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Objectives Investigate the relationship between quantified terminal ileal (TI) motility and histopathological activity grading, Crohn Disease MRI Index (CDMI) and faecal calprotectin. Methods Retrospective review of children with Crohn disease or unclassified inflammatory bowel disease, who underwent MR enterography. Dynamic imaging for 25 patients (median age 12, range 5 to 16) was analysed with a validated motility algorithm. The TI motility score was derived. The primary reference standard was TI Endoscopic biopsy Assessment of Inflammatory Activity (eAIS) within 40 days of the MR enterography. Secondary reference standards: (1) the Crohn Disease MRI Index (CDMI) and (2) faecal calprotectin levels. Results MR enterography median motility score was 0.17 a.u. (IQR 0.12 to 0.25; range 0.05 to 0.55), and median CDMI was 3 (IQR 0 to 5.5). Forty-three percent of patients had active disease (eAIS > 0) with a median eAIS score of 0 (IQR 0 to 2; range 0 to 5). The correlation between eAIS and motility was r  = − 0.58 ( p  = 0.004, N  = 23). Between CDMI and motility, r  = − 0.42 ( p  = 0.037, N  = 25). Motility score was lower in active disease (median 0.12 vs 0.21, p  = 0.020) while CDMI was higher (median 5 vs 1, p  = 0.04). In a subset of 12 patients with faecal calprotectin within 3 months of MR enterography, correlation with motility was r  = − 0.27 ( p  = 0.4). Conclusions Quantified terminal ileum motility decreases with increasing histopathological abnormality in children with Crohn disease, reproducing findings in adults. TI motility showed a negative correlation with an MRI activity score but not with faecal calprotectin levels. Key Points • It is feasible to perform MRI quantified bowel motility assessment in children using free-breathing techniques. • Bowel motility in children with Crohn disease decreases as the extent of intestinal inflammation increases. • Quantified intestinal motility may be a candidate biomarker for treatment efficacy in children with Crohn disease.

Objective To compare quantified terminal ileal (TI) motility during MR enterography (MRE) with histopathological severity of acute inflammation in Crohn’s disease. Methods A total of 28 Crohn’s patients underwent MRE and endoscopic TI biopsy. Axial and coronal TrueFISP, HASTE and post-gadolinium VIBE images were supplemented by multiple coronal TrueFISP cine motility sequences through the small bowel volume. TI motility index (MI) was quantified using validated software; an acute inflammation score (eAIS; 0–6) was assigned to the biopsy. Two observers qualitatively scored mural thickness, T2 signal, contrast enhancement and perimural oedema (0–3) to produce an activity score (aMRIs) based on anatomical MRI. The association among the MI, eAIS and aMRIs was tested using Spearman’s rank correlation. Wilcoxon rank sum test compared motility in subjects with and without histopathological inflammation. Results Mean MI and mean eAIS were 0.27 (range 0.06–0.55) and 1.5 (range 0–5), respectively. There was a significant difference in MI between non-inflamed (mean 0.37, range 0.13–0.55) and inflamed (mean 0.19, range 0.06–0.44) TI, P  = 0.002, and a significant negative correlation between MI and both eAIS (Rho = −0.52, P  = 0.005) and aMRIs (R = −0.7, P  < 0.001). Conclusion Quantified TI motility negatively correlates with histopathological measures of disease activity and existing anatomical MRI activity biomarkers. Key Points • Magnetic resonance imaging is increasingly used to assess Crohn’s disease. • MRI measurements can provide a quantitative assessment of small bowel motility. • MR enterography can grade Crohn’s disease. • Small bowel motility can be used as a marker of inflammatory activity.

