Strukturierte Befundung der intestinalen MRT bei Morbus Crohn

Beim Morbus Crohn kommt der MRT bei Diagnose, Verlauf und Therapie eine große Bedeutung zu. Dabei sind gemeinsame Befundungsstandards für die MRT (und den Darmultraschall) eine wichtige Voraussetzung für die Zusammenarbeit von Gastroenterologen, Radiologen und Chirurgen. Die wesentlichen Standards sind in diesem Beitrag zusammengefasst.

Kernaussagen

• Eine Nahrungskarenz von mindestens 4 Stunden vor der MRT ist ausreichend.

• Die MRT kann ohne Sondenapplikation als MR-Enterografie mit oraler Gabe von Mannitol oder Methylcellulose sicher durchgeführt werden.

• Befundungs- und Bildkriterien werden systematisch und strukturiert erhoben:

  • mural (Lokalisation, Länge, Wanddicke, Stenose, Wandödem, Ulzera, Diffusionsrestriktion, Enhancement, Wandmuster)

  • extramural („creeping fat“, mesenteriales Ödem, „comb sign“, Lymphadenopathie einschließlich Komplikationen wie Sinus Tracts, Fisteln, Konglomerattumoren, Abszesse)

  • extraintestinal (Sakroiliitis, avaskuläre Knochennekrose, primär sklerosierende Cholangitis, Pankreatitis, mesenteriale Venenthrombose sowie Cholelithiasis und Nephrolithiasis)

• In der Beurteilung bewertet man im klinischen Kontext den Entzündungs-, den Stenose-, den Penetrations-, den Perianal- und den extraintestinalen Komplikationsstatus.

  • Vermutete Stenosen werden als sichere oder wahrscheinliche Stenose kategorisiert und systematisch in Hinblick auf ihre Entzündungsaktivität charakterisiert (prädominant entzündlich vs. prädominant fibrotisch).

  • Vorrangige Kriterien der Entzündungsaktivität sind Darmwandödem, Darmwandschichtung, Ulzera, Sinus Tract, Fistel und Abszess.

• Eine Verbesserung der Erhebung wie auch der Dokumentation der Befunde einer MR-Enterografie bei chronisch entzündlichen Darmerkrankungen kann zur besseren Kommunikation und damit Versorgung der Patienten beitragen.

