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## Complete Summary

#### GUIDELINE TITLE

Crohn\'s disease.

#### BIBLIOGRAPHIC SOURCE(S)

Huprich JE, Bree RL, Foley WD, Gay SB, Glick SN, Heiken JP, Levine MS,
Ros PR, Rosen MP, Shuman WP, Greene FL, Rockey DC, Expert Panel on
Gastrointestinal Imaging. Crohn\'s disease. \[online publication\].
Reston (VA): American College of Radiology (ACR); 2005. 11 p. \[46
references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology
(ACR), Expert Panel on Gastrointestinal Imaging. Imaging recommendations
for patients with Crohn\'s disease. Reston (VA): American College of
Radiology (ACR); 2001. 11 p. (ACR appropriateness criteria).

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Crohn\'s disease (CD)

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Gastroenterology\
Internal Medicine\
Nuclear Medicine\
Pediatrics\
Radiology\
Surgery

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
patients with Crohn\'s disease (CD)

#### TARGET POPULATION

-   Patients with suspected Crohn\'s disease (CD)

-   Patients with known Crohn\'s disease and acute exacerbation or
    suspected complications

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  X-ray

    -   Small bowel follow-through (SBFT) with compression

    -   Small bowel, enteroclysis

    -   Abdomen, supine and upright

    -   Colon, barium enema, with air contrast

    -   Small bowel, peroral pneumocolon

    -   Colon, barium enema, single contrast

    -   Colon, water soluble contrast enema

2.  Computed tomography (CT)

    -   Abdomen and pelvis with neutral oral contrast, intravenous (IV)
        contrast (CT enterography)

    -   Abdomen and pelvis, oral contrast

    -   Abdomen and pelvis, with positive contrast, IV contrast

3.  Ultrasound (US)

    -   Abdomen/pelvis

    -   Abdomen, Color Doppler

    -   Endorectal

4.  Nuclear medicine (NUC), leucoscintigraphy

5.  Magnetic resonance imaging (MRI) of abdomen and pelvis, with or
    without contrast

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals, and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed to reach agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by the participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Evaluation of Crohn\'s Disease**

**Variant 1: Adult; initial presentation (abdominal pain, fever, or
diarrhea); Crohn\'s disease suspected.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, abdomen and      8                    
  pelvis with neutral                      
  oral contrast, IV                        
  contrast (CT                             
  enterography)                            

  X-ray, small bowel   7                    
  follow-through with                      
  compression (SBFT)                       

  X-ray, small bowel,  7                    
  enteroclysis                             

  CT, abdomen and      7                    
  pelvis, oral                             
  contrast                                 

  CT, abdomen and      7                    
  pelvis, with                             
  positive contrast,                       
  IV contrast                              

  X-ray, abdomen,      6                    
  supine and upright                       

  X-ray, colon, barium 6                    
  enema, with air                          
  contrast                                 

  X-ray, small bowel,  6                    
  peroral pneumocolon                      

  MRI, abdomen and     6                    
  pelvis, with or                          
  without contrast                         

  X-ray, abdomen,      5                    
  supine                                   

  X-ray, colon, barium 5                    
  enema, single                            
  contrast                                 

  US, abdomen/pelvis   5                    

  X-ray, colon, water  4                    
  soluble contrast                         
  enema                                    

  US, abdomen, Color   4                    
  Doppler                                  

  US, endorectal       3                    

  NUC,                 3                    
  Leucoscintigraphy                        

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the table are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: Initial presentation of a child (less than 14 years old);
Crohn\'s disease suspected.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, abdomen and      8                    
  pelvis with neutral                      
  oral contrast, IV                        
  contrast (CT                             
  enterography)                            

  X-ray, SBFT with     7                    
  compression                              

  CT, abdomen and      7                    
  pelvis, oral                             
  contrast                                 

  CT, abdomen and      7                    
  pelvis, with                             
  positive contrast,                       
  IV contrast                              

  X-ray, small bowel,  6                    
  enteroclysis                             

  MRI, abdomen and     6                    
  pelvis, with or                          
  without contrast                         

  US, abdomen/pelvis   6                    

  US, abdomen, Color   6                    
  Doppler                                  

  X-ray, abdomen,      5                    
  supine and upright                       

  X-ray, colon, barium 5                    
  enema, with air                          
  contrast                                 