Inflammation-related enteric dysmotility has been postulated as a cause for abdominal symptoms in Crohn's disease (CD). We investigated the relationship between magnetic resonance imaging–quantified small bowel (SB) motility, inflammatory activity, and patient symptom burden.MethodsThe Harvey–Bradshaw index (HBI) and fecal calprotectin were prospectively measured in 53 patients with CD (median age, 35; range, 18–78 years) the day before magnetic resonance enterography, which included a dynamic (cine), breath-hold motility sequence, repeated to encompass the whole SB volume. A validated registration-based motility quantitation technique produced motility maps, and regions of interest were drawn to include all morphologically normal SB (i.e., excluding diseased bowel). Global SB motility was correlated with calprotectin, HBI, and symptom components (well-being, pain, and diarrhea). Adjustment for age, sex, smoking, and surgical history was made using multivariate linear regression.ResultsMedian calprotectin was 336 (range, 0–1280). Median HBI, motility mean, and motility variance were 3 (range, 0–16), 0.33 (0.18–0.51), and 0.01 (0.0014–0.034), respectively. Motility variance was significantly negatively correlated with calprotectin (rho = −0.33, P = 0.015), total HBI (rho = −0.45, P < 0.001), well-being (rho = −0.4, P = 0.003), pain (rho = −0.27, P = 0.05), and diarrhea (rho = −0.4, P = 0.0025). The associations remained highly significant after adjusting for covariates. There was no association between mean motility and calprotectin or HBI (P > 0.05).ConclusionsReduced motility variance in morphologically normal SB is associated with patient symptoms and fecal calprotectin levels, supporting the hypothesis that inflammation-related enteric dysmotility may explain refractory abdominal symptoms in CD.

Purpose MR elastography and magnetization-tagging use liver stiffness (LS) measurements to diagnose fibrosis but require physical drivers, specialist sequences and post-processing. Here we evaluate non-rigid registration of dynamic two-dimensional cine MRI images to measure cardiac-induced liver deformation (LD) as a measure of LS by (i) assessing preclinical proof-of-concept, (ii) clinical reproducibility and inter-reader variability, (iii) the effects of hepatic hemodynamic changes and (iv) feasibility in patients with cirrhosis. Methods Sprague–Dawley rats ( n  = 21 bile duct ligated (BDL), n  = 17 sham-operated controls) and fasted patients with liver cirrhosis ( n  = 11) and healthy volunteers (HVs, n  = 10) underwent spoiled gradient-echo short-axis cardiac cine MRI studies at 9.4 T (rodents) and 3.0 T (humans). LD measurements were obtained from intrahepatic sub-cardiac regions-of-interest close to the diaphragmatic margin. One-week reproducibility and prandial stress induced hemodynamic changes were assessed in healthy volunteers. Results Normalized LD was higher in BDL (1.304 ± 0.062) compared with sham-operated rats (1.058 ± 0.045, P  = 0.0031). HV seven-day reproducibility Bland–Altman (BA) limits-of-agreement (LoAs) were ± 0.028 a.u. and inter-reader variability BA LoAs were ± 0.030 a.u. Post-prandial LD increases were non-significant (+ 0.0083 ± 0.0076 a.u., P  = 0.3028) and uncorrelated with PV flow changes ( r  = 0.42, p  = 0.2219). LD measurements successfully obtained from all patients were not significantly higher in cirrhotics (0.102 ± 0.0099 a.u.) compared with HVs (0.080 ± 0.0063 a.u., P  = 0.0847). Conclusion Cardiac-induced LD is a conceptually reasonable approach from preclinical studies, measurements demonstrate good reproducibility and inter-reader variability, are less likely to be affected by hepatic hemodynamic changes and are feasible in patients with cirrhosis. Grahpic Abstract

(1) Background: Intestinal failure-associated liver disease (IFALD) in adults is characterized by steatosis with variable progression to fibrosis/cirrhosis. Reference standard liver biopsy is not feasible for all patients, but non-invasive serological and quantitative MRI markers for diagnosis/monitoring have not been previously validated. Here, we examine the potential of serum scores and feasibility of quantitative MRI used in non-IFALD liver diseases for the diagnosis of IFALD steatosis; (2) Methods: Clinical and biochemical parameters were used to calculate serum scores in patients on home parenteral nutrition (HPN) with/without IFALD steatosis. A sub-group underwent multiparameter quantitative MRI measurements of liver fat fraction, iron content, tissue T1, liver blood flow and small bowel motility; (3) Results: Compared to non-IFALD (n = 12), patients with IFALD steatosis (n = 8) demonstrated serum score elevations in Enhanced Liver Fibrosis (p = 0.032), Aspartate transaminase-to-Platelet Ratio Index (p < 0.001), Fibrosis-4 Index (p = 0.010), Forns Index (p = 0.001), Gamma-glutamyl transferase-to-Platelet Ratio Index (p = 0.002) and Fibrosis Index (p = 0.001). Quantitative MRI scanning was feasible in all 10 sub-group patients. Median liver fat fraction was higher in IFALD steatosis patients (10.9% vs 2.1%, p = 0.032); other parameter differences were non-significant; (4) Conclusion: Serum scores used for non-IFALD liver diseases may be useful in IFALD steatosis. Multiparameter MRI is feasible in patients on HPN.

