Expert Consensus on Optimal Acquisition and Development of the International Bowel Ultrasound Segmental Activity Score [IBUS-SAS]: A Reliability and Inter-rater Variability Study on Intestinal Ultrasonography in Crohn's Disease

Kerri L Novak, Kim Nylund, Christian Maaser, Frauke Petersen, Torsten Kucharzik, Cathy Lu, Mariangela Allocca, Giovanni Maconi, Floris de Voogd, Britt Christensen, Rose Vaughan, Carolina Palmela, Dan Carter, Rune Wilkens, Kerri L Novak, Kim Nylund, Christian Maaser, Frauke Petersen, Torsten Kucharzik, Cathy Lu, Mariangela Allocca, Giovanni Maconi, Floris de Voogd, Britt Christensen, Rose Vaughan, Carolina Palmela, Dan Carter, Rune Wilkens

Abstract

Background and aims: Intestinal ultrasound [IUS] is an accurate, patient-centreed monitoring tool that objectively evaluates Crohn's disease [CD] activity. However no current, widely accepted, reproducible activity index exists to facilitate consistent IUS identification of inflammatory activity. The aim of this study is to identify key parameters of CD inflammation on IUS, evaluate their reliability, and develop an IUS index reflecting segmental activity.

Methods: There were three phases: [1] expert consensus Delphi method to derive measures of IUS activity; [2] an initial, multi-expert case acquisition and expert interpretation of 20 blinded cases, to measure inter-rater reliability for individual measures; [3] refinement of case acquisition and interpretation by 12 international experts, with 30 blinded case reads with reliability assessment and development of a segmental activity score.

Results: Delphi consensus: 11 experts representing seven countries identified four key parameters including: [1] bowel wall thickness [BWT]; [2] bowel wall stratification; [3] hyperaemia of the wall [colour Doppler imaging]; and [4] inflammatory mesenteric fat. Blind read: each variable exhibited moderate to substantial reliability. Optimal, standardised image and cineloop acquisition were established. Second blind read and score development: intra-class correlation coefficient [ICC] for BWT was almost perfect at 0.96 [0.94-0.98]. All four parameters correlated with the global disease activity assessment and were included in the final International Bowel Ultrasound Segmental Activity Score with almost perfect ICC (0.97 [0.95-0.99, p <0.001]).

Conclusions: Using expert consensus and standardised approaches, identification of key activity measurements on IUS has been achieved and a segmental activity score has been proposed, demonstrating excellent reliability.

Keywords: Ultrasound; activity index; monitoring; reliability.

© The Author(s) 2020. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation.

Figures

Figure 1.
Figure 1.
Measurement of bowel wall thickness. Measures of the bowel wall occur in two orientations: cross-section and longitudinal. The calipers are placed perpendicular to the wall, with two individual measures taken in each orientation, at least 1 cm apart in longitudinal and more than 90° in cross section, in the segment of bowel most affected by disease. The caliper placement occurs from the interface of the mucosa and muscularis mucosae, to the serosa [interface between the serosa and muscularis propria]. All four measures are averaged. Yellow double-headed arrow is the first measurement. Green double-headed arrows are valid second measurements, where red double-headed arrows are invalid caliper placements.
Figure 2.
Figure 2.
The association between scan quality and rater confidence. Quality and confidence scored on a 5-point Likert scale. Red line is the linear association, grey lines are confidence intervals.
Figure 3.
Figure 3.
The association between physician global disease activity assessment and individual intestinal ultrasound parameters. Associations between A] mean activity and bowel wall thickness [top left], B] mean activity and inflammatory fat [top right], C] mean activity and colour Doppler imaging [bottom left], and D] mean activity and bowel wall stratification.
Figure 4.
Figure 4.
Application of the segmental activity and severity scores. Applying the scores: Bowel wall thickness [BWT] = [7.8 + 7.1 + 8.5 + 8.4] / 4 = 7.95 ≈ 8.0. Blood flow/ colour Doppler signal [CDS] = 0 [no signals]. Inflammatory fat [i-fat] = 2 [certain]. Bowel wall stratification [BWS] = 2 [focal disruption · 4 + 2 · 15 + 0 · 7 + 2 · 4 = 70.

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Source: PubMed

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