Use of ultrasound as an adjunctive tool to extend the physical examination,at the point of care has transformed service delivery in field such as the emergency department, and increasingly in acute care, in internal medicine. Despite the proven use of intestinal ultrasound (IUS) for evaluation of the small and large bowel for detection of inflammation, perforation, diverticulitis, acute bowel obstruction (1,2), gastroenterology has remained well behind in its internal medicine and emergency medicine colleagues in the adoption of this non-invasive, safe and effective diagnostic tool. It is used widely and routinely, particularly for assessment of IBDin Western Europeand Australiaandtrainingis present as a foundational part of standard medical school curriculum in countries like Germany and Italy.
Use of transabdominal intestinal ultrasound in inflammatory bowel disease (IBD)to assess disease activity, exclude complications and assess therapeutic response to medical treatment is well established in the literature for inflammatory bowel disease (IBD) and is now recommended as a first-line modality, comparable to either computed tomography (CT )or magnetic resonance(3,6). Recurrent use of CThas safety concerns, given exposure to ionizing radiation, particularly in children(4). Alternate, safe modalities such an MR and MR enterography, pose different challenges, including patient intolerance given need for large volume small bowel contrast ingestion, long acquisition times, need for general anesthetic in childhood to ensure image quality, as well as challenges with access given long waits in many provinces in Canada. In addition, some questions have been raised around safety of the intravenous contrast agent gadolinium, particularly in children. Alternatively, ultrasound is relatively inexpensive, portable, and well tolerated by patients, with established accuracy for detecting disease activity and associated complications of IBD(3). Given the chronic nature of IBD and its increasing prevalence, novel, innovative ways to ensure accurate, objective detection of disease that occurs at regular intervals to guide disease management and optimization, is crucial to change the course of the disease and improve outcome.
Canadian gastroenterologists are adopting this innovative tool with passion and enthusiasm, in both adult and pediatric, community and expert IBD academic centers. In collaboration with the International Bowel Ultrasound Group (IBUS), an established expert international IUS group that advocate for and support training and research, in collaboration with the European Crohn’s and Colitis Organization (ECCO), there are now 6 adult centers and 5 pediatric centers in 7 2 provinces using this modality on a regular basis and more in development. Globally, there are now 32 countries that have participated in training courses run through IBUS, including the USA with two recent meetings, the last at DDW in San Diego 2019 to begin to plan for the share and spread of IUS in the USA. The lead applicant of this special interest group, Dr. Kerri Novak is the Scientific Chair for IBUS, a founding and executive member, who will continue to leverage Canada as an international site for expert IUS provision. She leads the only currently active expert training site in Canada, with 2 more to follow in the next 6 months (Saskatoon and Edmonton). There is significant industry support for this modality and we hope to continue to partner with them to further support the spread. In addition, Crohn’s and Colitis Canada is increasingly interested and a supportive advocate for IUS to improve access to this patient-centered modality across Canada.
This useful modality is changing the way routine assessments in IBD are conducted, also being actively investigated as a useful screening tool for patients with functional gut disorders such as irritable bowel disease, to screen for inflammation. In addition, the scientific office of IBUS has two active clinical trials running in Europe to evaluate the utility of IUS as an endpoint in clinical trials, a future utility that will be game-changing for IUS. Healing seen on cross-sectional imaging has been shown to predict outcome, and response/ sonographic improvement portends better outcomes for patients, such as fewer hospital admission, less use of steroids, lower surgical rates (5). Therefore, this tool, used in conjunction with additional non-invasive measures such as C reactive protein and fecal calprotectin, will help to safely and effectively improve the course for IBD patients in Canada and is thus recommended by ECCO as a first-line modality for determining the extent, severity and complexity of disease in patients with IBD (6).
Canada is in a perfect position to lead North America in the expansion of the use of IUS, given the current growth in Canadian expertise and enthusiasm for IUS. The establishment of this interest group will help enthusiasts lead the region in expanding expert training opportunities in Canada, curriculum development with expansion to core gastroenterology training programs, and importantly expand research in IUS.
- Expand the awareness and utility of IUS across Canada, with the adoption of this modality in more community and academic centers
- Establish standardized workflow, reporting, and quality
- Advocate for provincial remuneration for expert physicians providing the service
- Advocate for and develop the curriculum for hands-on training during core GI fellowship training
- Improve Canadian-based, single, and multi-center studies to evaluate the utility of IUS in both IBD and in symptomatic patients, to improve access and appropriateness of specialty care