MRI has recently been applied as a tool to quantitatively evaluate the response to therapy in patients with Crohn's disease, and is the preferred choice for repeated imaging. Bowel wall thickness on MRI is an important biomarker of underlying inflammatory activity, being abnormally increased in the acute phase and reducing in response to successful therapy; however, a poor level of interobserver agreement of measured thickness is reported and therefore a system for accurate, robust and reproducible measurements is desirable. We propose a novel method for estimating bowel wall-thickness to improve the poor interobserver agreement of the manual procedure. We show that the variability of wall thickness measurement between the algorithm and observer measurements (0.25mm ± 0.81mm) has differences which are similar to observer variability (0.16mm ± 0.64mm).

BackgroundAfter colectomy, many patients with ileo-anal pouch anastomosis develop high bowel frequency and become refractory to antimotility agents despite normal pouch morphology. Recently it has been shown that Liraglutide reduces bowel frequency.1 We investigate the potential underlying contractility (hereafter referred to as ‘motility’) of the pouch with motility MRI (which measures regional peristalsis) in this retrospective study.Methods30 patients with ileoanal pouches (mean age 44 years, 9 female) and 10 controls (mean age 44, 5 male: 5 with non-colonic Crohn’s disease, 5 with ulcerative colitis) underwent standard MR Enterography including motility ‘cine’ imaging. All pouches were delineated by an experienced radiologist (Entrolytics, Motilent, UK). Clinical observations were extracted from medical records by a Gastroenterologist. Motility assessment of the pouch/rectum was performed using GIQuant (Motilent, London, UK) with a bowel wall contour placed at the pouch, to produce a numerical score for pouch/rectum wall motion. We 1) compared pouch against normal rectum, 2) compared pouch motility in the cohort separated by inflammation activity on pouchoscopy, 3) compared frequency against pouch motility and finally 4) against symptoms. Non-parametric statistics were used.ResultsMean pouch motility score was 157 (25 to 391) and in controls was 59 (23 to 104). Difference of 98, P = 0.002.Patients with pouchoscopy were dichotomised into normal vs non–normal. Endoscopically normal pouch had motility of 185 vs 119, P = 0.05.Based on Pouch Frequency, when dichotomised into =>10 (bowel movements) and <10 (bowel movements), pouch motility was 205 vs 116, a significant difference of 88 units P = 0.007 and correlation of bowel movements with motility showed positive relationship, Rho = 0.46, p =0.01.Based on Patient Reported Symptoms, dichotomised as ‘symptomatic’ vs ‘coping,’ pouch motility was 183 vs 132 with a non–significant difference of 50 units P = 0.1.Abstract P114 Figure 1A) patient with symptomatic J-pouch and high pouch motility B) and asymptomatic J-pouch C) showing similar distention but low motility[Figure omitted. See PDF]ConclusionJ-Pouch demonstrates markedly altered physiology with an elevated contractility phenotype, in terms of peristalsis, compared to disease-free controls. Pouch motility was associated with pouch frequency providing supportive mechanistic evidence for the efficacy of Liraglutide.1 A weaker association was seen with pouchoscopy and symptoms which may now be followed up in an appropriately powered study.ReferenceHerfarth H, Long MD, Hansen JJ, et al. Efficacy and safety of liraglutide in patients with an ileal pouch-anal anastomosis and chronic high bowel frequency: a placebo-controlled, crossover, proof-of-concept study. Am J Gastroenterol. 2024;119(9):1935-1938. doi:10.14309/ajg.0000000000002801

