Optimizing Patient Management in Crohn’s Disease in a Tertiary Referral Center: the Impact of Fast-Track MRI on Patient Management and Outcomes
Akos Ilias1*, Barbara D. Lovasz1,2*, Lorant Gonczi1, Zsuzsanna Kurti1, Zsuzsanna Vegh1, Liza D. Sumegi1, Petra A. Golovics3, Gabor Rudas4, Peter L. Lakatos1,5
1) Semmelweis University, First Department of Medicine, Budapest, Hungary
2) Institute of Applied Health Sciences, Semmelweis University, Budapest, Hungary
3) Military Hospital – State Health Centre, Budapest, Hungary
4) Semmelweis University, Magnetic Resonance Imaging Research Center, Budapest, Hungary
5) Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
ABSTRACT Background & Aims: Rapid optimization of treatment algorithms and disease outcomes requires an objective measurement of disease activity in patients with Crohn’s disease (CD). Our aim was to evaluate the impact of rapid-access to magnetic resonance imaging (MRI) on treatment optimization, clinical decision-making and outcomes for CD patients in a specialized tertiary care for inflammatory bowel disease (IBD) patients. Methods: A cohort of 75 referral CD patients (median age: 34, IQR: 25-43 years) who had underwent 90 fasttrack MR enterography (MRE) scans between January 2014 and June 2016 were retrospectively enrolled. The MRI results were compared to clinical activity scores and biomarkers (C-reactive protein). The immediate impact of fast-track MRI on clinical decision-making, including changes in medical therapy, the need of hospitalization and surgery were evaluated. Results: The location of CD was ileo-colonic in 61% of the patients with perianal fistulas in 56% and previous surgeries in 55%. The indication for fast-track MRI scans was active disease (clinical or biomarker activity) in 55.6%. The radiological activity (including mild radiological signs to severe lesions) was detected in 94% of cases. Significant/severe MRI activity was depicted in 68% of these patients. Correlation between MRI radiological activity and clinical disease activity or colonoscopy was moderate (kappa: 0.609 and 0.652). A change in therapeutic strategy was made in 94.1% of cases with severe MRI radiological activity vs. 50% of patients without severe MRI radiological activity (p=0.001). Significant/severe MRI activity was followed by higher surgery rates among patients with clinical disease activity (50% vs. 12.5%; p=0.013). MRI performed on patients with clinical and biomarker remission identified disease activity in a significantly smaller proportion. Conclusions: Fast-track MRI had a great impact on patient management in CD patients with clinical or biomarker activity, leading to better patient stratification and faster optimization of the therapy (medical or surgical), while MRI revealed previously undiagnosed disease activity only in a small proportion of patients in clinical remission. Key words: inflammatory bowel disease – magnetic resonance imaging – clinical activity – clinical outcome. Abbreviations: CD: Crohn’s disease; CDAI: Crohn‘s Disease Activity Index; CDEIS: Crohn’s Disease Endoscopic Index of Severity; CRP: C-reactive protein; CT: computer tomography; IBD: inflammatory bowel diseases; MRE: magnetic resonance enterography; MRI: Magnetic resonance imaging; US: ultrasonography.