  X-ray, colon, barium 5                    
  enema, single                            
  contrast                                 

  X-ray, small bowel,  5                    
  peroral pneumocolon                      

  X-ray, abdomen,      4                    
  supine                                   

  X-ray, colon, water  4                    
  soluble contrast                         
  enema                                    

  US, endorectal       2                    

  NUC,                 2                    
  Leucoscintigraphy                        

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the table are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: Adult with known Crohn\'s disease and fever, increasing
pain, leukocytosis, etc.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, abdomen and      8                    
  pelvis with neutral                      
  oral contrast, IV                        
  contrast (CT                             
  enterography)                            

  X-ray, abdomen,      7                    
  supine and upright                       

  CT, abdomen and      7                    
  pelvis, with                             
  positive contrast,                       
  IV contrast                              

  CT, abdomen and      6                    
  pelvis, oral                             
  contrast                                 

  X-ray, abdomen,      5                    
  supine                                   

  X-ray, colon, water  5                    
  soluble contrast                         
  enema                                    

  X-ray, small bowel   5                    
  follow-through with                      
  compression (SBFT)                       

  X-ray, small bowel,  5                    
  peroral pneumocolon                      

  MRI, abdomen and     5                    
  pelvis, with or                          
  without contrast                         

  US, abdomen/pelvis   5                    

  X-ray, colon, barium 4                    
  enema, with air                          
  contrast                                 

  X-ray, colon, barium 4                    
  enema, single                            
  contrast                                 

  X-ray, small bowel,  4                    
  enteroclysis                             

  US, abdomen, Color   4                    
  Doppler                                  

  US, endorectal       4                    

  NUC,                 3                    
  Leucoscintigraphy                        

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the table are listed at the end of the
\"Major Recommendations\" field.

**Variant 4: Child (less than 14 years of age) with known Crohn\'s
disease and fever, increasing pain, leukocytosis, etc.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, abdomen and      8                    
  pelvis with neutral                      
  oral contrast, IV                        
  contrast (CT                             
  enterography)                            

  CT, abdomen and      7                    
  pelvis, with                             
  positive contrast,                       
  IV contrast                              

  X-ray, abdomen,      6                    
  supine and upright                       

  CT, abdomen and      6                    
  pelvis, oral                             
  contrast                                 

  US, abdomen/pelvis   6                    

  X-ray, small bowel   5                    
  follow-through with                      
  compression (SBFT)                       

  MRI, abdomen and     5                    
  pelvis, with or                          
  without contrast                         

  US, abdomen, Color   5                    
  Doppler                                  

  X-ray, abdomen,      4                    
  supine                                   

  X-ray, colon, barium 4                    
  enema, with air                          
  contrast                                 

  X-ray, colon, barium 4                    
  enema, single                            
  contrast                                 

  X-ray, colon, water  4                    
  soluble contrast                         
  enema                                    

  X-ray, small bowel,  4                    
  enteroclysis                             

  X-ray, small bowel,  4                    
  peroral pneumocolon                      

  NUC,                 4                    
  Leucoscintigraphy                        

  US, endorectal       2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the table are listed at the end of the
\"Major Recommendations\" field.

**Variant 5: Adult with known Crohn\'s disease; stable, mild symptoms.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, abdomen and      7                    
  pelvis with neutral                      
  oral contrast, IV                        
  contrast (CT                             
  enterography)                            

  X-ray, small bowel   6                    
  follow-through with                      
  compression (SBFT)                       

  CT, abdomen and      6                    
  pelvis, with                             
  positive contrast,                       
  IV contrast                              

  X-ray, abdomen,      5                    
  supine                                   

  X-ray, abdomen,      5                    
  supine and upright                       

  X-ray, colon, barium 5                    
  enema, with air                          
  contrast                                 

  X-ray, colon, barium 5                    
  enema, single                            
  contrast                                 

  X-ray, small bowel,  5                    
  enteroclysis                             

  X-ray, small bowel,  5                    
  peroral pneumocolon                      

  CT, abdomen and      5                    
  pelvis, oral                             
  contrast                                 

  MRI, abdomen and     4                    
  pelvis, with or                          
  without contrast                         

  US, abdomen/pelvis   4                    

  US, abdomen, Color   4                    
  Doppler                                  

  X-ray, colon, water  2                    
  soluble contrast                         
  enema                                    

  US, endorectal       2                    

  NUC,                 2                    
  Leucoscintigraphy                        

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the table are listed at the end of the
\"Major Recommendations\" field.

