Now, let's welcome Kimberly Collins for our next two talks. Kim is a nurse practitioner that specializes in adult gastroenterology for Dooley Health and Care in Hoffman Estates, Illinois. For the past 15 years, she has been providing both inpatient and outpatient healthcare specializing in adult gastroenterology. Her healthcare philosophy focuses on education, disease prevention, and health promotion. She's a member of the American Academy of Nurse Practitioners, Illinois Society of Nurse Practitioners, Crohn's and Colitis Foundation, and a long-term member of the American Gastroenterological Association. She is currently serving as the co-chair for Crohn's and Colitis Diversity and Inclusion Committee and is a member of Crohn's and Colitis RNAPP Committee. Kimberly is the co-founder of MidGut, a professional society dedicated to the education, mentorship, and collaboration of nurse practitioners and physician assistants specializing in gastroenterology and hepatology. She has been an invited speaker on several topics in gastroenterology at both regional and national meetings. She will actually co-chair with me a session at DDW this year. Education for staff, students, peers, and most importantly, patients are truly her passion. Kim, the audience is yours. Thank you so much for such a grand introduction. I just want to, of course, thank the course organizers for having me come back again this year. How exciting. It's almost St. Patrick's Day and I live in Chicago, so I got to represent my Patrick's Day green here, so forgive me for that. All right, let's get going. I know that they gave me a full hour to talk this year because last year I definitely went over. This year, we're going to start with the role of imaging and managing Crohn's disease. With that being said, here are my disclosures. In our 20 minutes that we have to talk about the role of imaging in Crohn's disease, we're going to talk about the utility in current imaging modalities, explore indications, and of course, what would a course about APPs not have, but including the integration of the APP role when it comes to diagnostics and Crohn's disease. Why of course talk about diagnostics and Crohn's disease? Because of course, we use ileocolonoscopy, but we have to recognize that about 75% of the time that Crohn's disease falls within the small bowel, which always isn't seen by our colonoscopies, right? And the location we know is important. I like to say location, location of location, because this does, of course, impact the therapy and selected outcome of our therapies. Small bowel proximal lesions may have a more severe prognosis and jejunal disease increases the risk for stricturing behavior and of course, resulting in multiple abdominal surgeries. Small bowels, of course, Crohn's disease follows a pattern of fibrostenotic stricture formation along with penetrating lesions, making management of these patients difficult. And of course, again, it talks about the importance of recognizing and diagnosing small bowel Crohn's disease. So this is just a grand table, of course, to talk about the diagnostic imaging that we have when it comes to Crohn's disease. And although we've mentioned it before, ileocolonoscopy is a proven method to diagnose Crohn's disease, it's still limited. And by, you know, maximal extent of where we get to in the ileum, right? There's an inability to detect transmural complications, and of course, limited ability to assess deep bowel wall involvement. So what we see here by this table, and I love tables, by the way, so we've got our small bowel follow-through, CT entorography, MR entorography, intestinal ultrasound, and of course, capsule endoscopy we're going to talk about as well. As you can see here, part of our objectives was to review the utility in Crohn's disease along with discussing the pros and cons of each. So where do we start, right? With this ginormous list that we have here, and again, multiple modalities. But I do have to say, if there's a diagnosis or suspicion of small bowel Crohn's disease, evidence-based practice does suggest diagnostic imaging of the small bowel should be performed to localize extent and severity of the disease. Now let's take a look at this table here, right? We talked about small bowel follow-through, kind of the tried and true. We're going to go into these a little bit more detail. Again, success for, of course, active disease, and of course, pretty good in developing, or looking for stricture, right? The pros, of course, that it's widely available. The cons, of course, limited in the evaluation of transluminal inflammation. And we're going to go over each of these a little bit more in detail, but I just wanted to give you guys an assessment and have this table so you can refer back to it. So we'll look at CT and MR entorography. I just want to suggest that the utility in Crohn's disease is very similar, right? Diagnosis, assessment of disease extent, activity, monitor for disease response. And of course, it's a great modality to determine presence or absence of fistula. Now we're looking at our CT entorography. Specifically, we're looking at our pros. We've got evaluation of luminal disease along with