Jeff L. Fidler

Due to increasingly nuanced Crohn disease therapy selection and disease evaluation, radiologic assessment of transmural healing, although aspirational, may be more complete than endoscopic assessment of mucosal healing, which is the current treatment target.

Background: The evaluation of gastrointestinal (GI) bleeding is frequently negative despite a prolonged workup involving several different radiologic and endoscopic tests. Ferumoxytol, a superparamagnetic iron oxide agent used for treatment of iron deficiency anemia, can be used off-label as a blood pool contrast agent at MRI. Purpose: To perform a proof-of-concept study to determine if ferumoxytol-enhanced MRI (FeMRI) can be performed to assist in detecting the presence and location of GI bleeding in patients who have undergone a negative standard evaluation. Methods: A retrospective convenience cohort of patients examined with FeMRI at a single center over a 2-year period was evaluated. Inclusion criteria included clinical suspicion for slow or intermittent, active GI bleeding not localized following conventional testing. Exclusion criteria included any allergy to ferumoxytol or iron-containing agents, additional MRI scans scheduled within the following 72 hours, current pregnancy or breastfeeding, history of medication-related hypotensive episodes not related to an acute illness, syncopal events, arrhythmia, or low resting blood pressure. The patient’s clinical characteristics, examination results, and outcome during their hospital stay were examined. Results: Five males and 1 female with average age of 66 years (range, 37-79 years) were imaged with FeMRI. All had undergone full diagnostic evaluation of the GI tract including upper and lower endoscopy and small bowel evaluation with imaging and/or endoscopic testing; in all patients, repeated rounds of testing were performed. Diagnostic images were obtained in all patients who underwent FeMRI. In 4/6 (67%) patients, FeMRI demonstrated active bleeding in the small bowel (n = 3) and colon (n = 1). Conclusion: FeMRI was able to demonstrate the presence and location of active GI bleeding in hospitalized patients with previous extensive negative evaluation. FeMRI should be further evaluated to determine its performance characteristics as an examination in evaluating patients with GI bleeding.

Crohn’s disease is a transmural inflammatory bowel disease, which can progress to stricturing and internal penetrating complications. Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) are utilized with endoscopy to detect and stage small bowel Crohn’s disease. Small bowel strictures and associated penetrating complications are commonly missed complications of fibrostenosing Crohn’s disease at CTE/MRE. This educational review focuses on factors contributing to unreported or overcalled strictures including disease location, postoperative anatomy, erroneous understanding of threshold dilation for stricture diagnosis, and underappreciation for how stricture diagnosis can improve patient care, emphasizing current understanding of Crohn’s small bowel strictures using illustrative cases. In addition, we explain emerging consensus for how strictures and their associated obstruction can be consistently measured and described. We also review frequently missed complications of fibrostenosing Crohn’s disease such as chronic mesenteric venous occlusion and penetrating complications, including blind-ending sinus tracts, and ileoappendiceal and complex enteroenteric fistulas. Finally, common mimics of fibrostenosing Crohn’s disease including NSAID enteropathy, radiation enteritis, and other entities are discussed, highlighting key distinguishing imaging and clinical features. Radiologists must be proactive in identifying strictures to improve patient outcomes and prevent unnecessary delay in surgical intervention or access to targeted biologic therapies.

Purpose Crohn’s disease (CD) is characterized by enteric inflammation, often resulting in strictures and penetrating complications, which may alter patient management prior to the initiation of biologic therapy. Our aim is to assess the frequency of missed stricturing and internal penetrating complications in CD patients on computed tomography enterography (CTE) and magnetic resonance enterography (MRE) performed prior to anti-TNF therapy. Methods We retrospectively reviewed patients from two tertiary centers who underwent CTE\MRE within six months before starting anti-TNF therapy. Patients with prior intestinal surgery, anti-TNF therapy, or radiology reports indicating strictures or penetrating complications were excluded. Two GI radiologists re-evaluated CTE\MRE images for active inflammation, small bowel strictures (SAR/AGA/SPR criteria), and internal penetrating complications. Senior radiologists reviewed CTE/MRE exams with missed findings and identified potential causes of error. Descriptive statistics were used to summarize the prevalence of missed findings. Where applicable, comparisons were made using chi-square test. Results 250 CD patients were included. 239 (96%) exhibited active terminal ileal (TI) inflammation by expert review of CTE\MRE images. Missed TI strictures were identified in 56 patients (22%). 16 patients (6.4%) had unreported penetrating complications, including ileoappendiceal fistulas (n = 6), sinus tracts (n = 6), complex fistulas (n = 4), inflammatory masses (n = 3), ileocecal fistula (n = 1), and abscess (n = 1). There were no significant differences between institutions in the rates of strictures (18/69 vs. 38/181, P = 0.4) or penetrating complications (5/69 vs. 11/181, P = 0.77). 46% of the strictures appeared obvious upon re-evaluation by senior radiologists, potentially implicating a failure to measure associated small bowel dilation. 38% of missed strictures had multifocal areas of luminal narrowing, and maximal proximal dilation was located 10 cm or more proximal to a stricture in 27%. Conclusion A substantial proportion of strictures and penetrating complications in CD are missed at baseline CTE/MRE prior to anti-TNF therapy initiation, even in specialized centers.

