Active Small Bowel Crohn's Disease Research Articles

Utility of panenteric capsule endoscopy for the detection of small-bowel Crohn's disease in patients with a normal magnetic resonance enterography: A prospective observational pilot study.

Capsule endoscopy allows the direct visualization of the small bowel. We examined the diagnostic utility of a new modality, namely panenteric Crohn's capsule endoscopy (CE), in detecting active small-bowel Crohn's disease (CD) in those with normal magnetic resonance enterography (MRE). We prospectively recruited patients with a diagnosis of CD or suspected small-bowel CD in whom the MRE was normal. Inclusion criteria included abdominal symptoms and abnormal serum or fecal biomarkers. The primary outcome was the detection of active small-bowel CD (measured through the Lewis score [LS]). Secondary outcomes included change in Montreal classification for those with a pre-existing CD diagnosis, change in medical therapy, clinical activity, and biomarkers at baseline and 6 months, and quality-of-life measures. A total of 22 patients with a diagnosis of CD or suspected new diagnosis were recruited, with CE complete to the caecum in 21 and 18/21 (86%) showing evidence of active small-bowel CD (LS > 135). Of the patients with a pre-existing diagnosis of CD, 9/11 (82%) had a change in Montreal classification. At 6 months following CE, 17/18 (94%) had clinician-directed change in therapy. This correlated with an improvement in the quality of life (P < 0.05 as per the Short Inflammatory Bowel Disease Questionnaire), a reduction in the Harvey Bradshaw index (median: 7-4, P < 0.001), and favorable CRP and albumin response. Crohn's CE is a useful diagnostic test for assessing active small-bowel CD when imaging is normal but clinical suspicion is high. Crohn's CE should be integrated into the diagnostic algorithm for small-bowel CD.

Comparison of gastrointestinal ultrasound with capsule endoscopy in patients with small bowel Crohn's disease

ObjectiveWe aimed to investigate the association between gastrointestinal ultrasound (GIUS) and capsule endoscopy (CE) in assessing disease activity in patients with small bowel Crohn's disease (CD).MethodsMedical records of 74 patients with small bowel CD who were treated at our hospital between January 2020 and March 2022 were retrospectively reviewed, including 50 men and 24 women. All patients underwent both GIUS and CE within one week after their admissions. The Simple Ultrasound Scoring of Crohn's Disease (SUS‐CD) and Lewis score were used to assess disease activity during GIUS and CE, respectively. P &lt; 0.05 was considered as statistically significant.ResultsThe area under the receiver operating characteristic curve (AUROC) of SUS‐CD was 0.90 (95% confidence interval [CI] 0.81–0.99; P &lt; 0.001). And the diagnostic accuracy of GIUS was 79.7%, with a sensitivity of 93.6%, a specificity of 81.8%, a positive predictive value of 96.7%, a negative predictive value of 69.2% in predicting active small bowel CD. Furthermore, the agreement between GIUS and CE was assessed using Spearman's correlation analysis and SUS‐CD was correlated with Lewis score (r = 0.82, P &lt; 0.001)ConclusionOur findings demonstrate a strong correlation between GIUS and CE in assessing the disease activity in patients with CD affecting the small intestine.

1559 Chronic Peri-Oral Dermatitis as the First Manifestations of Crohn's Disease

INTRODUCTION: Oral manifestations (OM) have been reported in crohn's disease (CD). The prevalence of these manifestations ranges between 0.5%-50% in adults and 10%-80% in pediatrics. OM of CD may coincide with the intestinal manifestations, or less commonly precede them. Aphthous ulcers, angular cheilitis, swelling of the lips and gingiva, cobblestoning of the mucosa, deep linear ulcers and periodontal disease have been reported in the literature. CASE DESCRIPTION/METHODS: An 18-year-old female with no significant history presented to her PCP with recurrent lip swelling and dryness. She was diagnosed initially with angioedema without urticaria. History of an environmental exposure was inconsistent and testing for hereditary angioedema, including C1 esterase and C4 levels were unremarkable. She was referred to a dermatologist who diagnosed her with peri-oral dermatitis. Treatment with antihistamines, topical steroids, antifungals, antibiotics and petroleum jelly were unsuccessful. She was treated with PO prednisone for a presumed pemphigus vulgaris with symptomatic improvement, but with relapse two weeks after weaning steroids. Due to chronicity of symptoms, a lip biopsy was done and showed a psoriasiform dermatitis with a granulomatous inflammation. Direct immunofluorescent testing was unremarkable. Results were concerning for CD versus cheilitis granulomatosa. She denied GI symptoms, weight loss or family history of IBD. Further testing revealed a normal ferritin, vitamin B12, folate, ANCA, and QuantiFERON-TB. She was referred to GI for further evaluation. An EGD showed a normal esophagus, stomach and examined duodenum. Biopsies from stomach and duodenum were unremarkable. A colonoscopy showed a normal perianal area, colon and terminal ileum. Biopsies from the left colon showed a focal active colitis, foci of neutrophilic cryptitis and focal epithelioid granuloma without dysplasia. Stains for acid fast bacilli and fungi were negative. Biopsies from the right colon and terminal ileum were unremarkable. MRE showed no evidence of active small bowel CD. Given the early onset and widespread distribution, the decision was to start adalimumab. Her OM improved significantly. A repeat colonoscopy with biopsies was unremarkable. DISCUSSION: The recognition of OM can play an important clue in diagnosis and management of CD, especially that an isolated oral disease is uncommon as a first presentation. Infections, nutritional deficiencies and medication side effects are important to consider as differential diagnosis.

