Imaging in IBD: Capsule, NBI, and chromoendoscopy.

Use and Misuse of Small Bowel Video Capsule Endoscopy in Clinical Practice

Objective To investigate the correlation between any two of Capsule Endoscopy Scroring Index （Lewis score）, simplified Crohn Disease Activity Index （CDAI） and C-reactive protein （CRP） in small bowel Crohn disease （CD）. Methods A total of 58 consecutive patients with known small bowel CD were enrolled. We evaluated disease activity with Lewis score and simplified CDAI. Correlations among CRP, simplified CDAI and Lewis score were calculated with Spearman＇s rank order correlation coefficient. The optimal CRP cut-off value was calculated using the ROC curve. Results The Lewis score showed inac- tive, mild and moderate-severe patients were 13, 21 and 24, respectively. CRP of moderate-severe group was significantly higher than that in mild and inactive groups （P 〈 0.05）. The optimal CRP cut-off value that differentiated patients with moderate to severe disease from the others was 13.50 mg/L with sensitivity of 87. 5% and specificity of 82. 4%. The area under the ROC curve to analyze the cut-off was 0. 849. Lewis score was moderately correlated with CRP （ r = 0. 58, P 〈 0.01 ）, and weakly correlated with the simplified CDAI （ r = 0. 40, P 〈 0. 01 ）. Conclusion Serum CRP and the simplified CDAI cannot replace Lewis score for capsule endoscopy in the assessment of disease activity in small bowel CD. However, CRP may be considered as an inflammatory marker for evaluating the moderate to severe capsule endoscopic activity. Key words: C-reactive protein; Capsule endoscopy scoring index; The simplified Crohn disease activity index; Small bowel Crohn disease

The role of video capsule endoscopy (VCE) in inflammatory bowel disease (IBD) has evolved from small bowel to a panenteric evaluation tool over the past two decades. We systematically reviewed the techniques, applications, outcomes, and complications of VCE in IBD. A systematic literature search was performed using PubMed, Embase, and Medline. All relevant original articles involving VCE in IBD were included from 2003 to July 2022. After screening 3,089 citations, finally 201 references were included. The diagnostic yield of VCE in suspected Crohn's disease (CD) was highly variable (6–80%) with excellent sensitivity (77–93%) and specificity (80–89%). The diagnostic yield in known CD was 52 to 88.3% leading to a change in management (26–75%) and disease reclassification with variable retention rates. VCE was superior to small bowel series, computed tomography (CT) and could be better than magnetic resonance enterography (MRE), especially for proximal and superficial lesions. Colon or panenteric VCE has strong correlation to ileo-colonoscopy (IC) and combined magnetic resonance imaging and IC, respectively. The VCE retention rate in CD is higher in known CD which significantly decreases after the negative patency capsule test or CT/MRE. VCE can identify lesions beyond the reach of IC in postoperative CD. Colon Capsule Endoscopy is a noninvasive monitoring tool in ulcerative colitis (UC) having a strong correlation with IC and may uncover small bowel involvement. VCE is specifically useful in IBD-unclassified (IBD-U) which can lead to the diagnosis of CD in 16.7 to 61.5%. Various scoring systems have been established and validated for small bowel CD (Lewis score and capsule endoscopy CD activity index—CECDAI), UC (capsule scoring of UC: Capsule Scoring of Ulcerative Colitis), panenteric evaluation (Capsule Endoscopy Crohn's Disease Activity Index, Elaikim score), and flare prediction (APEX score). Technological advances include double head, three-dimensional reconstruction, sampling system, panoramic view (344 and 360 degree lateral), and panenteric capsule. Artificial intelligence and software like TOP100 and Quickview can help reduce capsule reading time with excellent sensitivity and specificity. VCE in IBD has widespread application in suspected and known small bowel CD, monitoring of UC, postoperative CD, IBD-U, and for panenteric evaluation. Patency capsule testing helps to reduce retention rates significantly. Artificial intelligence and technical advances can help evolve this novel technology.

