Intest Res.  2023 Jan;21(1):126-136. 10.5217/ir.2021.00166.

Characteristics and usefulness of transabdominal ultrasonography in immune-mediated colitis

• Sakurai K
• Katsurada T
• Nishida M
• Omotehara S
• Fukushima S
• Otagiri S
• Nagashima K
• Onishi R
• Takagi R
• Komatsu Y
• Sakamoto N

• KMID: 2539011
• DOI: http://doi.org/10.5217/ir.2021.00166

Abstract

Background/Aims
The usefulness of ultrasonography (US) in diseases of the gastrointestinal tract has been reported recently. This prospective study aimed to determine the features of US findings in immune-mediated colitis (IMC), an adverse event induced by immune checkpoint inhibitor, and examine the correlation between US findings, colonoscopy (CS) findings, and severity of colitis.
Methods
We studied patients examined using CS and US upon suspicion of IMC in Hokkaido University Hospital between April 2018 and February 2021. Endoscopic findings of IMC were assessed using the Ulcerative Colitis Endoscopic Index of Severity (UCEIS). The severity of US findings in IMC was evaluated using US grade, which is the ultrasonographic grading scale in ulcerative colitis. Bowel wall thickness and the intensity of the color Doppler signal were also analyzed. Severity of colitis was evaluated using Common Terminology Criteria for Adverse Events (CTCAE) grade version 5.
Results
Fourteen patients with IMC were enrolled. The US findings were bowel wall thickening, loss of stratification, ulceration and increased blood flow signal. The US grade was moderately correlated with the UCEIS (r=0.687, p=0.009) and CTCAE grade (r=0.628, p=0.035). Bowel wall thickness and UCEIS (r=0.628, p=0.020), as well as color Doppler signal grade and CTCAE grade (r=0.724, p=0.008), were significantly correlated.
Conclusions
US findings in IMC were mainly similar to those of ulcerative colitis, but there were some findings that were characteristic only of IMC. Significant correlation was found between US findings, CS findings, and severity of colitis. Hence, US could be useful for the evaluation of IMC.

Keyword

Transabdominal ultrasonography; Colonoscopy; Immune-mediated colitis; Immune checkpoint inhibitor; Immune-related adverse events

Figure

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  Fig. 1. Patient enrollment. Between April 2018 and February 2021, 528 patients received immune checkpoint inhibitor (ICI), 30 of them presented with diarrhea, bloody stools, or abdominal pain during ICI therapy or after discontinuation of ICI. Of these 30 patients, 18 patients underwent colonoscopy (CS) and ultrasonography (US) for the suspicion of immune-mediated colitis (IMC). Those whose CS or US showed no inflammatory findings as well as those who were diagnosed with other diseases such as infectious enteritis based on tissue biopsy and stool culture were excluded from the study. A total of 14 patients were enrolled who were diagnosed with IMC based on CS findings.

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  Fig. 2. Correlations between BWT, CDS grade, UCEIS, and CTCAE grade of colitis. (A) A moderate correlation was found between BWT and UCEIS, (B) while no significant correlation was found between BWT and CTCAE. (C) The CDS grade and UCEIS showed no significant correlation. (D) However, the CDS grade and CTCAE were strongly correlated. BWT, bowel wall thickness; CDS, color Doppler signal; UCEIS, Ulcerative Colitis Endoscopic Index of Severity; CTCAE, Common Terminology Criteria for Adverse Events.

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  Fig. 3. Ultrasonography and colonoscopy findings of immune-mediated colitis (IMC) in a patient who had anti-PD-L1 antibody therapy (durvalumab). IMC was resistant to steroids and anti-tumor necrosis factor α antibodies. The remission was inducted using vedolizumab. At the onset of colitis, ultrasonography (US) shows a thickened bowel wall, the stratified structure is partially indistinct (arrows) (A), and color Doppler shows an increased blood flow signal (B). Colonoscopy (CS) shows a circular erosion from the cecum to the rectum, and there are exudates and spontaneous bleeding (C). After administering vedolizumab, US shows the bowel wall thickening improvement, and the stratified structure becomes clearly visible (arrows) (D), color Doppler shows no blood flow signal (E). CS findings improves that the erosion and exudates are disappeared, and the mucosal vascular pattern becomes also visible (F). PD-L1, programmed cell death receptor ligand 1.

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