronicdiseasehasbeenalteredbytheintroductionofbiologicagentssuchasantitumornecrosisfactoralphasupplementingexistingmedicaltherapy[2].Thisisturn,hasnecessitatedaccurateimagingdiagnosistohelpguideappropriatetherapyandimprovepatientoutcomes.
MRI,withitsabsenceofionizingradiation,superiorsofttissueresolutionandmultiplanarcapabilityisthestandardofcareforimagingperianalfistulizingdisease.PerianalMRIintheCrohnpopulationisindicatedinpatientswithanysymptomssuggestiveofperianaldisease,detailedmappingofdiseaseextentwhenpartiallyimagedonMRenterography(MRE)orforrulingoutanabscessthatwouldpreventinitiationofbiologics.
Atourinstitution,weofferacombinedMRprotocol,imagingbothbowelandperianalregionatthesametime.Bothpediatricandadultpatientscanbeimagedsupineoneithera1.5Tor3Tmachineusingthesameprotocolandaphasedarraysurfacecoilplacedoverthepelvis.Nopreparationisrequiredpriortoscanning.Protocolsmayvaryslightlyamongvariousinstitutions,however,requireaminimumoftwoplanesperpendiculartoeachother.Followingtriplanelocalizerimages,weobtainsmallfieldofviewobliqueaxialandcoronalT2weightedsequenceswithandwithoutfatsuppression,usingthelongitudinalaxisoftheanalcanalasthereferenceline,prescribedundersupervisionbyradiologists.SagittalT2weightedsequencesandT1weightedsequencesintheobliqueaxialplanewithoutandafteradministrationofintravenousgadoliniumbasedcontrast(0.1mmol/kg)compriseatypicaladultacquisitionprotocol[3].Awidefieldofviewpelvisisaddedtodetectremoteextensionsoffistulasandassessbowelwallinflammation.Diffusionweightedimagesareoftenaddedtothepediatricprotocol,especiallyifintravenouscontrastcannotbeadministered[4].Thetotalscantimerangesfromabout30minutesforperianalMRIaloneoranhourforacombinedMREandperianalMRIcombinationstudy.
Usingastructuredtemplatereportforinterpretationassuresstandardizationofterminology,decreasedchanceofmissingkeyfindingsandpotentialforresearch[5].Thetemplateusedisoftenaninstitutionalpreference,howevertheESGARconsensusguidelinesappropriatelyillustratesallkeyelementstobedescribedwhileinterpretingtheseperianalMRIstudies[6].Traditionally,thesurgicalbasedParksClassificationsystemandtheMRbasedSt.JamesUniversityHospitalclassificationsystemhavebeenusedtodescribefistulae,applicableinbothpediatricandadultpopulations.However,theseonlyprovideanatomiclocalizationwithoutconsideringdiseaseactivity.ThemodifiedVanAsscheindex(mVAI),animprovisationontheoriginalMRIVAIproposedbytheAmericanGastroenterologyAssociation(AGA)in2003isanMRbasedscoringsystemspecifictotheCrohndiseasepopulation,takesintoaccountfistulainflammationinadditiontoanatomiclocalization[7][8].TheMagneticResonanceNovelIndexforFistulaImaginginCD(MAGNIFICD)isanMRIbasedperianalinflammatoryscoredemonstratingimprovedoperatingindicescomparedtomVAI,promisingtobeusefulinclinicaltrialsforassessmentoftreatmentresponse,butneedsadditionalvalidation[9].ThePediatricMRIbasedPerianalCrohnDisease(PEMPAC)IndexisarecentlydescribedMRIbasedscoreexclusivetothepediatricpopulation,enablingdifferentiationoftheseverityofdiseaseactivityandremission[10].
Acompletereportwouldstartbydefiningthefistulaassimpleorcomplex[11].Thereafter,listingthenumberoffistulae,thenfocusingoneachfistulaindividuallytodescribetheinternalanalopeningbasedontheanalclock;courseandtraversinganatomiccomponentsoftheanalsphinctercomplexandlevatorani;externalopening;singletractorpresenceofsecondarytracts;associatedsinustractsorabscesses;extensiontosurroundingperineum;anypostsurgicalchangesincludingpresenceofsetons;diseaseactivitybasedonMRsignalcharacteristicsandfinallypresenceofrectalwallinflammation.Aspersonalizedmedicineandadvancesintherapeuticoptionsprogress,newerimagingtechniquesarebeingexploredtooptimizepatientcare.3DprintedanalfistulamodelsgeneratedfromhighresolutionT2weightedMRIvolumetricdatasetstakeabout6hourstogenerate.ThesehavebeenproposedtolowertheinterobserverbiasconnectedwithinterpretationofcomplexconventionalMRimagingbeforeplannedsurgerybyGuzWetal[12].Useofmagnetizationtransferimagingtocreateastandardizedmagnetizationtransferratio(MTR)parameterforpredictingseverityofintestinalfibrosisinCrohndiseasepatientsisanotherexampleofneweradvances[13][14].
Althoughprogressiveadvancementsintreatmenthaveattemptedtocontrolandtreatthisdebilitatingcondition,prognosticbiomarkersarenotyetrobustinpredictingtreatmentoutcomesasalsoemphasizedbyGreer,MaryLouiseCandTaylor,StuartA[4].SincetherapyreliesheavilyonaccurateMRdiagnosis,MRIcanalsoplayacomplementaryroleasaprognosticbiomarker[15][16][17].MorestudiestoproveMRIasausefultoolnotonlyforinitialdiagnosisandsurveillancebutalsotobeusedasaprognostictoolwouldindeedcementtheroleofMRIinimagingperianalCrohndiseaseinpediatricandadultpatients.Finally,anopportunitytoexploretheroleofMRIinVeryEarlyOnsetIBD(VEOIBD)exists,withmoreresearchneededinthisarea.