extraluminal pathology. What I want to point out, of course, is this is a rapid exam, right? That we can get this done quickly. There is less user dependence on that as well. We look at the cons. We've got radiation and, of course, IV contrast, especially those with chronic kidney disease. We already talked about the utility when it comes to MR entorography. But again, the evaluation of luminal disease and, of course, extraluminal pathology can sometimes be superior to CTE when we're talking about the pros. And again, there is less, or I'd like to say minimal, right, radiation exposure. And with the cons, though, it's a prolonged exam. If you've ever had an MRI, you know what this is like. There's a lack of accessibility. And of course, there's cost that's involved in that as well. How about intestinal ultrasound? Kind of the new kid on the block, right? And we're going to go into this a bit further. But again, utility, diagnosis, assess disease extent, activity, monitor response to therapy. And there's some studies that we're going to review with that as well. The pros about this, of course, now we've got possibly point-of-care testing. So doing it bedside, non-invasive monitoring, no radiation, and, of course, no bowel prep. The cons, of course, is that they're not universally accepted or validated as of yet. There's potential for limitation in rectal evaluation. And keep that in mind. Again, the evaluation in rectal or just proctitis is, right now, there's some potential limitation for that, lack of accessibility. I don't have this, to be honest with you. This, of course, is at our university-based practices. And of course, performance is really dependent on operator experience. And last but not least, capsulendoscopy, which I'm not going to just give up my bias right now, is that I read capsulendoscopy. I've read it for over 20 years. And I love this tool specifically for diagnostic imaging for Crohn's disease. Again, a use for diagnosis, assess disease extent, activity, and, of course, monitor response for therapy. The pros, of course, in this is that you allow direct evaluation of luminal disease. There's a lack of radiation. And then there's higher diagnostic yield for Crohn's disease compared to other diagnostic modalities, according to some studies. But on the same hand, when we look at the cons, small bowel, it only allows for small bowel interluminal evaluation, right? We can't really look for colonic. Of course, there's bowel prep, plus or minus. I use bowel prep, not going to lie. There's a small risk of retention, which we're going to go over. And of course, there's that little element of incomplete exam. Now, before we go any further, we talk about all these diagnostic imaging. But of course, there's the hot topic, of course, of radiation, right? And in the US, again, radiation has become a hot topic over the last 30 years. And this, of course, has caught the attention of the public. And patients now, even my own, sometimes refuse CT. And if we think about our overall population of our IBD patients, again, sometimes pediatric and sometimes our young adults. So as APPs, we need to, of course, be considerate of cumulative radiation exposure. And again, think about your choices when considering a diagnostic imaging. And of course, choose the test that best represents what you need for your patient. All right, small bowel follow-through it is. Let's start with this one, the tried and true, right? We used to use this one, I think, most frequently, right? Oh gosh, there's another little piece that's coming up here. Forgive me. There's another piece that comes up. Let's get that up right away. Excellent. So this is actually an image of my patient's small bowel follow-through, right? One of the first tests that was originally utilized to evaluate the small bowel. And again, fortunately or unfortunately, these tests have kind of gone by the wayside, especially, I don't know, anybody back in the day, we used to do a small bowel intercalisive. So one of the limitations that you can see here, even from this patient's x-ray that you see, the small bowel follow-through, sometimes you have that overlap of the small intestine on top of the other small bowel loop. So again, sometimes it doesn't always give us all the information that we need. But what I want to point out in a prospective study, looking at CT enterography, MRE and small bowel follow-through, we're found to be equally accurate. And again, this is a generalized term, but detective of active inflammation in the small bowel. And why do I bring that up? Because you use what you have, right? Use the tool that you have and use the tool that can be accessible to your patients. The sensitivity values of CT enterography, again, 89%, MRE, 83% were slightly higher than those of small bowel follow-through. Again, I bring that up because of the fact that, yes, if we're going to choose a test, we want to choose one, of course, that might be more sensitive. But again, look at the tools that you have. Small bowel follow-through, again, less sensitive to detect extra intestinal manifestations. And as mentioned, they've been replaced kind of by the newer modalities of the CTE and the MRE. So