More than half of patients with Crohn disease will develop strictures. Strictures are areas of bowel luminal narrowing composed of a combination of inflammatory cells, muscular hypertrophy, and fibrosis. Most patients with strictures eventually require endoscopic or surgical intervention. This article reviews small bowel Crohn disease stricture histopathology, current imaging definitions and challenges, and stricture management. Current imaging-based stricture definitions use different criteria and do not recognize strictures without upstream dilation nor failed endoscopic passage. This consensus was endorsed by the Society of Abdominal Radiology and developed by the Society of Abdominal Radiology Inflammatory Bowel Disease Disease Focused Panel as well as gastroenterology and pathology experts in Crohn disease strictures. Updated imaging stricture definitions and recommendations are presented. Most importantly, the panel now defines a Crohn disease small bowel stricture using a threshold small bowel dilation of 2.5 cm (rather than 3.0 cm) and incorporates failed endoscopic passage, even when there is no associated bowel dilation at CT or MR enterography. With these updated imaging stricture definitions, it is hoped that patients with Crohn disease may benefit from more timely stricture identification and management.

The morphologic imaging features of Crohn disease (CD) small bowel strictures have been defined by intersociety recommendations and expert panels. CD small bowel strictures result in penetrating and obstructing complications that often lead to surgery. Imaging biomarkers in fibrostenosing CD can be used to reproducibly diagnose and measure strictures and identify those at high risk for subsequent surgery. Emerging biomarkers seek to accurately and reproducibly identify and measure histopathologic correlates of fibrosis, inflammation, and smooth muscle hyperplasia or hypertrophy, as well as to reflect biomechanical properties such as stiffness. The authors review and define imaging features of small bowel strictures using routine MR and CT enterography, which should be incorporated into clinical reports to guide management decisions or to use in clinical trials. The most promising quantitative imaging biomarkers reflecting histopathologic composition of small bowel strictures are reviewed with a focus on MRI and US methods. Imaging is a critical tool for the management of patients with stricturing CD. ©RSNA, 2025 See also the related articles by Rieder and Ma et al and Rieder et al in Radiology.

J-pouch imaging is a unique segment of bowel imaging. The distinct anatomic and functional characteristics of the J-pouch lead to important clinical and radiologic features that differ from that of the native small bowel and the native rectal reservoir. Imaging can provide critical insights into the complications and functions of the J-pouch, and radiologists should familiarize themselves with pouch imaging to maintain a high standard of care in this patient population.

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. We retrospectively reviewed patients from two tertiary centers who underwent CTEwithin 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 CTEimages 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. 250 CD patients were included. 239 (96

To evaluate correlation between terminal ileal (TI) stricture diagnosis at MR enterography (MRE) and ileocolonoscopy (IC) in patients with Crohn’s disease (CD). One hundred and four patients with CD (51

PurposeThe purpose of this investigation was to assess the effect of visceral adipose tissue volume (VA) on reader efficacy in diagnosing and characterizing small bowel Crohn's disease using lower exposure CT enterography (CTE). Secondarily, we investigated the effect of lower exposure and VA on reader diagnostic confidence.MethodsProspective paired investigation of 256 CTE, 129 with Crohn's disease, were reconstructed at 100% and simulated 50% and 30% exposure. The senior author provided the disease classification for the 129 patients with Crohn's disease. Patient VA was measured, and exams were evaluated by six readers for presence or absence of Crohn's disease and phenotype using a 0-10-point scale. Logistic regression models assessed the effect of VA on sensitivity and specificity.ResultsThe effect of VA on sensitivity was significantly reduced at 30% exposure (odds radio [OR]: 1.00) compared to 100% exposure (OR: 1.12) (p = 0.048). There was no statistically significant difference among the exposures with respect to the effect of visceral fat on specificity (p = 0.159). The study readers' probability of agreement with the senior author on disease classification was 60%, 56%, and 53% at 100%, 50%, and 30% exposure, respectively (p = 0.004). When detecting low severity Crohn's disease, readers' mean sensitivity was 83%, 75%, and 74% at 100%, 50%, and 30% exposure, respectively (p = 0.002). In low severity disease, sensitivity also tended to increase as visceral fat increased (ORs per 1000 cm3 increase in visceral fat: 1.32, 1.31, and 1.18, p = 0.010, 0.016, and 0.100, at 100%, 50%, and 30% exposure).ConclusionsWhile the interaction is complex, VA plays a role in detecting and characterizing small bowel Crohn's disease when exposure is altered, particularly in low severity disease.

