A recent review (JPGN 2014; 59: 429-39) regarding imaging for inflammatory bowel disease reiterates the accepted view that magnetic resonance enterography (MRE) is typically the most useful imaging test for children with inflammatory bowel disease; in Table 5, MRE is listed for each indication, though CT scan is recommended “if emergent or after hours.” The review reviews prior pediatric publications, radiation risks (with non-MRE studies), and alternative imaging. The discussion on costs is minimized, though the authors note that MRE is the most expensive and can be compromised by motion artifact. As a practical matter, I think giving a typical charge (or range) for each of the imaging techniques would be helpful. Also, another important issue is assuring that radiologists have the technical expertise to obtain quality imaging.
Another study (Clin Gastroenterol Hepatol 2014; 12: 1702-07) retrospectively looked at 1095 emergency room visits by 613 individuals (average age ~40 years) to determine if they could develop a model to limit unnecessary CT scans. Of the 1095 CT scans, 24.8% were normal; 10.9% had either perforation or non-perianal abscess. In their discussion, they note that the equation “no scan for ESR (mm/h) + 5*CRP (mg/dL) ≤10” would avoid 18.5% of CT scans. Implementation of a more complex model could eliminate up to 43% of the CT scans. The algorithm (Figure 2) suggested by the authors:
- Assess for obstruction. If suggestive symptoms, obtain abdominal X-rays. If concerns for obstruction remain, consider CT scan.
- If not concerned about obstruction, is there a high likelihood of perforation or abscess? If yes proceed with CT scan. If not, consider anti-inflammatory therapy if CD symptoms present (without imaging).
Here’s the link to the abstract –supplementary materials can be obtained by those who log in. http://dx.doi.org/10.1016/j.cgh.2014.02.036
Bottomline: Cross-sectional imaging is particularly helpful at determining whether complications are developing in patients with inflammatory bowel disease. Increasing use of MRE will reduce radiation risks.
With regard to costs, a recent NPR story discussed “How Much Is That MRI, Really? Massachusetts Shines A Light.” While this story discussed costs related to a Massachusetts law which mandates that insurers reveal the costs of various tests, it did not relate any information regarding quality. The study implied that an MRI at one institution would be equivalent to an MRI at another. This is not the case.
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