let's move on to CTE, right? So fun facts. CT was first developed in 1972. No, I wasn't born just yet. And CT enterography, 1997. And again, CT is usually our first radiological procedure that should be performed, right? And what I also want to point out is that if you need something done acutely, this should be your first test, a CT, right? Maybe not a CTE, but a CT needs to be your first test, right? It's established and often first line of testing. Again, we already talked about the utilities. So interluminal and extraluminal findings to assess medical treatment response and differentiate between both active and fibrotic disease. And we talk about CTE technique. And the reason I want to bring this up is because of the fact that patients are asked to drink about 1.35 to 2 liters of oral contrast. That's a bit of a lot, right? And some of my patients actually have a very hard time drinking this, especially my Crohn's patients. And this is usually followed, of course, by IV contrast as well. When we look at superiority compared to small bowel follow-through, again, there are multiple studies that have all kinds of sensitivity and specificity listed. So I try to come up with the ones that I think are at least most give a summary, right? But sensitivity and specificity of CTE are 78% and 83% versus, of course, small bowel follow-through with 62% and 90%. But what I want to point out is the sensitivity of CTE is comparable to MRE when it comes to specifically looking at assessing active disease. Now, I want to bring this up, and I know we had some radiology discussions yesterday, but I really find it important as an APP, we need to understand what our radiologist findings are. So what we see here are three images, of course, from a CTE. And the earliest radiological findings in Crohn's disease are characterized by mucosal hyperenhancement. So when you see a diagnostic finding on a CTE, right, that says mucosal hyperenhancement, start to think about inflammation. As the disease progresses, right, and we see then mural thickening. And this is noticed with a combination of mucosal hyperenhancement. Again, these findings are usually suggestive of active inflammatory bowel disease, specifically Crohn's, right? So let's look at these images over on the left. We have asymmetry, okay? We've got asymmetry in the bowel wall thickening. So the arrowheads, right, if you see all the way on the left, these are showing the thickening of the small bowel right there, right? The asymmetry, look at the opposite side of that bowel wall loop. So you can see, of course, those little arrows, the full arrows, that shows the asymmetry of what's going on from that small bowel loop. And again, this is consistent with active inflammatory bowel disease. Now, the image also shows active inflammation and luminal narrowing in a different loop of small bowel. That's that dashed arrow up a little bit further on the top hand side of that screen. Now, we want to look at colonic, of course, inflammation. That's that curved arrow on the side. That's actually showing us colonic inflammation. Now, let's move on to another common finding that is seen a lot of times in MRE. This is called a comb sign. So what we see here in active Crohn's disease is the mesenteric vessels become distended, and become frequently spaced apart due to fibro fatty proliferation of the mesentery, resulting in appearance that looks like a comb. So look at that orange kind of arrows right there. It kind of looks like a comb there, right? So the other thing I want to show is what's illustrated here more by the yellow arrows, of course, is this is something that's common known as a string sign. So you look proximal to that, you can see all the contrast that's coming in there, right? That big lumen that's really kind of large. And then you can see that the contrast kind of goes down to almost nothing. That is called a string sign. Now, on the all the way right hand side, you can see a cross section of this abnormal ileum, which looks like the target sign. So you can see that very small area of contrast right in the middle looks much like a target. All right, let's move on to MRE, right? So MRE entomography, again, identification of intramural and extra intestinal findings, again, tends to be superior for soft tissue contrast resolution. So it's considered the first line imaging for depicting perianal and pelvic pathology. So keep that in mind. We have lots of tests to choose from, choose the right test. Perianal complications and pelvic pathology should be MRE. It may demonstrate fistula and stricture a little bit better than CTE. And what I want to point out too, we talk about modalities and combining modalities, MR of pelvis plus or minus endoscopic ultrasound can be useful in further characterizing both perianal Crohn's disease and of course, perirectal abscess along with healing, right? With MRE, we can sometimes detect unsuspecting penetrating disease. And of course, assess for medical treatment response. Now, again, I am an adult nurse practitioner, but for those of that are pediatric in the office, this should be first line image modality of choice for evaluating children with or young children