Capsule Endoscopy Diagnosed Small Bowel Ulceration: Is This Really Crohn's Disease?

Abstract

Background: Capsule endoscopy (CE) is a means of evaluating the small intestine primarily for obscure GI bleeding (OGIB). We have noticed a small group of patients that have presented with OGIB (without NSAID use) with small bowel ulcerations. They had no signs or symptoms of Crohn's disease (CD) or in fact any other small bowel disorder (besides OGIB). We sought to evaluate this group of patients more thoroughly as we believe they represent a sub-set of CD that is unique from those with stenosing, fistulizing or ulcerating disease. Methods: All patients undergoing CE studies were reviewed with a prospectively collected database on patient demographics, indication for CE, previous investigations, transfusions, and management before and after CE. Patients were all followed long term after their CE studies. Results: 10 patients were identified from the database (of 410 CE) with small bowel ulcerations. Of the 10 patients (mean age 52, 60% men), 7 patients were referred because of suspected occult bleeding and 3 patients because of overt bleeding. The duration of symptoms was 12-24 weeks in one patient, greater than 24 weeks in 7 patients and not documented in 2 patients. None of the patients took NSAIDs, was on any anti-platelet agents, or had a history of inflammatory bowel disease, celiac disease or other vascular abnormalities. There were no associated masses. The ulcerations were distributed throughout the small bowel and were consistent with CD. No patient had other significant comorbid disorders to suggest vasculitis, ischemia, lymphoma or other small intestine abnormality. Additionally, 3 patients were from Southeast Asia (where CD is uncommon) and all patients lacked extra-intestinal manifestations of IBD. Over a follow up mean of 16 months, no patient has progressed with obstructive, fistulizing or other GI symptoms. All patients have remained with intermittent bleeding without progression of disease. No patients have undergone surgery. Conclusion: Through CE, we have found a small group of patients with OGIB with small bowel ulcerations (in absence of NSAIDS), which we have labeled as CD. This type of CD is unique in that there is no progression to stenosing, fistulizing or even small bowel symptoms (i.e. diarrhea) and the presentation and subsequent management is strictly one of bleeding. We believe that this represents a unique sub-set of CD with different presentation, progression, outcomes and likely management from other CD subtypes.