**Variant 6: Child (less than 14 years of age) with known Crohn\'s
disease; stable, mild symptoms.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  US, abdomen/pelvis   6                    

  US, abdomen, Color   6                    
  Doppler                                  

  X-ray, abdomen,      5                    
  supine                                   

  X-ray, abdomen,      5                    
  supine and upright                       

  X-ray, small bowel   5                    
  follow-through with                      
  compression (SBFT)                       

  X-ray, small bowel,  5                    
  peroral pneumocolon                      

  CT, abdomen and      5                    
  pelvis with neutral                      
  oral contrast, IV                        
  contrast (CT                             
  enterography)                            

  CT, abdomen and      5                    
  pelvis, with                             
  positive contrast,                       
  IV contrast                              

  MRI, abdomen and     5                    
  pelvis, with or                          
  without contrast                         

  X-ray, colon, barium 4                    
  enema, single                            
  contrast                                 

  CT, abdomen and      4                    
  pelvis, oral                             
  contrast                                 

  X-ray, colon, barium 3                    
  enema, with air                          
  contrast                                 

  X-ray, colon, water  2                    
  soluble contrast                         
  enema                                    

  X-ray, small bowel,  2                    
  enteroclysis                             

  US, endorectal       2                    

  NUC,                 2                    
  Leucoscintigraphy                        

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the table are listed at the end of the
\"Major Recommendations\" field.

Crohn\'s disease (CD) is a chronic inflammatory disease involving the
gastrointestinal tract. The etiology is unknown, but evidence suggests
that a genetic predisposition combined with an abnormal interaction
between the gut and enteric microorganisms may play a role in the
pathogenesis. Patients usually present with the abrupt or insidious
onset of abdominal pain and diarrhea frequently accompanied by fever and
weight loss. The small intestine and colon are most commonly affected,
but any portion of the bowel from mouth to anus may be involved. The
small bowel is affected alone in about a third of patients, the colon
alone in 20 to 30% of patients, and combined involvement of the colon
and the small bowel is seen in 40 to 50% of patients. The severity of
symptoms, frequency of complications, and likelihood of intestinal
resection due to CD are typically greater in patients with ileocolic
involvement than in those with disease limited to the small bowel or
colon alone.

Characteristic pathologic findings of CD in the gut include transmural
granulomatous inflammation; deep ulcers which may progress to sinus
tracts and fistulae; strictures that may lead to intestinal obstruction;
and discontinuous involvement, with skip areas between diseased
segments. Extraintestinal manifestations are common and include
arthritis, cholelithiasis, ocular manifestations, dermatologic
abnormalities, and, in children, growth retardation.

**Role of Radiology**

The initial diagnosis of CD is based on a combination of clinical,
laboratory, histological, and imaging findings. No single diagnostic
test allows unequivocal diagnosis. The imaging characteristics and
distribution of disease provide supportive evidence for the diagnosis of
CD. Imaging is commonly called upon to distinguish CD from other
conditions causing colitis. In particular, the presence of small bowel
involvement helps distinguish CD from ulcerative colitis.

In the last decade many new therapeutic strategies have been developed
that have allowed the gastroenterologist and surgeon to treat virtually
all forms of CD effectively. The success of these treatments (which
target specific subtypes of CD) depends on accurate diagnosis of the
nature and extent of disease. Therefore, it is no longer sufficient for
the radiologist to only detect the presence of CD\--he must also
accurately assess its subtype, location, and severity. This is
particularly important in distinguishing segmental small bowel narrowing
due to active disease (which is effectively treated with medical
therapy) from fibrotic strictures (more amenable to stricturoplasty).
Likewise, complex fistulas may be more effectively treated surgically,
while simple fistulas usually respond to anti-tumor necrosis factor
(TNF) agents like infliximab. Therefore, accurate delineation of the
frequently complex anatomy of these lesions is essential.

