Role of Imaging in Detecting Bowel Fibrosis and Bowel Damage

  • Cristiana BonifacioEmail author
  • Nicolò Gennaro
  • Gionata Fiorino


Imaging plays a key role in the comprehensive assessment of bowel structural damage. Radiology is fundamental to confirm the initial diagnosis and the extent of disease along the digestive tract. Moreover, imaging is a critical tool in the monitoring of the response to drug therapy. In this chapter, technique, indications and limitations of the major imaging methods used in the assessment of CD (ultrasound, computed tomography, magnetic resonance imaging) are reviewed. A special focus is dedicated to the detection and quantification of bowel fibrosis and bowel wall damage with CT and MRI. Future perspectives are finally reviewed according to the latest developments in imaging technology.


  1. 1.
    Freeman HJ. Natural history and clinical behavior of Crohn’s disease extending beyond two decades. J Clin Gastroenterol. 2003;37:216–9.CrossRefGoogle Scholar
  2. 2.
    Sasaki T, Kunisaki R, Kinoshita H, et al. Doppler ultrasound findings correlate with tissue vascularity and inflammation in surgical pathology specimens from patients with small intestinal Crohn’s disease. BMC Res Notes. 2014;7:363.CrossRefGoogle Scholar
  3. 3.
    Dignass A, Van Assche G, Lindsay JO, et al. The second European evidence-based consensus on the diagnosis and management of Crohn’s disease: current management. J Crohns Colitis. 2010;4:28–62.CrossRefGoogle Scholar
  4. 4.
    Yamamoto T. Factors affecting recurrence after surgery for Crohn’s disease. World J Gastroenterol. 2005;11:3971–9.CrossRefGoogle Scholar
  5. 5.
    Peyrin-Biroulet L, Cieza A, Sandborn WJ, et al. Development of the first disability index for inflammatory bowel disease based on the international classification of functioning, disability and health. Gut. 2012;61:241–7.CrossRefGoogle Scholar
  6. 6.
    Gasche C, Scholmerich J, Brynskov J, et al. A simple classification of Crohn’s disease: report of the Working Party for the World Congresses of Gastroenterology, Vienna 1998. Inflamm Bowel Dis. 2000;6:8–15.CrossRefGoogle Scholar
  7. 7.
    Louis E, Collard A, Oger AF, et al. Behaviour of Crohn’s disease according to the Vienna classification: changing pattern over the course of the disease. Gut. 2001;49:777–82.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Cosnes J, Cattan S, Blain A, et al. Long-term evolution of disease behavior of Crohn’s disease. Inflamm Bowel Dis. 2002;8:244–50.CrossRefGoogle Scholar
  9. 9.
    Molenaar ETH, Voskuyl AE, Dinant HJ, et al. Progression of radiologic damage in patients with rheumatoid arthritis in clinical remission. Arthritis Rheum. 2004;50:36–42.CrossRefGoogle Scholar
  10. 10.
    Danese S, Fiorino G, Peyrin-Biroulet L. Early intervention in Crohn’s disease: towards disease modification trials. Gut. 2017;66:2179–87.CrossRefGoogle Scholar
  11. 11.
    Ordás I, Rimola J, Rodríguez S, et al. Accuracy of magnetic resonance enterography in assessing response to therapy and mucosal healing in patients with Crohn’s disease. Gastroenterology. 2014;146:374–82.e1.CrossRefGoogle Scholar
  12. 12.
    Fiorino G, Bonifacio C, Allocca M, et al. Bowel damage as assessed by the Lémann index is reversible on anti-TNF therapy for Crohn’s disease. J Crohns Colitis. 2015;9:633–9.CrossRefGoogle Scholar
  13. 13.
    Bodini G, Giannini EG, De Maria C, et al. Anti-TNF therapy is able to stabilize bowel damage progression in patients with Crohn’s disease. A study performed using the Lémann index. Dig Liver Dis. 2017;49:175–80.CrossRefGoogle Scholar
  14. 14.
    Fiorino G, Morin M, Bonovas S, et al. Prevalence of bowel damage assessed by cross-sectional imaging in early Crohn’s disease and its impact on disease outcome. J Crohns Colitis. 2017;11:274–80.CrossRefGoogle Scholar
  15. 15.
    Peyrin-Biroulet L, Loftus EV, Colombel J-F, et al. Early Crohn disease: a proposed definition for use in disease-modification trials. Gut. 2010;59:141–7.CrossRefGoogle Scholar
  16. 16.
    Fiorino G, Bonifacio C, Peyrin-Biroulet L, et al. Preventing collateral damage in Crohn’s disease: the Lémann index. J Crohns Colitis. 2016;10:495–500.CrossRefGoogle Scholar
  17. 17.
    Silverberg MS, Satsangi J, Ahmad T, et al. Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol. 2005;19(Suppl A):5A–36A.CrossRefGoogle Scholar
  18. 18.
    Vester-Andersen MK, Prosberg MV, Jess T, et al. Disease course and surgery rates in inflammatory bowel disease: a population-based, 7-year follow-up study in the era of immunomodulating therapy. Am J Gastroenterol. 2014;109:705–14.CrossRefGoogle Scholar
  19. 19.