Fibrostenosis of the small bowel is common in patients with Crohn’s disease. No consensus recommendations on definition, diagnosis and management in clinical practice are currently available. In this Consensus Statement, we present a clinical practice RAND/UCLA appropriateness study on the definition, diagnosis and clinical management of fibrostenosing Crohn’s disease. It was conducted by a panel of 28 global experts and one patient representative. Following a systematic literature review, 526 candidate items grouped into 136 questions were generated and subsequently evaluated for appropriateness. Strictures are best defined as wall thickening, luminal narrowing and prestenotic dilation. Cross-sectional imaging is required for accurate diagnosis of fibrostenosing Crohn’s disease, and it is recommended before making treatment decisions. It should also assess the degree of inflammation in the bowel wall. Multiple options for medical anti-inflammatory, endoscopic and surgical therapies were suggested, including follow-up strategies following therapy. This Consensus Statement supports clinical practice through providing guidance on definitions, diagnosis and therapeutic management of patients with fibrostenosing small bowel Crohn’s disease. In this Consensus Statement, a global multidisciplinary panel of experts provides recommendations for the definitions, diagnosis and management of patients with fibrostenosing small bowel Crohn’s disease.

SummaryBackgroundStricturing Crohn's disease (CD) occurs most commonly in the terminal ileum and poses a clinical problem. Cross‐sectional imaging modalities such as intestinal ultrasound (IUS), computed tomography enterography (CTE), and magnetic resonance enterography (MRE) allow for assessment of the entire bowel wall and associated peri‐enteric findings. Radiologic definitions of strictures have been developed for CTE and MRE; their reliability and responsiveness are being evaluated in index development programs. A comprehensive assessment strategy for strictures using IUS is needed.AimsTo provide a detailed summary of definitions, diagnosis and monitoring of strictures on IUS as well as technical aspects of image acquisition.MethodsWe searched four databases up to 6 January 2024. Two‐stage screening was done in duplicate. We assessed risk of bias using QUADAS‐2.ResultsThere were 56 studies eligible for inclusion. Definitions for strictures on IUS are heterogeneous, but the overall accuracy for diagnosis of strictures is high. The capability of IUS for characterising inflammation versus fibrosis in strictures is not accurate enough to be used in clinical practice or trials. We summarise definitions for improvement of strictures on IUS, and discuss parameters for image acquisition and standardisation.ConclusionsThis systematic review is the first step for a structured program to develop a stricture IUS index for CD.

Background Diagnostic imaging using CT enterography, magnetic resonance enterography, and intestinal ultrasound are important tools in evaluating stricturing Crohn's disease. Definitions of strictures have been developed for CT enterography and magnetic resonance enterography. However, expert recommendations for definitions and treatment response of strictures on intestinal ultrasound are not available. The aim of this study was to standardise definitions, diagnosis, and treatment response criteria in small bowel stricturing Crohn's disease on intestinal ultrasound. Methods Using modified RAND-University of California Los Angeles Appropriateness Method, a diverse expert panel of 13 gastroenterologists, seven radiologists, and two patient representatives was assembled. A total of 466 statements on definitions and response to therapy of stricturing Crohn's disease on intestinal ultrasound were generated from a systematic review and from expert opinion, with subsequent rating for appropriateness. Two rounds of voting with an interposed survey result discussion were performed. Statements were classified as inappropriate, uncertain, or appropriate based on the median panel rating and degree of disagreement. Appropriateness was rated using a nine-point Likert scale (1 being inappropriate, 9 being highly appropriate). Findings A naive or anastomotic small bowel Crohn's disease stricture on intestinal ultrasound is defined by the combination of bowel wall thickening, luminal narrowing, and pre-stenotic dilation. Bowel wall thickness is defined as being more than 3 mm. Luminal narrowing is defined as either a luminal diameter reduction of more than 50% in the narrowest area and relative to a normal adjacent bowel loop, or a luminal diameter of less than 1 cm. Pre-stenotic dilation is defined as more than 2 center dot 5 cm or an increase in bowel diameter relative to a normal adjacent bowel loop. Definitions for grading hyperaemia, inflammatory fat, wall stratification, intestinal ultrasound machine technical parameters, and image acquisition were also devised. Treatment response of strictures was defined as reduction in stricture length, bowel wall thickening, luminal narrowing, pre-stenotic dilation, and motility abnormalities. Interpretation To our knowledge, this is the first intestinal ultrasound appropriateness rating exercise conducted for defining, diagnosing, and measuring response to therapy in small bowel stricturing Crohn's disease and informs future clinical use and intestinal ultrasound index development for clinical trials. Copyright (c) 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.