Radiology has traditionally played a smaller role in the long-term
surveillance of patients with known CD because there is a poor
correlation between clinical disease activity and the radiographic
changes on barium studies. New imaging techniques discussed in the
following sections of this article hold promise in predicting disease
activity. It is well recognized that imaging is important in the
evaluation of patients with complications of the disease, such as bowel
obstruction, fistula formation, and abscess. This narrative will discuss
the role of various imaging modalities in the initial diagnosis of CD
and in the management of suspected complications of the disease.

**Initial Presentation**

*Plain Films of the Abdomen*

Plain films often depict abnormalities in patients with inflammatory
bowel disease (IBD), and some authors advocate their routine use.
Findings include mural thickening and dilatation; mucosal abnormalities
of the small bowel and colon; and abnormal distribution of feces, with
areas of colonic involvement devoid of fecal material. However, a false
positive rate of 16 to 20%, and a low positive predictive value of a
normal film (62%), make plain radiography a poor screening test in
patients at initial presentation: negative films cannot preclude further
studies, and positive findings would also lead to other radiological
procedures to more accurately characterize the type of IBD and to map
its anatomic distribution in the gut. For these reasons, plain films are
not essential when the initial presentation is typical for IBD and is
not severe.

*Barium Studies of the GI Tract*

Along with endoscopy and other imaging techniques, barium studies remain
an important diagnostic tool in the evaluation of patients with CD. The
recent introduction of wireless capsule endoscopy is likely to play an
increasing role in early diagnosis of CD. However, because of a 5%
incidence of capsule retention proximal to unsuspected strictures,
barium studies are likely to remain an important screening tool prior to
capsule endoscopy exams.

The small bowel can be evaluated by either conventional SBFT or
enteroclysis, and each has its proponents. Each technique is quite
accurate in detecting small bowel involvement when performed correctly
(89 to 97% for conventional SBFT and 83 to 100% for enteroclysis), and
the superior diagnostic accuracy of enteroclysis in other conditions
(e.g., detecting small bowel neoplasms and Meckel\'s diverticula) is not
as well established in the evaluation of IBD. While enteroclysis has a
shorter overall examination time, the peroral SBFT requires less total
room time and radiologist time, and substantially less radiation
exposure. It also has fewer side effects and greater patient acceptance.
For these reasons, detailed SBFT, with frequent fluoroscopy using graded
compression, is the best means of evaluating the small bowel,
particularly in younger patients. Enteroclysis is usually reserved for
problematic cases.

The peroral pneumocolon is a useful adjunct to SBFT or enteroclysis.
Once the terminal ileum has been opacified, air is instilled through the
rectum to obtain a double contrast examination of the distal small bowel
(or the ascending colon, or both). Often this technique will result in
better distention of the terminal ileum, and in better mucosal detail.
It is particularly useful when the appearance of the ileum is
indeterminate by SBFT or enteroclysis alone. One milligram of glucagon,
given intravenously, facilitates reflux of air retrograde through the
ileocecal valve, with a failure rate of about 10%.

Endoscopy is the preferred initial examination of the colon in patients
suspected of having IBD. It is superior to the barium enema in detecting
early changes and has largely replaced it as the initial diagnostic
exam. The barium enema is reserved for those patients with unsuccessful
colonoscopy or with contraindications such as patients on
anticoagulation therapy.

*Ultrasound*

Numerous US studies have documented the ability of transabdominal US to
demonstrate the presence of CD. US findings of CD include bowel wall
thickening (4-5 mm or greater), producing the target sign when seen in
cross-section, and reduced or absent peristalsis in affected loops.

More recently, proponents have argued that ultrasound could replace SBFT
in the initial evaluation of patients suspected to have CD or in the
surveillance of patients (particularly children) with CD, because of its
acceptable sensitivity and the advantage of no radiation exposure. In
the one prospective comparison of US and barium studies, which used the
barium study as the gold standard, in the initial evaluation of
suspected CD, the sensitivity of US was 75% and the specificity was 97%.
The authors describe a steep learning curve, with sensitivity increasing
to 87% as experience is gained. This finding emphasizes the frequently
made point that US is quite operator-dependent, perhaps more so than
other modalities.  Recent introduction of US contrast agents and power
Doppler techniques suggest an increasing role for these techniques in
the future. These data point to a potential role for US as the initial
modality in patients (especially children) suspected of having CD.

