Noa Krugliak Cleveland, MD, on Intestinal Ultrasound in Clinical Practice

Dr Krugliak Cleveland reviews the results of research and real-world experience in using intestinal ultrasound in clinical practice when diagnosing and monitoring inflammatory bowel disease.

Noa Krugliak Cleveland, MD, is an assistant professor of medicine and director of the Intestinal Ultrasound Program at the University of Chicago.

TRANSCRIPT:

 Any views and opinions expressed are those of the authors and /or participants, and do not necessarily reflect the views, policies, or positions of the AIBD Network or HMP Global, its employees, and affiliates.

Welcome to this podcast from the Advances in Inflammatory Bowel Disease Network. I'm your moderator, Rebecca Mashaw, and I'm delighted to have with us today Dr.Noa Krugliak Cleveland, who's an assistant professor and director of the Intestinal Ultrasound Program at the University of Chicago. She's going to talk to us about some findings that were recently published in Current Gastroenterology Reports about the clinical applications for intestinal ultrasound in the care of patients with IBD. Thanks for joining us today.

Dr Cleveland: Thank you for having me, Rebecca.

Rebecca Mashaw: So for the benefit of the listeners who aren't familiar with IUS or intestinal ultrasound, can you give us an overview of this process and how it's best used?

Dr Cleveland: Intestinal ultrasound is a noninvasive monitoring tool for patients with inflammatory bowel disease. It is unique in a sense that it's a point of care test and one of the only monitoring tools we can use in real time while seeing patients in clinic. And so the ideal way of utilizing this tool is in ultrasounding a patient during a clinic visit and both the provider and the patient get to see what is going on in the disease process and whether the disease is active and whether therapies are working in real time during the clinic visit, and we can make decisions based on our findings right there and then.

Rebecca Mashaw: Well, that sort of helps to answer the second question, which is what advantages does intestinal ultrasound offer in diagnosing and monitoring IBD?

Dr Cleveland: So the ability for real -time monitoring by intestinal ultrasound is one of the greatest advantages to intestinal ultrasound. And being able to get real time objective assessment of disease activity and also providing both patient and provider with that information is incredibly valuable. We've also demonstrated at University of Chicago that it accelerates treatment decisions and also time to remission.

So this is a very, very important aspect of intestinal ultrasound. Apart from that, it's a very accurate tool. So it's important that when we use a monitoring tool, that it is accurate and can really represent the true disease state.

And we have demonstrated that again and again, that it's also highly comparable with our gold standard, endoscopy. Of course, in addition, it's not invasive, it doesn't require any preparation, and that is a great advantage to patients, especially to the pediatric patients, where endoscopy and imaging modalities are really limited in their utility because of the invasive nature and the preparation required and the lack of tolerability of those tests.

And that goes to also emphasize that this is a tool for both adults and pediatrics.

Rebecca Mashaw: Your article highlights the effectiveness of IUS in detecting therapeutic response among patients with IBD. Could you tell us a little bit more about that?

Dr Cleveland: Intestinal ultrasound is a very responsive tool. So when we think about monitoring tools, we need to think about a tool that shows us changes as we treat patients and if that tool is able to detect a change early on and proceed outcome of interest, it allows you time to intervene. With intestinal ultrasound, we've seen that particularly in ulcerative colitis patients, as early as days, within days, we can see response on intestinal ultrasound parameters to different therapies.

And we see that with Crohn’s disease as well. So one really beautiful example is a study that looked at patients with ulcerative colitis who were admitted with severe disease and were receiving IV corticosteroids. And these patients all underwent intestinal ultrasound at admission, and then around day 3 and around a week.

What they demonstrated is that day 3, patients who have had more than 20% reduction in their bowel thickness had a 23 times greater likelihood of responding to therapy by the end of the week. And the converse in the group who had only 20% reduction or less, the chance of being nonresponders at the end of the week was more than 80%.

And so, you know, bringing that to the clinical practice, it's such a concrete tool to help you within 3 days of an admission and to help the patient also understand what it is that we expect and when it's time to move on to different salvage therapy. And this has been demonstrated with other mechanisms of action, not just steroids, but with anti-TNFs and our JAK inhibitors as well in both Crohn's and colitis. But of course, there's more room for more studies in that area.

Rebecca Mashaw: That again leads nicely into the next question, which is, is IUS better for patients with Crohn's disease than those with UC or vice versa?

Dr Cleveland: Intestinal ultrasound can be used both in Crohn's and ulcerative colitis and the utility, I would say, is quite equal. Although most of the studies have been done in Crohn's disease and we extrapolate out of Crohn's disease quite a bit. And so there is room to study ulcerative colitis a bit more in the context of intestinal ultrasound. But the utility in ulcerative colitis is great and especially as we see that we can detect responses so early with colitis patients that that really helps accelerate decision making and provide either reassurance or assist us in going in a different route or trying different therapies when we don't see that we see that we expect.

Rebecca Mashaw: You mentioned in the case study about ulcerative colitis that it was good at predicting whether somebody was going to respond to that therapy or not respond within just a few days of doing the studies with the acute severe UC patients. Is this good tool for helping the prognosis of patients who are not necessarily hospitalized or in a crisis? Is it useful in determining whether a patient is likely to develop complications or require surgery?