Background: Clinical decision making and drug development for fibrostenosing Crohn disease is constrained by a lack of imaging definitions, scoring conventions, and validated end points. Purpose: To assess the reliability of MR enterography features to describe Crohn disease strictures and determine correlation with stricture severity. Materials and Methods: A retrospective study of patients with symptomatic terminal ileal Crohn disease strictures who underwent MR enterography at tertiary care centers (Cleveland Clinic: September 2013 to November 2020; Mayo Clinic: February 2008 to March 2019) was conducted by using convenience sampling. In the development phase, blinded and trained radiologists independently evaluated 26 MR enterography features from baseline and follow-up examinations performed more than 6 months apart, with no bowel resection performed between examinations. Follow-up examinations closest to 12 months after baseline were selected. Reliability was assessed using the intraclass correlation coefficient (ICC). In the validation phase, after five features were redefined, reliability was re-estimated in an independent convenience sample using baseline examinations. Multivariable linear regression analysis identified features with at least moderate interrater reliability (ICC >= 0.41) that were independently associated with stricture severity. Results: Ninety-nine (mean age, 40 years +/- 14 [SD]; 50 male) patients were included in the development group and 51 (mean age, 45 years +/- 16 [SD]; 35 female) patients were included in the validation group. In the development group, nine features had at least moderate interrater reliability. One additional feature demonstrated moderate reliability in the validation group. Stricture length (ICC = 0.85 [95% CI: 0.75, 0.91] and 0.91 [95% CI: 0.75, 0.96] in development and validation phase, respectively) and maximal associated small bowel dilation (ICC = 0.74 [95% CI: 0.63, 0.80] and 0.73 [95% CI: 0.58, 0.87] in development and validation group, respectively) had the highest interrater reliability. Stricture length, maximal stricture wall thickness, and maximal associated small bowel dilation were independently (regression coefficients, 0.09-3.97; P < .001) associated with stricture severity. Conclusion: MR enterography definitions and scoring conventions for reliably assessing features of Crohn disease strictures were developed and validated, and feature correlation with stricture severity was determined. (c) RSNA, 2024

INTRODUCTION:Aortic graft infection (AGI) is a rare complication following endovascular aneurysm repair and is associated with substantial morbidity and mortality. The traditional management of AGI is intravenous antibiotic therapy and surgical explantation. In this case series, percutaneous drainage was used as a bridge therapy in the treatment of AGI. METHODS:We report two cases, 78-year-old male and 57-year-old female, in whom image-guided percutaneous drainage was used to treat AGI in two contrasting contexts. Informed consent was obtained from both cases/relatives for publication. RESULTS:Both cases underwent successful percutaneous drainage of AGI utilized as a bridge therapy before definitive surgical reconstruction and graft explantation. Each patient had a different outcome. In the first case, the patient's comorbidities and severe disease state could not be overcome, resulting in his death. The second patient benefitted from the percutaneous drainage by allowing her more time ameliorate her malnutrition before definitive surgery. CONCLUSION:Data on the outcomes of percutaneous drainage of AGI is limited. The successful procedure described in this case series emphasizes the need to conduct more research to evaluate the safety and efficacy of this treatment approach before the surgical explantation.

Current classification of achalasia does not account for variability in esophageal tortuosity. The esophageal length-to-height ratio (LHR) was developed to objectively quantify tortuosity, based on the premise that the esophagus must elongate to become tortuous. Hence, we assess the relationship of esophageal tortuosity, measured by LHR, to preoperative patient characteristics and post-myotomy outcomes, including longitudinal symptom relief and esophageal emptying. From 01/2014 to 01/2020, 420 eligible adult patients underwent myotomy for achalasia at our institution, 216 (51