Acknowledgements

Sudha Anupindi, MD, FSAR; Attending Radiologist; Chief, Division of Body ImagingDirector, Section of Gastrointestinal and Hepatic Imaging; Soroosh Mahboubi Endowed Chair in Body ImagingAssociate Professor; Perelman School of Medicine at the University of Pennsylvania, PA.

Michael S Gee, MD, PhD; Attending Radiologist; Deputy Chair, Section Chief, Division of Pediatric Imaging, Massachusetts General Hospital for Children, Boston, MA.

References

1.Adler J, Dong S, Eder SJ, Dombkowski KJ (2017) Perianal Crohn Disease in a Large Multicenter Pediatric Collaborative. Journal of Pediatric Gastroenterology & Nutrition 64:e117–e124. https://doi.org/10.1097/MPG.00000000000014472.

2.Lopez N, Ramamoorthy S, Sandborn WJ (2019) Recent advances in the management of perianal fistulizing Crohn’s disease: lessons for the clinic. Expert Review of Gastroenterology & Hepatology 13:563–577. https://doi.org/10.1080/17474124.2019.16088183.

3.Santillan CS, Huang C, Eisenstein S, Al-Hawary MM (2021) MRI of Perianal Crohn Disease: Technique and Interpretation. Topics in Magnetic Resonance Imaging 30:63–76. https://doi.org/10.1097/RMR.00000000000002684.

4.Greer M-LC, Taylor SA (2021) Perianal Imaging in Crohn Disease: Current Status With a Focus on MRI, From the AJR Special Series on Imaging of Inflammation. American Journal of Roentgenology AJR.21.26615. https://doi.org/10.2214/AJR.21.266155.

5.Sudoł-Szopińska I, Santoro GA, Kołodziejczak M, et al (2021) Magnetic resonance imaging template to standardize reporting of anal fistulas. Tech Coloproctol 25:333–337. https://doi.org/10.1007/s10151-020-02384-66.

6.Halligan S, Tolan D, Amitai MM, et al (2020) ESGAR consensus statement on the imaging of fistula-in-ano and other causes of anal sepsis. Eur Radiol 30:4734–4740. https://doi.org/10.1007/s00330-020-06826-57.

7.van Rijn KL, Lansdorp CA, Tielbeek JAW, et al (2020) Evaluation of the modified Van Assche index for assessing response to anti-TNF therapy with MRI in perianal fistulizing Crohn’s disease. Clinical Imaging 59:179–187. https://doi.org/10.1016/j.clinimag.2019.10.0078.

8.Wang W-G, Lu W-Z, Yang C-M, et al (2020) Modified Van Assche magnetic resonance imaging-based score for assessing the clinical status of anal fistulas: Medicine 99:e20075. https://doi.org/10.1097/MD.00000000000200759.

9.Hindryckx P, Jairath V, Zou G, et al (2019) Development and Validation of a Magnetic Resonance Index for Assessing Fistulas in Patients With Crohn’s Disease. Gastroenterology 157:1233-1244.e5. https://doi.org/10.1053/j.gastro.2019.07.02710.

10.Choshen S, Turner D, Pratt L-T, et al (2021) Development and Validation of a Pediatric MRI-Based Perianal Crohn Disease (PEMPAC) Index—A Report from the ImageKids Study. Inflammatory Bowel Diseases izab147. https://doi.org/10.1093/ibd/izab14711.

11.Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB (2003) AGA technical review on perianal Crohn’s disease. Gastroenterology 125:1508–1530. https://doi.org/10.1016/j.gastro.2003.08.02512.

12.Guz W, Ożóg Ł, Aebisher D, Filip R (2021) The use of magnetic resonance imaging technique and 3D printing in order to develop a three-dimensional fistula model for patients with Crohn’s disease: personalised medicine. pg 16:83–88. https://doi.org/10.5114/pg.2020.10162913.

13.Pazahr S, Blume I, Frei P, et al (2013) Magnetization transfer for the assessment of bowel fibrosis in patients with Crohn’s disease: initial experience. Magn Reson Mater Phy 26:291–301. https://doi.org/10.1007/s10334-012-0355-214.

14.Meng J, Huang S, Sun C, et al (2020) Comparison of Three Magnetization Transfer Ratio Parameters for Assessment of Intestinal Fibrosis in Patients with Crohn’s Disease. Korean J Radiol 21:290. https://doi.org/10.3348/kjr.2019.021715.

15.Shenoy-Bhangle A, Nimkin K, Goldner D, et al (2014) MRI predictors of treatment response for perianal fistulizing Crohn disease in children and young adults. Pediatr Radiol 44:23–29. https://doi.org/10.1007/s00247-013-2771-516.

16.Karmiris K, Bielen D, Vanbeckevoort D, et al (2011) Long-Term Monitoring of Infliximab Therapy for Perianal Fistulizing Crohn’s Disease by Using Magnetic Resonance Imaging. Clinical Gastroenterology and Hepatology 9:130-136.e1. https://doi.org/10.1016/j.cgh.2010.10.02217.

17.Chambaz M, Verdalle-Cazes M, Desprez C, et al (2019) Deep remission on magnetic resonance imaging impacts outcomes of perianal fistulizing Crohn’s disease. Digestive and Liver Disease 51:358–363. https://doi.org/10.1016/j.dld.2018.12.010

Figures

Title page

Adult perianal MR protocol

MR sequences = pathology

Intersphincteric fistula ( Park's classification) with supralevator extension in a 23 year old male.

Posterior intersphincteric fistula with complete treatment response on biologics in a 9-year old girl

Proc. Intl. Soc. Mag. Reson. Med. 30 (2022)