Indeterminate colitis – The role of wireless capsule endoscopy: author's reply

Abstract

Sirs, The findings reported by Drs Viazis and Karamanolis are similar to those from a recent multicentre study by Maunoury in which five of 30 patients with indeterminate colitis were found via capsule endoscopy to have ≥3 ulcerations in the small bowel.1 In these two studies, the findings were interpreted as being diagnostic or suggestive of Crohn’s disease, but these conclusions may be inaccurate. The criterion of ≥3 small bowel ulcers found at capsule endoscopy as diagnostic of Crohn’s disease was introduced by Mow et al. who noted it was arbitrary.2 Indeed, multiple small bowel ulcers and erosions can be found in healthy controls, as demonstrated in a study by Goldstein et al.3 Among 462 healthy subjects who have abstained from non-steroidal anti-inflammatory drugs (NSAIDs) and alcohol for at least 2 weeks, capsule endoscopy revealed mucosal lesions in 14%. The 351 remaining subjects without small bowel lesions were randomized to receive an NSAID or placebo for 2 weeks and then another capsule endoscopy study was performed. Among the 118 who received placebo, 7% had mucosal breaks, defined as ulcers or erosions, and two of the subjects had three mucosal breaks.3 Thus, these two otherwise healthy individuals met the criterion for a diagnosis of Crohn’s disease, according to these recent studies using capsule endoscopy in patients with indeterminate colitis.1, 2 As noted by Bar-Meir, doctors should not make a diagnosis of Crohn’s disease based solely on the presence of a few small bowel erosions. Perhaps capsule endoscopy will find its place in the further assessment of indeterminate colitis when used in combination with positive serum and faecal markers of inflammation, but the positive predictive value is still too low for capsule endoscopy to be a standalone diagnostic test in this group of patients.