with Crohn's disease. And again, in a study evaluating active Crohn's disease in the terminal ileum, MRE demonstrated a sensitivity of 89%. So when we look at the image here, because I think it's important, I think as we mentioned yesterday, it is really good to meet with your radiology counterparts. Throughout my career, I would always go down to our radiology department and meet with one of the radiologists and ask him to review the images with me. You know, his favorite thing was Diet Coke and cookies, and that used to help a little bit too. Then I would sit next to him, then he would help me kind of go through and look at all the images. Nowadays, I pull up my images myself. I'm not a radiologist, but at least I can look at it and find it and even point out the findings to patients when they come into the office. And I think sometimes that visual representation is so helpful when you're explaining their disease activity or even their response to medication. With that being said, you can clearly see here, this is another image of asymmetry, right? The arrowheads, you can see the thickening of the small bowel. If you look very carefully, you can see a cone sign again, right? Underneath those arrowheads. And then the full arrows again, that area that is not completely in pain. So again, a finding that we typically see when we see active inflammation. So what are the MR impacts though on outcomes of Crohn's disease? Because I think it's important. If we're going to choose a modality of therapy, does it actually impact our therapy? So what I want to show you is a retrospective study of about 120 patients with a history or high suspicion of Crohn's disease. The objective was to assess the impact of MRE on therapeutic decision-making for patients with Crohn's disease. After MRE, what I'm going to point out here is that 53% of patients had additional medical management for active inflammation, and 16% underwent a surgical intervention for complication of Crohn's disease. So does it make an impact? The answer, of course, is yes. Now let's look at our MRE images on the opposite side of the screen here. When we see this, this is a post-gandolinium injection. This is image A. And what you can see on here is a cobblestone appearance of the small intestine, right directly next to our arrow, that small intestine there. But the more important thing that you can see there is that fistula, right? You can see the fistula that had been developed. And of course, if we look at the B image, again, this is mural thickening due to inflammation. And again, you see that narrowing and that string sign kind of in the middle, right? That's another, of course, sign of inflammation of the small bowel. Now, when it comes to MRE technique, again, there's about 1.5 liters of oral contrast that has to be taken. And then there is IV contrast, which is gandolinium. Now, I know usually we can say we can use MRE in pregnancy, but you should avoid gandolinium in pregnancy. So videocapsulendoscopy, I've already said I have a love for videocapsulendoscopy. Here are a few images that just show you Crohn's disease. You can see that the arrows in blue in the middle image shows an ulcer. On the left-hand side, again, blue arrow shows ulcers. And then you can see on the bottom three images, these are more intraluminal. You can see circumferential inflammation, edema, and, of course, just overall, just ugly appearance of the small intestine, as I like to see. And usually I cross my fingers at one of these images and pray that that capsule went through, right? So when we're talking a little bit about videocapsulendoscopy, in particular, there's an increase, this has been an increased advocate as an alternative to radiology techniques for imaging of the small intestine, right? As we just talked about, we have an offering for direct visualization of the small bowel mucosa in a relatively non-invasive manner. However, there is debate as to where we actually place capsulendoscopy relative to our other techniques. So what I placed here is that capsulendoscopy may be particularly beneficial in evaluation of Crohn's disease in the following clinical situations. So one, in patients with clinical and or biological suspicion of Crohn's disease who have normal results of radiological and or traditional endoscopic procedures. Evaluation of the extent of small bowel lesions in patients with newly diagnosed or known Crohn's disease. The diagnosis of disease recurrence after surgery. How about evaluation of discrepancy between symptoms, right? And objective evidence of inflammation. I think all of us have seen this before. And of course, to further evaluate indeterminate colitis by detection of intestinal lesions and thus directing double balloon endoscopy with biopsy. So this is just a great algorithm. And again, I know we talked earlier about not holding directly to algorithms, but with that being said, this is a great algorithm as to where we might place video capsulendoscopy with established Crohn's disease. All right. So let's talk about diagnostic accuracy, because I think that this always becomes a bit of an issue. And here we've got actually two studies that I wanted to show you. The