The diagnosis of isolated small bowel Crohn's disease (CD) can be challenging. Symptoms are non-specific and both imaging and capsule endoscopy (CE) may be misleading as several diseases may mimic CD. Double balloon enteroscopy (DBE) allows a more extensive endoscopic and histologic evaluation of the small bowel. Our aim was to describe the diagnostic utility and impact of DBE on management of patients with known CD and in patients with suspected/rule-out CD. Retrospective review of our institution's DBE database from February 2009 to May 2013. Adult patients referred for DBE for further evaluation of known or suspected CD (due to symptoms, abnormal imaging and/or CE) were included. Patient demographics, clinical characteristics, imaging and CE results, prior DBE, indication for DBE, DBE findings, DBE adverse events, pathology findings, final diagnosis, treatment prior and post DBE and follow-up DBE were abstracted from the electronic medical record. A total of 108 patients were included, 61 (56%) females, mean age 52 years (range 20-83). Indications for DBE included: disease activity assessment/therapeutic in 10 patients with established diagnosis of CD and for diagnostic purposes in 98 patients with suspected CD (31 patients due to abnormal imaging, 29 due to abnormal CE and 26 due to both abnormal imaging and CE). Upper, lower, bidirectional upper and lower, and stomal DBE were performed in 21, 24, 62 and 1 patients, respectively. DBE revealed active disease in 8/10 patients with known CD with one patient undergoing dilation of a stricture. Changes in management were recommended for all patients with active disease - start thiopurine (2), optimize thiopurine dose (1), start biologics (3) change biologics (1), systemic steroids (1) and budesonide (1). The patient who underwent stricture dilation ultimately required surgery. A definitive diagnosis of CD (both endoscopic and histologic) was reached in only 39/98 (40%) patients who were referred for suspected CD. Changes in management were recommended in 32/39 (82%) patients. Interestingly, 24/98 patients had been diagnosed with CD at outside institutions and were recommended to initiate therapy for CD. Of these, CD was confirmed in only 15/24 (63%) patients. Adverse events included perforation in 1 patient (1%) who required surgical management and mouth swelling/abrasion in 3 patients (3%). Follow-up DBE to re-assess disease activity was performed in 10/49 (20%) patients with definitive diagnosis of CD, average time between procedures 4.5 years (range 0.7-11.6). One patient with CD was diagnosed with lymphoma 2.4 years after initial DBE. Changes in management were recommended in 6 patients: de-escalation of therapy (3, two underwent surgery), start thiopurine and/or biologic (2) and switch biologics (1). No complications were seen at follow-up DBE. DBE is a useful technique to confirm a diagnosis in patients who have suspected CD and can help establish a diagnosis of several diseases that may mimic CD on CT scan or CE. Additionally, DBE in patients with established diagnosis of small bowel CD is an effective tool to assess disease activity and guide therapy. Serious complications are infrequent.

Small-bowel imaging in Crohn's disease: a prospective, blinded, 4-way comparison trial

Assessment of small bowel mucosal healing by video capsule endoscopy for the prediction of short-term and long-term risk of Crohn's disease flare: a prospective cohort study

P190 Comparison of two endoscopic scores of inflammatory activity in small-bowel Crohn's disease and its correlation with clinical activity and biomarkers

Balloon by balloon, inch by inch

Utility of video capsule endoscopy for longitudinal monitoring of Crohn’s disease activity in the small bowel: a prospective study

The Lewis Score (LS) and Capsule Endoscopy Crohn's Disease Activity Index (CECDAI) are the two currently used small bowel capsule endoscopy (SBCE) scoring systems for Crohn's disease (CD). The present study describes a new scoring system for evaluation of small bowel CD, especially mucosal inflammation. In this cross-sectional study, 108 CD patients underwent 196 SBCEs. The small bowel lesions were scored using our new Crohn's Disease Activity in Capsule Endoscopy (CDACE). CDACE is the sum of scores for location of inflammation, range of inflammation, and stenosis, with a value ranging from 0 to 1643. We analyzed the relation between CDACE and LS, CECDAI, CDAI, and CRP values and evaluated the inter-rater reliability of CDACE using the intraclass correlation coefficient (ICC) (2.1). The mean (±SD) values of LS, CECDAI, and CDACE were 501 ± 1177, 5.8 ± 5.4 and 431 ± 356, respectively. CDACE correlated significantly with LS and CECDAI (ρ = 0.737, P < 0.0001 for LS and ρ = 0.915, P < 0.0001 for CECDAI). CDACE also correlated significantly with CDAI (ρ = 0.36) and CRP (ρ = 0.23). The ICC (2.1) was 0.829, indicating strong agreement among readers. CDACE is a potentially useful SBCE scoring system for small bowel CD, as it represents the extent and spread of small bowel mucosal inflammation and stenosis.