Background: Standardized methods to measure and describe Crohn disease strictures at CT enterography are needed to guide clinical decision making and for use in therapeutic studies. Purpose: To assess the reliability of CT enterography features to describe Crohn disease strictures and their correlation with stricture severity. Materials and Methods: A retrospective study was conducted in 43 adult patients with symptomatic terminal ileal Crohn disease strictures who underwent standard-of-care CT enterography at a tertiary care center at the Cleveland Clinic between January 2008 and August 2016. After training on standardized definitions, four abdominal radiologists blinded to all patient information assessed imaging features (seven continuous measurements and nine observations) of the most distal ileal stricture in two separate sessions (separated by >= 2 weeks) in random order. Features with an interrater intraclass correlation coefficient (ICC) of 0.41 or greater (ie, moderate reliability or better) were considered reliable. Univariable and multivariable linear regression analysis identified reliable features associated with a visual analog scale of overall stricture severity. Significant reliable features were assessed as components of a CT enterography-based model to quantitate stricture severity. Results: Examinations in 43 patients (mean age, 52 years +/- 16 [SD]; 23 female) were evaluated. Five continuous measurements and six observations demonstrated at least moderate interrater reliability (interrater ICC range, 0.42 [95% CI: 0.25, 0.57] to 0.80 [95% CI: 0.67, 0.88]). Of these, 10 were univariably associated with stricture severity, and three continuous measurements-stricture length (interrater ICC, 0.64 [95% CI: 0.42, 0.81]), maximal associated small bowel dilation (interrater ICC, 0.80 [95% CI: 0.67, 0.88]), and maximal stricture wall thickness (interrater ICC, 0.50 [95% CI: 0.34, 0.62])-were independently associated (Pvalue P value range, <.001 to .003) with stricture severity in a multivariable model. These three measurements were used to derive a well-calibrated (optimism- adjusted calibration slope = 1.00) quantitative model of stricture severity. Conclusion: Standardized CT enterography measurements and observations can reliably describe terminal ileal Crohn disease strictures. Stricture length, maximal associated small bowel dilation, and maximal stricture wall thickness are correlated with stricture severity.

Although much radiologic literature has focused on the short-term post-operative complications associated with ileal pouches, as the number of patients with long-term pouches has grown, there is increasing realization of the functional deficits that may occur long after pouch creation. Dynamic pouch imaging using fluoroscopy and MRI can provide assessment of the underlying causes of symptomatic pouch dysfunction and can provide critical insight to the management of this complex patient population. In this paper, we provide an overview of the unique problems encountered in patients with long-term ileal pouches, and provide an overview of the techniques, interpretation, and reporting for fluoroscopic and MR pouch defecography.

This manuscript is part of the ileal pouch symposium and will describe the water-soluble contrast enema, CT, and small bowel series. MRI and other imaging modalities are discussed elsewhere in the symposium. Water-soluble contrast enema and CT are excellent for the evaluation of the ileal pouch. Contrast enema and CT with anal contrast administration can allow for anastomotic integrity and pouch assessment. Pre-pouch ileum, extra-intestinal manifestations, and acute symptomatology are best assessed with CT. The contrast small bowel examination is of limited utility in pouch patients and should not be performed. Indications, imaging technique, and anatomic pouch assessment with water-soluble contrast enema, CT, and contrast small bowel examination will be reviewed here.

Einleitung/Ziele Fibrostenotische Komplikationen bei Patienten mit Morbus Crohn manifestieren sich häufig im terminalen Ileum. Bislang sind keine Konsensus-Empfehlungen zur Definition, Diagnostik und klinischem Management für eine standardisierte Behandlungspraxis etabliert. Die publizierte Studienevidenz zu fibrostenotischen Komplikationen beim Morbus Crohn ist jedoch zunehmend.

Esophageal morphology in achalasia is thought to affect outcomes, with “end-stage” sigmoidal morphology faring poorly; however, evaluation of morphology’s role in outcomes has been limited by lack of objective characterization. Hence, the goals of this study were twofold: characterize the variability of timed barium esophagram (TBE) interpretation and evaluate an objective classification of TBE tortuosity: length-to-height ratio (LHR). We hypothesized that the esophagus must elongate to become sigmoidal such that sigmoidal morphology would demonstrate a larger LHR. Ninety pre-operative TBEs were selected from an institutional database. Esophageal morphology was categorized as straight, intermediate, or sigmoidal. Esophageal length was measured by a mid-lumen line from the aortic knob to the esophagogastric junction on TBE; height was measured vertically from the aortic knob to the level of the esophagogastric junction. The length divided by the height generated the LHR. Descriptive statistics and frequency of expert agreement were calculated. Median LHR was compared between consensus morphologies. A receiver operating characteristic (ROC) determined the optimal LHR for sigmoidal vs non-sigmoidal characterization. From a total of 90 pre-operative TBEs, expert consensus morphology was reached in 56 (62.2