*Nuclear Medicine*

Nuclear medicine plays little role in the initial evaluation of patients
suspected of having CD. Radionuclide studies are not as effective as
endoscopy or other imaging studies in assessing disease extent, and they
lack the anatomic detail provided by those studies.

*Computed Tomography*

Although CT has traditionally been used to evaluate extraenteric
complications of CD such as bowel obstruction, abscess, and fistula,
multidetector CT has shown considerable promise in initial diagnosis and
estimation of disease severity. Two modifications of standard abdominal
CT technique are especially promising. These techniques differ from
standard abdominal CT by using intraluminal bowel distension with
neutral enteric contrast; multidetector CT with narrow slice thickness
and reconstruction interval; and IV contrast administration followed by
scan delays that optimize bowel wall enhancement. Large volumes of
enteric contrast are necessary to achieve adequate luminal distension
and may be administered orally (CT enterography) or injected through a
nasojejunal tube (CT enteroclysis). The peroral administration of
contrast enjoys greater patient acceptance and results in acceptable
degrees of luminal distention. The use of neutral rather than positive
enteric contrast is important so as not to obscure mucosal
enhancement\--an important indicator of active disease. Active disease
is identified by mucosal hyperenhancement, bowel wall thickening, mural
stratification, and hyperemic vasa recta. There is growing evidence
suggesting that CT is more sensitive than barium small bowel
examinations in detecting CD. Unlike conventional barium studies, CT
allows good visualization of pelvic small bowel loops that are often
obscured due to overlapping bowel in barium studies. CT also competes
favorably with conventional and capsule endoscopy.

*Magnetic Resonance Imaging*

Contrast enhanced MRI scanning using fast imaging techniques can
accurately display bowel wall changes in early CD. MRI appears to be
superior to barium small bowel studies in diagnosing and depicting
disease extent. Characteristic bowel wall changes such as mural
hyperenhancement, bowel wall thickening, mural stratification, and
hyperemic vasa recta are similar to these seen with CT. MR\'s ability to
visualize these changes without the risks associated with ionizing
radiation makes it a desirable technique for examining CD in children
and in patients who must be subjected to multiple serial exams.
Increased use of MR is very likely in the future.

**Patients with Known Crohn\'s Disease Presenting with Acute
Exacerbation or Symptoms, or with Suspected Complications**

CD is a chronic disease, with frequent relapses and superimposed
complications. These include bowel obstruction due to strictures;
intra-abdominal or pelvic abscess; development of fistulae to skin,
bladder, vagina, etc.; and toxic megacolon in patients with colonic CD.

*Plain Films of the Abdomen*

In patients with fulminant symptoms, plain films are useful, because
they can often detect the presence of bowel obstruction, perforation, or
toxic colon distention, directing further treatment quickly.

*Barium Studies of the Gastrointestinal (GI) Tract*

Barium small bowel exams remain useful in evaluating suspected
complications of CD. The presence and anatomy of strictures and fistulas
assist in preoperative planning. In patients who are acutely ill, with
peritoneal signs or acute diarrhea, barium studies are not indicated
because of the risk of perforation.

For evaluating the colon in patients with acute exacerbations,
colonoscopy has supplanted barium enema. In patients with a low risk of
perforation, a carefully performed barium enema can still provide
valuable information, especially if fistula or stenoses are suspected.

In patients with CD who present with pain, a palpable mass, or fever,
and in whom an abscess is suspected, barium studies have little role.
While they may demonstrate a fistulous communication with an abscess, a
negative study doesn\'t preclude other studies, and a positive one will
likewise lead to additional imaging to guide therapy, such as
percutaneous drainage.

*Ultrasound*

US has a limited role in management of suspected complications of CD
except in children and in patients with perianal fistulas. The risks
associated with ionizing radiation favor the role of US and MR in
evaluating pediatric CD patients who are likely to require multiple
exams over the course of their disease.