Relationships between the capsule endoscopy Lewis score (LS) and clinical disease activity indices and C-reactive protein (CRP) are controversial in adult patients with Crohn's disease (CD). Also, data on pediatric patients are relatively less. However, correlation between LS and small bowel transit time (SBTT) remains investigational. The aim of the present study was to explore the correlations between LS and clinical disease activity indices, CRP, SBTT in pediatric, and adult patients with small bowel CD.Retrospective, single-center study on consecutive inpatients with established small bowel CD was conducted. The clinical disease activity index was determined using the abbreviated Pediatric Crohn's Disease Activity Index (aPCDAI) in patients aged <18 years and the Harvey–Bradshaw Simple Index (HBI) in adults. Spearman's rank correlation coefficient was used to assess the correlations of LS with aPCDAI, HBI, CRP, and SBTT, respectively.150 patients were enrolled (30 children and adolescents). In pediatric patients, correlations between LS and aPCDAI, CRP were moderate (r1 = 0.413; r2 = 0.379; P1 = .023; P2 = .044). There was no correlation between LS and SBTT (r = –0.029; P = .88). In adults, weak correlations were found between LS and HBI, SBTT (r1 = 0.213; r2 = 0.237; P1 = .019; P2 = .009). Correlation between LS and CRP was moderate (r = 0.326; P < .001). Strong correlations were found between CRP and HBI, aPCDAI (r1 = 0.522; r2 = 0.650; P < .001). The follow-up patients were all in clinical remission after treatment within 4 months, whereas only a minority reached mucosal healing. HBI, aPCDAI, CRP, and LS in all patients were reduced after treatment, whereas difference in CRP in pediatric patients and difference in LS in adults between baseline and follow-up were not found to be statistically significant. Also, the average SBTT at baseline was not found to be different from that at follow-up in all patients.The role of capsule endoscopy should be emphasized both in pediatric and adult patients with small bowel CD. Furthermore, the small bowel transit time may not be affected by the grade of small intestinal inflammation.

<h3>Introduction</h3> Isolated small bowel Crohn’s disease (CD) is reported to have a worse prognosis compared to colonic CD. The aim of this study was to understand the correlation between Crohn’s phenotype with biomarkers to identify differences in outcome and management. <h3>Methods</h3> Patients with ileocolonic or isolated small bowel CD were identified from an existing capsule endoscopy (CE) database. Harvey Bradshaw Index (HBI), biomarkers- c-reactive protein (CRP) and Faecal calprotectin (FC) , findings on CE and subsequent follow up data were collected. SPSS was used to analyse the data. <h3>Results</h3> 196 patients with CD were included in this study (median age 42.4 years (17- 83 years ; SD 16.5). A new diagnosis of small bowel CD was made in 36.7%(n=72), whilst 63.3% (n=124) had established CD. Magnetic resonance imaging/MRI was abnormal in 43.8% only. Seventy seven percent (n=150) had isolated SB disease whilst 24% had ileocolonic disease (n=46) with corresponding higher HBI values (isolated ileal disease :HBI median 5 +/-4.1 vs ileocolonic disease 7 +/- 4.8 p=0.006). Faecal calprotectin (FC) levels did not differ between subgroups (102ug/g vs 171 ug/g, p=0.105). CE showed distal disease in 95.4% (n=187), proximal involvement in 35.2% (n=69) and extensive disease in 2.6%(n=5).The median Lewis score (LS) was 562(SD 1147). Patients with extensive disease had a higher LS than other groups (1050+/-1393 vs 450 +/-960; p=0.001) The correlation between CRP and LS on CE was significant (p=0.0001) as was HBI (p=0.002). In contrast FC correlated poorly with LS on CE (p=0.158). Patients were followed up for a median of 31 months ( range 1-68 months; SD 18) following their CE and management was altered in 67.3% (n=132) post CE. This included steroids in 52% (n=102), azathioprine (n=70, 35.7%) and methotrexate in 5.1% (n= 10) and commencement of biologics in 51.5% (n=101). HBI and CRP pre CE predicted a change in management (p=0.005 and 0.003 respectively) whilst FC did not (p=0.458) . Similarly, there was no corelation between the LS and histology taken at colonoscopy or subsequent enteroscopy (p= 0.611). Patients with isolated small bowel crohn’s disease were more likely to require biologic therapy compared to those with ileo- colonic disease (p= 0.007), however histological confirmation of terminal ileal disease had no impact on outcome (p=0.722). <h3>Conclusion</h3> CE is an important modality for the diagnosis of SB CD. CRP and HBI help predict patients who have active disease on CE. Patients with isolated SB CD on CE have a greater requirement for biological therapy.

Su1843 Lodged Foreign Bodies in the Small Bowel -Proceed to Surgery or Perform Double Balloon Enteroscopy First?

P234 High risk of leaving the workforce in US employees with ulcerative colitis

P233 How accurate are capsule endoscopy scoring systems in Crohn's disease?