Objectives Radiologist participation in multidisciplinary tumor board can be time-consuming and demanding, requiring substantial preparation. Anecdotally radiologist participation is felt to help identify discrepancies in previous interpretations; however, there are limited data assessing the actual impact of their tumor board review on patient management. This prospective study aims to evaluate how the reinterpretation of outside imaging and review at hepatobiliary tumor board (HBTB) affects the diagnosis and management of patients with hepatobiliary neoplasms. Methods This prospective analysis included all patients presented at the weekly HBTB between 6/13/2023—6/25/2024. One radiologist reviewed the available reports of outside imaging, the local reinterpretation of outside imaging, the updated local imaging, and documented conclusions from discussion of the case at HBTB. HBTB included 4 radiologists who had reviewed each case. Discrepancies (presence/absence, number, and reasons for) were recorded. When discrepancies occurred, the impact on patient management (5-point Likert scale) was determined by two of the radiologists present at the HBTB in consensus, with input from clinicians if needed. A six-month follow-up was performed to confirm suspected diagnoses. Results 208 cases (128 males, 104 chronic liver disease patients) were presented at HBTB. Disagreements in the detection or characterization of lesions were found in 59/208 (28.4%) of cases. A change in management occurred in 38/59 (64.6%) of these discrepant cases. In cases with recorded discrepancies in which follow-up confirmation was available, the final interpretation was confirmed in 34/41 (82.9%) of cases. Conclusion Our study found a discrepant interpretation in nearly one-third of cases presented at a weekly HBTB and a resultant change in management in 65% of those cases. These findings highlight the importance of reinterpretation of prior imaging studies and the presence of radiologists at HBTB to guide optimal patient management. Key message Patient care is substantially impacted by reinterpretation of prior imaging and participation of radiologists at hepatobiliary tumor board. Graphical abstract

This consensus by the Society of Abdominal Radiology Inflammatory Bowel Disease Disease Focused Panel provides an updated imaging-based definition of small bowel Crohn disease stricture for CT and MR enterography.

Alcohol use disorder is linked to a multitude of diseases and disorders, many of which can be diagnosed with imaging techniques such as US, CT, and MRI, enabling early detection and potentially preventing further damage and improving outcomes.

The evaluation of patients with gastrointestinal (GI) bleeding is complicated due to the variety of tests available and the large number of potential causes of bleeding. MRI is less commonly used than computed tomography and endoscopy but it can diagnose disease that causes GI bleeding and serve as a complementary role to other tests. MRI is most often used in the form of magnetic resonance enterography (MRE) to assess patients with suspected bleeding from the small bowel. While CT enterography (CTE) and video capsule endoscopy (VCE) are the more commonly used tests in the setting of GI Bleeding, MRE has characteristics which may make it the more favorable modality for a given patient. Potential advantages of MRE, protocol considerations and the literature delineating its diagnostic performance for detecting pathology which can cause GI bleeding relative to CTE and VCE are reviewed here. MRI is uncommonly used to assess patients with upper GI bleeding, lower GI bleeding and patients with bleeding sites that remain undetected despite a formal evaluation of the GI tract, however it may add value in specific clinical scenarios. These uncommon scenarios and specific clinical examples are also presented to highlight the potential benefits of MRI.

Radiologists are integral members of the interdisciplinary team for patients with mucinous appendiceal neoplasms and can directly affect care by suggesting the diagnosis of pseudomyxoma peritonei, optimizing imaging protocols for evaluating peritoneal implants, and reporting the primary tumor and spilled tumor cells thoroughly.