Endoscopic US has been shown to be superior to CT and conventional
fistulography and plays a complementary role with MRI in evaluation of
Crohn\'s perianal fistulas. Its ability to depict perianal anatomy makes
it a valuable tool for preoperative planning.

*Nuclear Medicine*

Numerous articles support the use of technetium hexamethyl propylene
amine oxime (HMPAO)-labeled white blood cells, with single photon
emission computed tomography (SPECT) imaging, in assessing disease
activity. These advocates propose that, once the histological diagnosis
of CD has been established, the disease activity can be reliably
assessed by this technique. Its advantages over barium studies include
the examination of both large and small bowel in one encounter, lower
radiation exposure (important in younger patients, especially children,
who will have multiple studies over their lifetime), and higher patient
acceptance. In addition, HMPAO-labeled leucoscintigraphy can accurately
distinguish CD from ulcerative colitis in a large proportion of
patients, and may actually exceed conventional radiology in this regard.
Recent application of SPECT leucoscintigraphy and positron emission
tomography (PET) has reduced the false positive rate from physiological
uptake in adjacent organs; however, the specificity remains limited.

While some advocates of leucoscintigraphy have argued that this
technique compares favorably with CT or US in diagnosing extraintestinal
complications of CD, this view is not widely accepted, and nuclear
medicine plays a subordinate role in patients with known CD who present
with signs and symptoms of abscess, fistula formation, or bowel
obstruction.

*Computed Tomography*

Currently, CT is the initial imaging technique of choice in suspected CD
complications, for both adults and children. In one large study of 80
patients, CT detected unsuspected findings that led to a change of
medical or surgical management in 28% of patients. CT can most often
differentiate the various causes of palpable abdominal mass (fibrofatty
proliferation, abscess, thickened bowel wall, phlegmon, or neoplasm),
and often can depict fistulas and sinus tracts.

*Magnetic Resonance Imaging*

Improvements in MR technology, such as fast scanning techniques, have
permitted accurate diagnosis of complications of CD, including abscess,
fistula, and stenosis. MRI is useful when ionizing radiation is
contraindicated, and it has been used successfully in children and
pregnant women. Along with endoscopic US, MRI is the preferred tool for
evaluating perianal complications of CD.

*Angiography and Interventional Radiology*

The primary role of interventional radiology is in the percutaneous
drainage of abscesses complicating CD. Numerous studies have documented
the effective use of this technique, which is now the procedure of
choice, often obviating the need for surgical resection.

*Abbreviations*

-   CT, computed tomography

-   IV, intravenous

-   MRI, magnetic resonance imaging

-   NUC, nuclear medicine

-   SBFT, small bowel follow-through

-   US, ultrasound

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
Crohn\'s disease (CD)

#### POTENTIAL HARMS

In patients who are acutely ill, with peritoneal signs or acute
diarrhea, barium studies are not indicated because of the risk of
perforation.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Huprich JE, Bree RL, Foley WD, Gay SB, Glick SN, Heiken JP, Levine MS,
Ros PR, Rosen MP, Shuman WP, Greene FL, Rockey DC, Expert Panel on
Gastrointestinal Imaging. Crohn\'s disease. \[online publication\].
Reston (VA): American College of Radiology (ACR); 2005. 11 p. \[46
references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1998 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Gastrointestinal
Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: James E. Huprich, MD (*Principal Author*); Robert L.
Bree, MD, MHSA (*Panel Chair*); W. Dennis Foley, MD; Spencer B. Gay, MD;
Seth N. Glick, MD; Jay P. Heiken, MD; Marc S. Levine, MD; Pablo R. Ros,
MD, MPH; Max Paul Rosen, MD, MPH; William P. Shuman, MD; Frederick L.
Greene, MD; Don C. Rockey, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology
(ACR), Expert Panel on Gastrointestinal Imaging. Imaging recommendations
for patients with Crohn\'s disease. Reston (VA): American College of
Radiology (ACR); 2001. 11 p. (ACR appropriateness criteria).

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalImaging/CrohnsDiseaseDoc5.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on March 19, 2001. The information
was verified by the guideline developer on March 29, 2001. This summary
was updated by ECRI on July 31, 2002. The updated information was
verified by the guideline developer on October 1, 2002. This summary was
updated by ECRI on March 21, 2006.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008