    Panés J, Bouzas R, Chaparro M, et al. Systematic review: the use of ultrasonography, computed tomography and magnetic resonance imaging for the diagnosis, assessment of activity and abdominal complications of Crohn’s disease. Aliment Pharmacol Ther. 2011;34:125–45.CrossRefGoogle Scholar
  20. 20.
    Pariente B, Peyrin-Biroulet L, Cohen L, et al. Gastroenterology review and perspective: the role of cross-sectional imaging in evaluating bowel damage in Crohn disease. AJR Am J Roentgenol. 2011;197:42–9.CrossRefGoogle Scholar
  21. 21.
    Fiorino G, Bonifacio C, Peyrin-Biroulet L, et al. Prospective comparison of computed tomography enterography and magnetic resonance enterography for assessment of disease activity and complications in ileocolonic Crohn’s disease. Inflamm Bowel Dis. 2011;17:1073–80.CrossRefGoogle Scholar
  22. 22.
    Daperno M, D’Haens G, Van Assche G, et al. Development and validation of a new, simplified endoscopic activity score for Crohn’s disease: the SES-CD. Gastrointest Endosc. 2004;60:505–12.CrossRefGoogle Scholar
  23. 23.
    Mary JY, Modigliani R. Development and validation of an endoscopic index of the severity for Crohn’s disease: a prospective multicentre study. Groupe d’Etudes Thérapeutiques des Affections Inflammatoires du Tube Digestif (GETAID). Gut. 1989;30:983–9.CrossRefGoogle Scholar
  24. 24.
    Pariente B, Mary J-Y, Danese S, et al. Development of the Lémann index to assess digestive tract damage in patients with Crohn’s disease. Gastroenterology. 2015;148:52–63.e3.CrossRefGoogle Scholar
  25. 25.
    Rimola J, Rodriguez S, García-Bosch O, et al. Magnetic resonance for assessment of disease activity and severity in ileocolonic Crohn’s disease. Gut. 2009;58:1113–20.CrossRefGoogle Scholar
  26. 26.
    Eder P, Michalak M, Katulska K, et al. Magnetic resonance enterographic predictors of one-year outcome in ileal and ileocolonic Crohn’s disease treated with anti-tumor necrosis factor antibodies. Sci Rep. 2015;5:10223.CrossRefGoogle Scholar
  27. 27.
    Tielbeek JAW, Ziech MLW, Li Z, et al. Evaluation of conventional, dynamic contrast enhanced and diffusion weighted MRI for quantitative Crohn’s disease assessment with histopathology of surgical specimens. Eur Radiol. 2014;24:619–29.CrossRefGoogle Scholar
  28. 28.
    Punwani S, Rodriguez-Justo M, Bainbridge A, et al. Mural inflammation in Crohn disease: location-matched histologic validation of MR imaging features. Radiology. 2009;252:712–20.CrossRefGoogle Scholar
  29. 29.
    Zappa M, Stefanescu C, Cazals-Hatem D, et al. Which magnetic resonance imaging findings accurately evaluate inflammation in small bowel Crohn’s disease? A retrospective comparison with surgical pathologic analysis. Inflamm Bowel Dis. 2011;17:984–93.CrossRefGoogle Scholar
  30. 30.
    Adler J, Punglia DR, Dillman JR, et al. Computed tomography enterography findings correlate with tissue inflammation, not fibrosis in resected small bowel Crohn’s disease. Inflamm Bowel Dis. 2012;18:849–56.CrossRefGoogle Scholar
  31. 31.
    Rieder F, Fiocchi C. Intestinal fibrosis in IBD—a dynamic, multifactorial process. Nat Rev Gastroenterol Hepatol. 2009;6:228–35.CrossRefGoogle Scholar
  32. 32.
    Lenze F, Wessling J, Bremer J, et al. Detection and differentiation of inflammatory versus fibromatous Crohn’s disease strictures: prospective comparison of 18F-FDG-PET/CT, MR-enteroclysis, and transabdominal ultrasound versus endoscopic/histologic evaluation. Inflamm Bowel Dis. 2012;18:2252–60.CrossRefGoogle Scholar
  33. 33.
    Latella G, Sferra R, Speca S, et al. Can we prevent, reduce or reverse intestinal fibrosis in IBD? Eur Rev Med Pharmacol Sci. 2013;17:1283–304.PubMedGoogle Scholar
  34. 34.
    Lahat A, Chowers Y. The patient with recurrent (sub) obstruction due to Crohn’s disease. Best Pract Res Clin Gastroenterol. 2007;21:427–44.CrossRefGoogle Scholar
  35. 35.
    Van Assche G, Geboes K, Rutgeerts P. Medical therapy for Crohn’s disease strictures. Inflamm Bowel Dis. 2004;10:55–60.CrossRefGoogle Scholar
  36. 36.
    Ram R, Sarver D, Pandey T, et al. Magnetic resonance enterography: a stepwise interpretation approach and role of imaging in management of adult Crohn’s disease. Indian J Radiol Imaging. 2016;26:173–84.CrossRefGoogle Scholar
  37. 37.
