ECR: Use MR enterography for complex IBD cases

Gastrointestinal imagers should use high-quality MR enterography for complex inflammatory bowel disease (IBD) cases that can't be dealt with using intestinal ultrasound, even though both tests contribute to overall assessment, said an expert leading an advanced course on imaging Crohn's disease at ECR 2025.

"MR enterography has a big strength in mapping, but ultrasound has a big strength in really looking at the bowel wall and assessing features of inflammation," stated course presenter Gauraang Bhatnagar, MD, of Frimley Health National Health Service (NHS) Foundation Trust in the U.K. "We all need to grow in our individual experience of how we balance which test is best," he said.

"We all need to grow in our individual experience of how we balance which test is best," said gastroenterological consultant and radiologist Gauraang Bhatnagar, MD, of Frimley Health National Health Service (NHS) Foundation Trust.

During his segment of the course, Bhatnagar also suggested that radiologists should take charge of ultrasound. "We won't be the people who do all the ultrasound, but it should be done via conduit from a radiologist who at least can do the tests themselves. The images should be on PACS to allow comparison, and I think we should be engaged, so I'm deciding to train my own gastroenterology team ... it's better that the right people do it."

Between case studies and speaker experiences, attendees could get a sense of the range of patient experiences with IBD -- from blood and stool testing and two ultrasound exams per year to multiple medications, surgeries, and numerous scans. Tight monitoring is important, some advised. It's a relatively long and complex journey for the patient.

During the session, Bhatnagar noted the following:

1. A British Society of Gastrointestinal Abdominal Radiology survey of 52 NHS Trusts in the U.K. found that MRI enterography is a mainstay of IBD imaging there, and ultrasound volumes are relatively small. The survey also found CT enterography and barium follow-throughs are still used in clinical practice; however, barium follow-through has a relatively diminishing role in IBD, and radiation exposure limits CT.
2. A survey of patients in the U.K. reported that they rated their IBD care as fair or poor, according to Bhatnagar. Educate your patient in every clinical contact, he advised. "Educated patients are empowered patients who tend to use health services in a more predictable and planned way."
3. Recognizing sustainability of patient care, baseline MR enterography is best, but baseline ultrasound has several advantages in terms of sustainability, Bhatnagar said. Reducing unnecessary investigations and following surveillance guidelines can reduce the carbon footprint of IBD clinical care.
4. Multisociety guidance for IBD is coming, according to Bhatnagar, referring to baseline imaging before treatment initiation and optimization; having within 12 weeks an assessment with imaging for patients on treatment; continuing to treat -- with transmural remission as a target -- as this may lead more sustained longer-term remission; and keeping people with clinical remission on proactive monitoring imaging. "That's a lot of MRI," he said.

"If we take our patient and he presents on day X, then may I suggest we add an intestinal ultrasound to the MR enterography, and 12 weeks later when we need to assess them again if we want to practice to the best guidance out there, then if we saw everything well on the intestinal ultrasound, we can just stick with the ultrasound," Bhatnagar explained.

"Of course, the more ultrasound you do, the better you get," he added. "If the patient is doing well, then they can go on a proactive monitoring program, again with ultrasound. And if they are not doing well, then they can have a drug regimen change and be reassessed again relatively quickly."

Other presenters included course chair Prof. Stuart Taylor from the British Journal of Radiology (BJR); Claudia Fuchs, PhD, from the Medical University of Vienna, who shared her personal experiences with IBD; Isabelle De Kock, MD, of Ghent University Hospital in Belgium; and Jordi Rimola, MD, PhD, of Hospital Clínic de Barcelona in Spain.

Check out AuntMinnieEurope.com's full coverage of ECR 2025 on our RADCast.