first one is a prospective study. It's a multicenter blinded cohort comparing the diagnostic yield of capsulendoscopy and small bowel follow-through. As we can see here, the combination of VCE and ileoscopy detected 97.3% of lesions. Combination of small bowel follow-through and ileocolonoscopy only 57%. So again, show that the utilization of a capsule was a bit higher than VCE. On the opposite side here, of course, we've got a comparability of the sensitivity and specificity of VCE, MRE, and CTE, right? So all of these things together. And as you can see here, all of these are great modalities. But what I want to point out too, is that we do see a high sensitivity and specificity in our video capsulendoscopy. So let's keep that in mind. How about the impacts on management of IVD? Just like we talked about with our MRE. So it's a retrospective review of about 124 patients, right? Let's see here. They all had Crohn's disease, of course, 15 with indeterminate colitis, 23 with pouchitis. And the study's directive was to determine if CE findings would result in management changes. The findings suggested that 61.6% had a change in their current medication and 39.5 initiated a new medication. So again, video capsulendoscopy resulted in medical management for these patients. Now, what about, of course, capsulendoscopy retention? And what I want to point out is that they had a newer study looking at overall capsule retention in Crohn's disease. And this is a meta-analysis. The overall retention rate was 3.2%, actually 3%. If they had established Crohn's disease, about almost 5%, so 4.6, and suspected Crohn's disease, 2.3. I think this has really made a difference by the utilization, of course, of an Agile or a Patency capsule first. And as you can see underneath the retention rates from the systematic review from 2017, also suggested that the rates of retention are much lower than are actually suspected. A good medical history is imperative. And again, using a capsule, the Patency capsule, has also changed the way that we see things. Yes, this is one of my own patients who has one stuck. Unfortunately, we were able to get it out eventually. Now, again, when we talk about the imaging, where do we actually place everything? I think I prefer the side B. So we've got assessment of known Crohn's disease, right? We do our ileopulmonoscopy. We look at our cross-sectional imaging of MR and CTE, you know, of course, because that should be first-line therapy, right? Then we need to determine, okay, does that show us some inflammation and do we need interluminal evaluation as well? So could we consider doing a video capsule endoscopy? Possibly. And of course, if there's any thought of a stricture, or if you think that the capsule will be retained, then do a Patency capsule first. But I do believe we always have to start with some kind of, you know, 3D imaging modality. And myself, I usually do a CTE or an MRE, depending on how urgent I need it done. Now, what about intestinal ultrasound? Because I think, you know, this is the new kid on the block, right? So let's talk a little bit about intestinal ultrasound. So the role of IUS for screening and diagnosis, evaluating the disease activity, and of course, postoperative recurrence in Crohn's disease. Now, we look at monitor response in therapy, especially in Crohn's disease and ulcerative colitis, we can see changes in ultrasound as early as two to four weeks of treatment. So that's pretty soon, right? Now, monitoring of disease activity in the colon can occur through all three trimesters in pregnancy and the terminal ileum in the first two trimesters. So again, for our pregnant patients, this might be another option for us. The overall sensitivity of IUS ranged anywhere from 54 to 93%, with a specificity of 97 to 100%, right? And this is specifically when evaluating small bowel disease. And again, remember, there is some limitation when we're specifically talking about rectal disease. Several studies have assessed IUS accuracy detecting intestinal strictures with a sensitivity ranging anywhere between 74 to 100%, with a specificity of 63 to 100%. And of course, IUS is less established in ulcerative colitis, but I think more data on that is coming. So we look specifically here at the metric trial. So is it comparable to MRE, what we already have? This is a prospective multicenter comparison trial, including 284 patients, and both MRE and ultrasound were highly accurate in detecting small bowel Crohn's disease. And what you see over here in the image on the left-hand side, of course, is we're looking at bowel wall thickness, of course, in A, we look at color doppler flow, in B, and C, of course, I believe that that is a, forgive me, that one was a loss of the fat plane. And then in D, of course, we see this increase, right, in mesenteric proliferation, and you see a lymph node, that's what the asterisk is. When it comes to IUS technique, remember, it's a bedside screening test, no prep is needed. Hmm, might be an option that we're all thinking about here. But how about a predictor of disease course? What I wanted to show you is this is IUS at IBD diagnosis. So at the diagnosis, could this predict