Schlüsselwörter

MR-Enterografie - Morbus Crohn

Key words

magnetic resonance enterography - Crohnʼs Disease

Publication History

Article published online:
01 September 2023

• Literatur

• 1 Sturm A, Atreya R, Bettenworth D. et al. Aktualisierte S3-Leitlinie „Diagnostik und Therapie des Morbus Crohn“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). Z Gastroenterol 2022; 60: 332-418
• 2 Kucharzik T, Tielbeek J, Carter D. et al. ECCO-ESGAR Topical Review on Optimizing Reporting for Cross-Sectional Imaging in Inflammatory Bowel Disease. J Crohns Colitis 2022; 16: 523-543
• 3 Oh K, Oh EH, Noh SM. et al. Combined Endoscopic and Radiologic Healing Is Associated With a Better Prognosis Than Endoscopic Healing Only in Patients With Crohnʼs Disease Receiving Anti-TNF Therapy. Clin Transl Gastroenterol 2022; 13: e00442
• 4 Bruining DH, Zimmermann EM, Loftus jr. EV. et al. Consensus Recommendations for Evaluation, Interpretation, and Utilization of Computed Tomography and Magnetic Resonance Enterography in Patients With Small Bowel Crohnʼs Disease. Gastroenterology 2018; 154: 1172-1194
• 5 Halligan S, Tolan D, Amitai MM. et al. ESGAR consensus statement on the imaging of fistula-in-ano and other causes of anal sepsis. Eur Radiol 2020; 30: 4734-4740
• 6 Kucharzik T, Atreya R, Bachmann O. et al. Position paper on reporting of intestinal ultrasound findings in patients with inflammatory bowel disease. Z Gastroenterol 2022; 60: 978-990
• 7 Rimola J, Rodriguez S, Garcia-Bosch O. et al. Magnetic resonance for assessment of disease activity and severity in ileocolonic Crohnʼs disease. Gut 2009; 58: 1113-1120
• 8 Steward MJ, Punwani S, Proctor I. et al. Non-perforating small bowel Crohnʼs disease assessed by MRI enterography: derivation and histopathological validation of an MRbased activity index. Eur J Radiol 2012; 81: 2080-2088
• 9 Ordás I, Rimola J, Alfaro I. et al. Development and Validation of a Simplified Magnetic Resonance Index of Activity for Crohnʼs Disease. Gastroenterology 2019; 157: 432-439.e1
• 10 Messadeg L, Hordonneau C, Bouguen G. et al. Early Transmural Response Assessed Using Magnetic Resonance Imaging Could Predict Sustained Clinical Remission and Prevent Bowel Damage in Patients with Crohnʼs Disease Treated with Anti-Tumour Necrosis Factor Therapy. J Crohns Colitis 2020; 14: 1524-1534
• 11 Bodily KD, Fletcher JG, Solem CA. et al. Crohn Disease: mural attenuation and thickness at contrast-enhanced CT enterography – correlation with endoscopic and histologic findings of inflammation. Radiology 2006; 238: 505-516
• 12 Taylor SA, Mallett S, Bhatnagar G. et al. Diagnostic accuracy of magnetic resonance enterography and small bowel ultrasound for the extent and activity of newly diagnosed and relapsed Crohnʼs disease (METRIC): a multicentre trial. Lancet Gastroenterol Hepatol 2018; 3: 548-558
• 13 Hallé E, Azahaf M, Duveau N. et al. Radiological Response Is Associated with Better Outcomes and Should Be Considered a Therapeutic Target in Crohnʼs Disease. Dig Dis Sci 2019; 65: 2664-2674
• 14 Rieder F, Bettenworth D, Ma C. et al. An expert consensus to standardise definitions, diagnosis and treatment targets for anti-fibrotic stricture therapies in Crohnʼs disease. Aliment Pharmacol Ther 2018; 48: 347-357
• 15 Guglielmo FF, Anupindi SA, Fletcher JG. et al. Small Bowel Crohn Disease at CT and MR Enterography: Imaging Atlas and Glossary of Terms. Radiographics 2020; 40: 354-375
• 16 Schulberg JD, Wright EK, Holt BA. et al. Magnetic resonance enterography for predicting the clinical course of Crohnʼs disease strictures. J Gastroenterol Hepatol 2020; 35: 980-987
• 17 Stocker D, King MJ, El Homsi M. et al. Luminal narrowing alone allows an accurate diagnosis of Crohnʼs disease small bowel strictures at cross-sectional imaging. J Crohns Colitis 2021; 22: 1009-1018
• 18 Zidar N, Langner C, Jerala M. et al. Pathology of fibrosis in Crohnʼs disease – contribution to understanding ist pathogenesis. Front Med 2020; 7: 167
• 19 Allocca M, Fiorino G, Bonifacio C. et al. Noninvasive Multimodal Methods to Differentiate Inflamed vs. Fibrotic Strictures in Patients With Crohnʼs Disease. Clin Gastroenterol Hepatol 2019; 17: 2397-2415
• 20 Orscheln ES, Dillman JR, Towbin AJ. et al. Penetrating Crohn disease: does it occur in the absence of stricturing disease?. Abdom Radiol (NY) 2018; 43: 1583-1589
• 21 Schreyer AG, Menzel C, Friedrich C. et al. Comparison of high-resolution ultrasound and MR-enterography in patients with inflammatory bowel disease. World J Gastroenterol 2011; 17: 1018-1025
• 22 Rimola J, Ordas I, Rodriguez S. et al. Magnetic resonance imaging for evaluation of Crohnʼs disease: validation of parameters of severity and quantitative index of activity. Inflamm Bowel Dis 2011; 17: 1759-1768
• 23 Tielbeek JA, Makanyanga JC, Bipat S. et al. Grading Crohn disease activity with MRI: interobserver variability of MRI features, MRI scoring of severity, and correlation with Crohn disease endoscopic index of severity. AJR Am J Roentgenol 2013; 201: 1220-1228
• 24 Park SH. DWI at MR enterography for evaluating bowel inflammation in Crohn disease. AJR Am J Roentgenol 2016; 207: 40-48
• 25 Punwani S, Rodriguez-Justo M, Bainbridge A. et al. Mural inflammation in Crohn disease: location-matched histologic validation of MR imaging features. Radiology 2009; 252: 712-720
• 26 Choi SH, Kim KW, Lee JY. et al. Diffusion-weighted magnetic resonance enterography for evaluating bowel inflammation in Crohnʼs disease: a systematic review and meta-analysis. Inflamm Bowel Dis 2016; 22: 669-679
• 27 Makanyanga J, Punwani S, Taylor SA. Assessment of wall inflammation and fibrosis in Crohnʼs disease: value of T1-weighted gadolinium-enhanced MR imaging. Abdom Imaging 2012; 37: 933-943
• 28 Church PC, Turner D, Feldman BM. et al. Systematic review with meta-analysis: magnetic resonance enterography signs for the detection of inflammation and intestinal damage in Crohnʼs disease. Aliment Pharmacol Ther 2015; 41: 153-166