Noa Krugliak Cleveland, MD, on Intestinal Ultrasound in IBD Care

Dr Krugliak Cleveland reviews the use of intestinal ultrasound for the monitoring of inflammatory bowel disease and the significant advantages of this noninvasive, point-of-care technology for patients and clinicians alike.

Noa Krugliak Cleveland, MD, is a clinical instructor of medicine and director of the Intestinal Ultrasound program at UChicago Medicine.

TRANSCRIPT:

Welcome to this podcast from the Gastroenterology Learning Network. I'm your moderator, Rebecca Mashaw, and today I'm speaking with Dr. Noa Krugliak Cleveland from the University of Chicago, where she is a clinical instructor of medicine and director of their intestinal ultrasound program. Dr. Cleveland is rapidly building a national reputation for her expertise in the use of intestinal ultrasound for monitoring inflammatory bowel disease, a subject she'll be discussing with me today. Thank you for joining us.

Dr Noa Krugliak Cleveland: Thank you for having me.

GLN: What first interested you about the potential uses of intestinal ultrasound technology, particularly in working with patients who have IBD?

Dr Cleveland: I first heard of intestinal ultrasound from my mentor, Dr. David Rubin, and I heard about this modality or this tool to assess for inflammation in patients with ulcerative colitis and Crohn's and get real-time results in clinic. And when I heard about the point-of-care ability of this test is what really piqued my interest, since we don't have anything like this to date. There is no tool that can give us real-time results in clinic and tell us whether a patient is actually having disease flare or disease relapse. And that is something that our field really needed.

GLN: This technology has been in use in Europe for some time now, I understand. Do you have any idea why it's taken this time for it to gain more attention and more use in the United States?

Dr Cleveland: It's a great question. It's important to also understand this so, we could change the current status to help integrate US into care. I think the main reason is that there was really nobody to champion this effort. Intestinal ultrasound is not part of — or abdominal ultrasound in general is not part of— training in the United States for internal medicine doctors or gastroenterologists, unlike Europe. And so there was really no voice here, especially in leadership in inflammatory bowel disease, to teach about this modality, to even notify people that it exists let alone talk about its value.

Second, there is really no opportunities to training intestinal ultrasound. So when it's not integrated into your core curriculum of gastroenterology, you then have to seek for training opportunities. And even at that point, if you are and you've heard of it, you would have to travel to Europe and other parts of the world. So it really was not offered. There was no training in the United States up until a year ago, and over the last year we're now offered 2 courses. And then the third part is that—and it's a question of the chicken or the egg—but there is really no clear remuneration process for bowel ultrasound and that is critical to integrate a new tool into care in the United States.

GLN: So have you seen some solutions to those problems?

Dr Cleveland: Yes. So in efforts to bring and to integrate intestinal ultrasound, we try to tackle each of these issues. And so one of the main reasons there's been growing interest and there's been a lot of talk about intestinal ultrasound is because there have been major figures in the inflammatory bowel disease world in the United States who have now championed this, have been outspoken about the importance and the use of this tool and how critical it is that we get it to all patients with inflammatory bowel disease across the United States. And with those figures, such as Dr. David Rubin, who's my mentor, and Marla Dubinsky at Mount Sinai, New York, when you have 2 figures like them speaking out and informing others of the use of it, that really helped a lot. And then of course activity on social media, that also helped a lot, between some of the work I've done and my colleague Mike Dolinger at Mount Sinai. And I think that really helped kind of get the voice out there.

In regard to training, we have with the international bowel ultrasound group brought training into the United States with the first course taking place in September of 2022 in New York. And then the second course was just now here in Chicago in March of 2023. And they were a great success. We trained 60 gastroenterologists, many of whom are IBD leaders here. And so that would also help continue to spread the word.

And lastly, we are working now on having a unique billing code for intestinal ultrasound. I've cofounded the Intestinal Ultrasound Group for the United States and Canada. And that is an effort to really tackle these issues and pressing issues are unique to the United States and Canada, one of which is the billing for this. We need not only a unique billing code but a fair one that really will serve both the clinicians and the patients. One of our major efforts will be creating a unique billing code, but for now we have a borrowed one. So whoever is doing this could use the limited abdominal ultrasound exam and other CPT codes to get compensated.

GLN: Have you run into issues, with insurers in particular, in getting paid for doing intestinal ultrasound? Are they resistant to this?

Dr Cleveland: Actually not at all. At University of Chicago, we looked into almost all the insurance companies that we see here and none of them required prior authorization and we've not had any issues with coverage. So patients could get this done during clinic without having to get a preapproval.

GLN: So this is gaining retention and acceptance in North America now, is it not?

Dr Cleveland: Yes, there has been just tremendous interest in intestinal ultrasound, it's been very well received over the last year or two. There’s been a lot of effort on my end and Dr. Rubin and a number of universities who've integrated this into spreading the word primarily. Also Mount Sinai, New York, Mike Dollinger over there who's also spearheading this effort. And so we've worked very hard to disseminate the knowledge that one, this tool exists, and how accurate and how useful and necessary it is that we integrate into care.

GLN: You mentioned training. What kind of training is required to learn how to apply this technology in the clinic?

Dr Cleveland: Intestinal ultrasound requires an operator that is competent and of course it's only as good as the operator. And so currently there is a curriculum that is designed through the International Bowel Ultrasound Group that is based in Europe. It has 3 different parts to it where the first one is a 2- to 3-day hands-on workshop that is offered about quarterly in different parts of the world. The second part is spending 2 to 4 weeks with an expert and doing one-on-one scanning and performing about 40 examinations.