surgery? This is a Copenhagen IBD cohort study. So again, looking at short-term risk of IBD-related surgery. So the results suggested that IUS may be used at diagnosis to identify patients at risk for IBD-related surgery. So what they looked for was the mean IVUS-SAS score. I know, all these acronyms, right? Let me break this down, right? International Bowel Ultrasound Segmental Activity score. Whew, gosh. Whew, calculated for the most inflamed segment with a high score indicating severity of disease. So again, the more inflamed the area, the higher the severity of the disease. So if their score at diagnosis was 92, right, among patients who underwent surgery during follow-up, 48% did not undergo surgery. So again, if that score was high during diagnosis, a lot of those patients did undergo surgery, and actually you can see it was very much statistically significant. This slide, to be fair and balanced, was borrowed from NOAA Cleveland from the Crohn's and Colitis Congress. And I thought this was a great option. You know, if we're thinking about using IUS as a bedside tool, could it be also used as a therapeutic target? We've all talked about stride guidelines and utilizing stride as we're looking at our therapeutic targets, but could we use IUS to look at short-term targets, intermediate targets, and of course, long-term targets, especially knowing that we can see changes in that bowel wall thickness as early as two to four weeks. So what about the role of the APP? Because I thought, most of you know me, we always have to talk about integration of the APPs. So specifically, we're going to start with video capsulendoscopy, and available data does suggest that at a basic reading level, reader extenders, and again, these are not my terms, forgive me, can save time and money without compromising diagnostic accuracy. And you can see, there's plenty of studies that go along with that. But how about the non-physician capsulendoscopy reader? And the reason it says non-physician, because it does include nurses, nurse practitioners, and PA. So it has to include non-physician capsulendoscopy reader. So again, results from independent studies suggested that, of course, a non-physician capsule reader, shorten the time for the pre-read, led to more careful approach, and of course, enhance the accuracy of CE investigation. So again, in another study published in 2012, so it wasn't just a one-off, the integration of a trained non-physician reader actually reduced physicians' reading time and improved diagnostic yield. So what about an APP capsulendoscopy reader? Well, I'm gonna tell you, you're looking at one of them, right? I'm a trained reader and I provide a valuable service to our practice. I'll tell you that. I read about 100 capsules a year. With that, I can help in generating revenue. I save the physician's time. They end up spending more time actually doing procedures because no one has to build time into their day to actually read a capsule. And of course, this is a unique skill. The NPPA can collaborate with the physician on diagnosis and even begin treatment. I myself, as soon as I start seeing diagnosis, I can instantly implement a plan. And of course, I alert my patients to, my physician partners to priority patients as needed. But what about IUS? Because I think we're talking about how this is all bedside, really looking at the fact that thinking of it as potential targets as we're moving through our stride guidelines. So training for APPs remains a bit of a barrier, but it's not impossible. An improvement in patient outcomes and of course, patient satisfaction has been documented with patients utilizing IUS. It could be a bedside point of care testing. And remember, it's complimentary to endoscopy. We're not taking anything away from our physician partners, right? It could be complimentary to endoscopy. And of course, there is element for generating revenue. And hopefully there's way more to come with this. So in regards to our summary, when we're talking about diagnostic testing, specifically for Crohn's disease, there are several imaging methods available to manage Crohn's disease. What we really need to think about is choosing the right test for the right patient. What are we looking for, right? Are we looking for extraluminal pathology? Is it pelvic? Is your patient younger? Are they pregnant, right? Keep those things in mind when you're choosing the right test for the right patient and also what pathology are you looking for? Consider the pros and cons of each study, which I've clearly outlined even in that initial table for you as well. I think IUS is an emerging diagnostic tool, possible predictor of disease course, and may even become a new therapeutic target when we're talking about our stride guidelines. The future of IBD care will continue to integrate the role of the APP. And I will tell you from an IBD perspective, there's no greater or more exciting time to be an APP in gastroenterology. With that, I think that that concludes this deck. And I know that we'll be moving on to a secondary deck in just a second here.

Kimberly Collins

nurse practitioner

Crohn's disease

diagnostic imaging

modalities

intestinal ultrasound