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The natural history of pediatric Crohn’s disease (CD) can lead to complications such as strictures and fistulae, increasing the risk of surgery. Magnetic resonance enterography (MRE) is unique in its ability to provide anatomic and functional characterization of intestinal morphological abnormalities. Prior adult studies have linked altered small bowel motility to strictures and fibrosis, but pediatric data are limited. In addition, it is unclear if motility can predict surgical risk in children with CD. Our study aims to evaluate motility in the small bowel and its association with clinical phenotype and surgical outcome in pediatric CD and compare it to patients with irritable bowel syndrome (IBS) and healthy controls (HC). In this single-center retrospective study we included pediatric CD patients with macroscopic ileal involvement (Paris classification L1 or L3) who underwent cine-MRE from 2012-2024. The images were anonymized and uploaded to the Entrolytics.io website by Motilent. Two pediatric radiologists identified the proximal, distal, and terminal ileum on dynamic cine-MRI sequences to attain GIQuant motility scores., Clinical, laboratory and additional MRE parameters were collected. GIQuant scores were collected also for patients with IBS and HC, who had radiologically normal studies. Patients who had more than one MRE for follow up were included in a subcohort to analyze longitudinal changes in intestinal motility. Descriptive and regression statistical analysis was performed. 33 pediatric CD patients (median age 14.7 years), 38 IBS patients and 9 HC were included. In the CD cohort, 79% had L3 ileocolonic and 21% L1 ileal disease, and 24% were inflammatory, 39% stricturing and 37% both stricturing and penetrating. Ileal and ileocolonic CD patients had lower mean terminal ileum GIQuant score (148.3±94.4) than IBS (271.3±112.4) and HC (269.6±74.7) (p < 0.01), while the mean proximal ileum GIQuant score was lower in CD (293.68±106.83) vs IBS (372.31±117.89) (p < 0.05). CD patients who underwent surgery showed similar terminal ileum scores to those who did not undergo surgery (median 120.3 (IQR (87.1-145.5)) vs 130.7(111.5-221.7)) but more frequently had mesenteric fatty proliferation (79% vs 29%). GIQuant scores did not differ significantly between complicated phenotypes (B2 or B2/B3) and inflammatory (B1) ones. In the longitudinal analysis (n = 12), an increase in terminal ileum GIQuant correlated with an increase in albumin. Ileal motility is reduced in children with CD compared to IBS and HC, consistent with prior studies. In our cohort, motility differences across CD phenotypes and surgical outcome were minimal. Additional studies are necessary to understand how quantitative motility assessment can provide complementary information on disease characterization in pediatric CD. Figure 1:GIQuant scores in the proximal, distal and terminal ileum of children with Crohn’s disease (CD), irritable bowel syndrome (IBS) and healthy controls (HC).

Abstract BACKGROUND In pediatric Crohn’s disease, endoscopy has remained the gold standard for diagnosis; however, Magnetic Resonance Enterography (MRE) is able to show inflammation of the bowel that a gastroenterologist cannot reach with endoscopy. For a standard MRE, a patient needs to ingest oral contrast, receive intravenous (IV) contrast and a spasmolytic agent, and hold his/her breath during portions of the study, which can be challenging in younger children. As shown in previous studies, quantitative Magnetic Resonance Imaging (MRI) can evaluate bowel motility in children with Crohn’s disease, showing that as motility decreases in the bowel, inflammation increases. A motility score obtained from GIQuant software (Motilent, UK) may allow existing MRE protocols to be shortened and can be done with free-breathing techniques and without IV contrast and the spasmolytic agent. AIM Our primary aim is to demonstrate that quantitative MRI, which uses the cine image to develop a motility score from GIQuant software, is as effective as standard MRE in assessing inflammation of the bowel. We secondarily hypothesize that the motility score will inversely correlate to the Endoscopic Biopsy Acute Histologic Inflammatory Score (eAIS), the Crohn’s Disease Endoscopic Index of Severity (CDEIS) score, and the MR Index of Activity (MaRIA) score. METHODS This was a retrospective study of 50 pediatric patients from Children’s Wisconsin with ileal and/ or cecal Crohn’s disease who underwent endoscopy and MRE within 7 days of each other without exposure to therapy. Cine images were used from patients’ previously obtained MREs to obtain a motility score using GIQuant. A cine image and GIQuant map example is shown in Figure 1. The relationships between motility score and MaRIA, eAIS, and CDEIS were then calculated by Spearman’s rank correlation coefficient (ρ). RESULTS MaRIA and motility scores inversely correlated (ρ = -0.66, p <.0001), which is seen in Figure 2. MaRIA positively correlated with CDEIS (ρ = 0.30, p= 0.03) and eAIS (ρ = 0.26, p = 0.07). The motility score showed a non-significant negative correlation with CDEIS (ρ = -0.17, p = 0.24) and eAIS (ρ = -0.23, p =0.11). CONCLUSION Quantitative MRI is as effective as standard MRE in identifying inflammation of the bowel in Crohn’s disease. The cine image is obtained much faster than standard MRE and without the use of intravenous contrast, spasmolytic agent, and breath-holding techniques, which is crucial for children who are too young to cooperate with current MRE protocols. Figure 1 MRE cine image with the Region of Interest in the terminal ileum identified via the polygon and the resulting Motility Map produced by GIQuant Figure 2 MaRIA and Motility scores of each patient in our cohort