And the third part is sitting through lectures and taking an examination. Right now, this curriculum has worked very well for Europe and some parts of the world, but now as there is increased interest and need to increase the number of providers who are training in intestinal ultrasound, we're working on adjusting some of this to be more scalable to the size of the United States. As you can imagine, some of this may be pretty difficult or slow down the process when you need one-on-one training for 4 weeks when some of us are parents; and also for the trainers, University of Chicago, we're one of the few centers that offer that in the United States. So it's going to be very hard to train all of the people that are interested in becoming proficient in this.

GLN: How have you found this most useful in your own practice?

Dr Cleveland: I think that intestinal ultrasound is best used as a point-of-care test. So in having the ultrasound machine in the room when I see a patient and as part of my abdominal exam, a continuation of that, I put a probe on the abdomen and do an assessment of disease activity right there while I make a plan for them, is the ideal use of it. And I think that's the beauty of intestinal ultrasound. Again, goes back to what piqued my interest initially, that it provides a point-of-care assessment and then I can make a plan with the patient based on objective data right there. And so that's to me I think the best use of intestinal ultrasound.

But of course, not everybody's going to become proficient at that. And so we still have an independent intestinal ultrasound clinic where colleagues of mine who don't do this can refer patients and they can have this done by me and get results. And it's still a modality or a tool that provides assessment of disease activity without radiation or prep and it's not painful. And some of my colleagues have their clinics at the same time as when I do my test ultrasound clinic, so they can get point-of-care assessment, and they can come back to the clinic room with their provider with these results and they can put together a plan with the same day assessment of their disease.

GLN: How have the patients responded to it?

Dr Cleveland: Patients love it, absolutely love it. So first of all, there's data showing the patient understand the disease better and they can participate in shared decision making by undergoing an intestinal ultrasound. But separately, patients tell me that they have never felt more informed and also no one has ever given this much time. So I think that this turning off the lights and having a doctor perform a radiologic exam and then based on that make an assessment and a plan, justifiably makes patient feel like they've really received a very thorough assessment by their provider. And they express this to me all the time. I've received messages from patients saying it's life-changing, because they have undergone many colonoscopies, uncomfortable radiologic scans, having to drink contrast, travel, and wait with delays to get results. And that's truly life-changing when they don't have to undergo all this hassle.

GLN: Are there any downsides?

Dr Cleveland: Intestinal ultrasound is not for everybody. I would say the vast majority of patients can be evaluated with this tool and it could give us very accurate results. But there is the minority of patients where it's hard to predict who it will be, but their body habitus somehow will influence the quality of the images that we get. Not all patients could be effectively evaluated and monitored with this, but these are minority of patients and there's no way for us to predict. So I offer it to everybody and within a minute I can tell whether this is for them or not. There are not a lot of other downsides to this. This is a very, very accurate tool.

GLN: You mentioned the equipment. Is it expensive?

Dr Cleveland: Intestinal ultrasound is done using an ultrasound machine and these machines can vary in terms of pricing—and the price also influences the quality of the image. The cost of a machine could definitely influence the availability, and could slow down integration of this into practice. But in reality, many hospitals and clinics already have existing ultrasound machine that could be used for this.

GLN: And what about its future potential?

Dr Cleveland: There is a lot to still understand and learn about intestinal ultrasound. Although if you look at the trend of publication test ultrasound, you'll see that it's just growing rapidly. And so the use of it in inflammatory bowel disease is really just booming and so is the data around it. There's still a great need to understand how to use this modality in a unique patient population, how we could use it or to best ability with the different therapies that we today have, given the different therapies, work at different timeframes.

I think that intestinal ultrasound is huge potential and not only in inflammatory bowel disease, but it's also used in Europe where there is training on abdominal ultrasound among gastroenterologists. It's used for other enteropathies or other conditions that affect the small intestines. You could use it in celiac disease. And it's used to even assess for malignancies and other types of various types of infections. So there's ways to use intestinal ultrasound. But right now, with our current focus integrated into inflammatory bowel disease, there's also lots more to learn. And our priority is to have large-scale and high quality studies in IBD to really demonstrate the best utility of intestinal ultrasound.

GLN: Is this useful for diagnosis as well as for monitoring a patient who has UC or Crohn's and you just want to get a read on how they're doing in terms of inflammation?

Dr Cleveland: Yeah, so intestinal ultrasound is an excellent tool to assess for one, disease activity. It's highly accurate, very sensitive for inflammation. It's highly comparable to endoscopy and those that are performing will even express to you that it provides more information sometimes, where we on ultrasound can see how old inflammation or scarring has affected a bowel motility, which you could see on bowel ultrasound for instance, in which you don't see on other modalities such as colonoscopies. You really can't assess for that. You could quantify the degree of involvement, which areas are involved, and sometimes it could be so sensitive, it could detect inflammation that may be endoscopically is not seen. So it's a wonderful tool, highly accurate for assessment of inflammation.

It's also very sensitive to assess for response to treatment. So unique intestinal ultrasound, we can assess response to treatment as early as 2 days in patients who have acute severe ulcerative colitis. And you can even with that, with the degree of response, you could see changes on the bowel wall and we could predict how patients will do within a week. And so that's something we again never had before, never had a tool that could predict outcomes as early as 2 days. In patients without such severe colitis we could utilize as in other ways, but it's highly sensitive to change.

GLN: That's a real game changer, isn't it?

Dr Cleveland: It's a real game changer.

GLN: Well, I look forward to talking to you again as things progress and thanks for your time.

Dr Cleveland: Thank you.