    Satsangi J, Silverberg MS, Vermeire S, et al. The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut. 2006;55:749–53.CrossRefGoogle Scholar
  38. 38.
    Fiorino G, Bonifacio C, Malesci A, et al. MRI in Crohn’s disease—current and future clinical applications. Nat Rev Gastroenterol Hepatol. 2011;9:23–31.CrossRefGoogle Scholar
  39. 39.
    Rimola J, Planell N, Rodríguez S, et al. Characterization of inflammation and fibrosis in Crohn’s disease lesions by magnetic resonance imaging. Am J Gastroenterol. 2015;110:432–40.CrossRefGoogle Scholar
  40. 40.
    Ripollés T, Rausell N, Paredes JM, et al. Effectiveness of contrast-enhanced ultrasound for characterisation of intestinal inflammation in Crohn’s disease: a comparison with surgical histopathology analysis. J Crohns Colitis. 2013;7:120–8.CrossRefGoogle Scholar
  41. 41.
    Wilkens R, Peters DA, Nielsen AH, et al. Dynamic contrast-enhanced magnetic resonance enterography and dynamic contrast-enhanced ultrasonography in Crohn’s disease: an observational comparison study. Ultrasound Int Open. 2017;3:E13–24.CrossRefGoogle Scholar
  42. 42.
    Morimoto K, Watanabe K, Noguchi A, et al. Clinical impact of ultrathin colonoscopy for Crohn’s disease patients with strictures. J Gastroenterol Hepatol. 2015;30(Suppl 1):66–70.CrossRefGoogle Scholar
  43. 43.
    Fraquelli M, Branchi F, Cribiù FM, et al. The role of ultrasound elasticity imaging in predicting ileal fibrosis in Crohn’s disease patients. Inflamm Bowel Dis. 2015;21:2605–12.CrossRefGoogle Scholar
  44. 44.
    Dillman JR, Stidham RW, Higgins PDR, et al. Ultrasound shear wave elastography helps discriminate low-grade from high-grade bowel wall fibrosis in ex vivo human intestinal specimens. J Ultrasound Med. 2014;33:2115–23.CrossRefGoogle Scholar
  45. 45.
    Calabrese E, Zorzi F, Zuzzi S, et al. Development of a numerical index quantitating small bowel damage as detected by ultrasonography in Crohn’s disease. J Crohns Colitis. 2012;6:852–60.CrossRefGoogle Scholar
  46. 46.
    Calabrese E, Zorzi F, Pallone F. Ultrasound of the small bowel in Crohn’s disease. Int J Inflam. 2012;2012:964720.CrossRefGoogle Scholar
  47. 47.
    Peng JC, Feng Q, Zhu J, et al. Usefulness of spectral computed tomography for evaluation of intestinal activity and severity in ileocolonic Crohn’s disease. Therap Adv Gastroenterol. 2016;9:795–805.CrossRefGoogle Scholar
  48. 48.
    Panes J, Bouhnik Y, Reinisch W, et al. Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines. J Crohns Colitis. 2013;7:556–85.CrossRefGoogle Scholar
  49. 49.
    Haas K, Rubesova E, Bass D. Role of imaging in the evaluation of inflammatory bowel disease: how much is too much? World J Radiol. 2016;8:124–31.CrossRefGoogle Scholar
  50. 50.
    Holtmann MH, Uenzen M, Helisch A, et al. 18F-Fluorodeoxyglucose positron-emission tomography (PET) can be used to assess inflammation non-invasively in Crohn’s disease. Dig Dis Sci. 2012;57:2658–68.CrossRefGoogle Scholar
  51. 51.
    Catalano OA, et al. Evaluation of quantitative PET/MR enterography biomarkers for discrimination of inflammatory strictures from fibrotic strictures in crohn disease. Radiology. 2016;278:792–800. Scholar
  52. 52.
    Stanley E, Moriarty HK, Cronin CG. Advanced multimodality imaging of inflammatory bowel disease in 2015: an update. World J Radiol. 2016;8:571–80.CrossRefGoogle Scholar
  53. 53.
    Giannetti A, Matergi M, Biscontri M, et al. Real-time elastography in Crohn’s disease: feasibility in daily clinical practice. J Ultrasound. 2017;20:147–55.CrossRefGoogle Scholar
  54. 54.
    Buisson A, Pereira B, Goutte M, et al. Magnetic resonance index of activity (MaRIA) and Clermont score are highly and equally effective MRI indices in detecting mucosal healing in Crohn’s disease. Dig Liver Dis. 2017;49:1211–7.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Cristiana Bonifacio
    • 1
    Email author
  • Nicolò Gennaro
    • 2
  • Gionata Fiorino
    • 3
    • 4
  1. 1.Department of RadiologyHumanitas Research HospitalMilanItaly
  2. 2.Department of Radiology, Humanitas Research HospitalHumanitas University, Training School in RadiologyMilanItaly
  3. 3.IBD Center, Department of GastroenterologyHumanitas Research HospitalMilanItaly
  4. 4.Department of Biomedical SciencesHumanitas UniversityMilanItaly

Personalised recommendations