Dr Cleveland: Intestinal ultrasound is a wonderful modality for prognostication. There have now been a number of indices developed for both Crohn's disease and ulcerative colitis. And some of these indices demonstrated a certain cut off by which you can differentiate patients who are at higher risk of admission, colectomy, or need for certain dose escalation. So that really helps if you utilize it in your practice, prognosticating your patients and being able to differentiate those who are at higher risk for these complications.

Now separately with intestinal ultrasound, we see complications of disease. Specifically, in general in Crohn's, we can assess for fibrosis or strictures and then fistulizing complications. And when we see those type of complications, it also helps with prognostication and be able to differentiate the patients who may benefit more from a surgical approach versus medical approach.

And that sometimes is not so clear cut, especially before the era of intestinal ultrasound. Being able to get some insight into what it is that we're about to face is very helpful both for patients and providers. So for example, a patient who comes with obstructive symptoms and you do an intestinal ultrasound and see a potential ileal stricture and this appears to be more fibrotic and with intestinal ultrasound, we can attempt to quantify how much seems inflammatory from fibrotic, although we're not perfect. We do have a number of ways to do that. I can get a sense whether therapy is likely to work or maybe this is really not the right direction and we can already speak about, you know, a surgical approach.

And even if we don't go to that approach right away, I can set the tone that this is likely going to go in that direction and it gives patients time and the provider also time to plan.

Rebecca Mashaw: Now of course ultrasound has one big advantage over colonoscopy in assessing response and monitoring the disease activity and that is no prep—and of course patients hate the prep. But can it take the place of colonoscopy in some situations?

Dr Cleveland: Intestinal ultrasound can take the place of colonoscopy for disease monitoring, assessment of disease activity, assessment of whether Crohn's disease recurred after surgery, and whether patients have complications, but it does not replace colonoscopy for colon cancer screening. And that is really important. It's a common question that patients ask because our patients are at high risk of colon cancer, at least some of our patients are and often are under close surveillance. Unfortunately, we do not replace colon cancer screening with intestinal ultrasound and that continues and has to be done by colonoscopy.

Rebecca Mashaw: You also noted in the article that IUS is highly comparable to CT and MR imaging, but how does it compare on cost?

Dr Cleveland: Intestinal ultrasound and ultrasound in general is a cheaper modality than MR and also CT. However, we don't have cost effectiveness studies quite yet, but we certainly know that if you just compare the imaging themselves, ultrasound is certainly a cheaper modality. But we do really need to explore how ultimately this translates to cost effectiveness.

Rebecca Mashaw: What are the limitations of intestinal ultrasound? Are there some cases in which another mode of imaging or another type of monitoring may be more appropriate for a particular patient?

Dr Cleveland: Certainly. Patients who have Crohn's disease in the upper part of the or the proximal small bowel or upper GI tract may benefit from other modalities for monitoring and that's one of the limitations, where sensitivity for detection of disease activity goes down by intestinal ultrasound. And similarly, if patients have other small bowel loops or complications in a deep pelvis, sometimes that can also be missed by intestinal ultrasound. So these are the two areas that we should be cautious in interpreting results. And if patients come with this type of phenotype of disease, we also need to be cautious and think about using other modalities either instead or concomitantly with intestinal ultrasound.

Rebecca Mashaw: What suggestions would you offer to a community practitioner about using intestinal ultrasound? How can they go about it? Should they be attempting this? What are the options available if you're not in an academic medical center?

Dr Cleveland: The overarching goal for both the International Ultrasound Group and now the Intestinal Ultrasound Group for the United States and Canada or IUScan, is to get intestinal ultrasound to all patients. And that means also patients who get their care in the community—these are probably the majority of our IBD patients, so this is a very important question.

And right now it's not really feasible for the community doctors, or most community doctors, to offer in -house but what I suggest is that you align yourself with an academic practice or academic center that does offer intestinal ultrasound. Now the hope is that ultimately that will be available in the community and I can tell you that it's a priority at least for IUScan to allow for that and increase the educational opportunity so our community doctors can also get trained. But for now, it has been the academic centers where the priority for is. Now, thinking of the future and how to really get this to other patients, we are also thinking about the importance of the next generations and ultimately integrating test and ultrasound back into the General GI curriculum. And so that would be of great importance as we have new generations graduating. It would be ideal that all gastroenterologists have at least a basic understanding of intestinal ultrasound. That's something we really hope to do in North America and at least the United States to start.

Rebecca Mashaw: Any last thoughts you'd like to share?

Dr Cleveland: I just want to thank you for having me. I think intestinal ultrasound has gained a lot of momentum because this is really a clear tool that our field needs and our patients love and appreciate and our clinicians have seen how it changes practice. So the more people understand and get exposed to it, the more likely they are to learn and utilize it and the more likely it is our patients and their patients will benefit from it. So thank you for having me.

Rebecca Mashaw: Well thank you for joining us. We appreciate you sharing your insights into this very interesting and hopefully exciting technology. Thank you.

Cleveland NK, St-Pierre J, Kellar A, Rubin DT. Clinical application of intestinal ultrasound in inflammatory bowel disease. Curr Gastroenterol Rep. 2024; 26(1):31-40. https://doi.org/10.1007/s11894-024-00915-x