By: Noa Krugliak Cleveland, MD
Case Presentation
A 75 year old male with a history of NASH/cirrhosis and fibrostenotic ileal Crohn's disease diagnosed more than 25 years ago presents to clinic for routine monitoring of a known ileal stricture. Previously, he has been treated with mesalamine, 6-mercaptopurine, adalimumab, and vedolizumab. Currently, he has been treated with risankizumab for the past 6 months. Intestinal ultrasound is performed during his follow-up visit.
Intestinal Ultrasound Assessment
When interpreting this intestinal ultrasound, you can see anatomical landmarks such as the right iliac vessels and psoas muscle to orient yourself. Hypoechoic (dark) regions represent ascites in the setting of known NASH/cirrhosis. Bright (hyperechoic) luminal air helps to identify the segment of terminal ileum. You can then see this is a narrowed long-segment of thickened ileum.
While not required for diagnosis of a stricture, there is dilation of the proximal ileum to greater than 2.5 cm.
Color Doppler Assessment
Color Doppler assessment of the ileal stricture reveals moderately active hyperemia, indicating that there is both significant ACTIVE and chronic inflammation. If there were no hyperemia on color Doppler assessment, this would indicate a fibrotic stricture WITHOUT the presence of active inflammation. However, that is not the case for our patient, which presents hope that an effective anti-inflammatory therapy may be able to further heal the bowel and reduce the active inflammation present.
Unfortunately, even with treatment with risankizumab, our patient presents to the clinic emergently for evaluation of flare symptoms concerning for an acute bowel obstruction. Intestinal ultrasound is then repeated.
Intestinal Ultrasound Reassessment with Convex (Low Frequency) Probe
Intestinal Ultrasound Reassessment with Linear (Mid-High Frequency) Probe
Reassessment with IUS reveals worsening thickening over a long-segment of the ileum. There is also the presence of significant angulation of the bowel. In the setting of worsening thickening, this is likely what led to an acute bowel obstruction in the setting of his known chronic stricture. The maximum bowel wall thickness of this segment had worsened from 4.4 mm to 8.9 mm over a short period of time while on treatment with risankizumab.
Color Doppler Reassessment
Color Doppler reassessment reveals worsening hyperemia, now classified as severe, despite treatment with risankizumab.
Summary
Intestinal ultrasound was utilized in this patient to monitor an ileal stricture. After obtaining a baseline intestinal intestinal ultrasound while on risankizumab, the patient presented acutely with concerns for obstruction. Intestinal ultrasound was repeated and demonstrated significantly worsening active inflammation, increased bowel wall thickness and hyperemia compared to the previous intestinal ultrasound. Intestinal ultrasound was used to guide the next steps in the decision-making process and shape the conversation around switching advanced therapies, adding additional therapies, utilization of corticosteroids, and the role of surgery in the management of this patients stricturing Crohn's disease.