A prospective 12-week mucosal healing assessment of small bowel Crohn’s disease as detected by capsule endoscopy

Mucosal healing is increasingly recognized as an important treatment goal in Crohn's disease (CD). Data from colonic disease shows improved long-term outcomes in patients achieving complete mucosal healing. Little is currently known of this with respect to ileitis, which is increasingly diagnosed using small bowel capsule endoscopy. The study aimed to prospectively assess mucosal healing and deep remission rates in a cohort of symptomatic small bowel CD patients commencing biologic or immunomodulator therapy. Baseline demographics, quality of life questionnaires and Harvey-Bradshaw index were collected along with C-reactive protein and calprotectin. Capsule endoscopy Crohn's disease activity (CECDAI) index was used to assess ileitis severity. All parameters were reassessed at week 12. Results at baseline and week 12 were compared using two-tailed Wilcoxon analysis, P value less than 0.05 was considered significant. In total, 43 patients of 71 screened underwent 80 small bowel capsule endoscopies. On the basis of the CECDAI, 39 (90%) demonstrated active small bowel CD at baseline with 37 (86%) undergoing 12-week assessment. Overall there was a statistically significant symptomatic and biochemical improvement at week 12. Furthermore, 10 (27%) had demonstrated a normalization in CECDAI (<3.5), which was statistically significant (P<0.0005, 95% confidence interval 0.12-0.15). However, no patient had achieved full mucosal healing. In patients with active small bowel CD early symptomatic and biochemical response to treatment is not mirrored by mucosal healing. Repeat mucosal healing assessment in this cohort is warranted following a longer duration of treatment to identify potential mucosal healing and deep remission rates.

A prospective 52 week mucosal healing assessment of small bowel Crohn's disease as detected by capsule endoscopy

BackgroundMucosal healing is increasingly recognised as an important treatment goal in Crohn's disease (CD). Data from colonic disease shows improved long-term outcomes in patients achieving complete mucosal healing. Little is currently known of this with regard to ileitis which is increasingly diagnosed using capsule endoscopy (SBCE). This is the first study to prospectively assess mucosal healing and deep remission rates following 52weeks of therapy in a cohort of symptomatic small bowel CD patients commencing immunomodulator or biologic therapy. MethodsBaseline demographics, quality of life questionnaires and Harvey Bradshaw Index were collected along with C-reactive protein & calprotectin. Capsule endoscopy Crohn's disease activity (CECDAI) index was used to assess ileitis severity. All parameters were reassessed at week 52. Results at baseline & week 52 were compared using univariate analysis, p < 0.05 considered significant. ResultsIn total, 108 capsule procedures were performed on 43 patients. Based on the CECDAI, 39 (90%) demonstrated active small bowel CD at baseline with 28 (65%) undergoing 52week assessment. In total, 12 (42%) participants achieved complete mucosal healing and deep remission by 52week assessment (p<0.0001 95% CI −0.62 to −0.22). Despite overall impressive mucosal healing rates, patients with strictures were less likely to demonstrate a decrease in CECDAI and were more likely to have symptoms. ConclusionIn patients with active small bowel CD symptomatic and biochemical response to treatment appears to be mirrored by endoscopic remission in 42% of individuals. Strictures identified prior to therapy appear to be a poor indicator for success of treatment.

Systematic review with meta-analysis: magnetic resonance enterography vs. computed tomography enterography for evaluating disease activity in small bowel Crohn's disease.

Magnetic resonance enterography (MRE) has been proposed as a non-ionising alternative method to computed tomography enterography (CTE). Some studies have directly compared CTE and MRE in patients with small bowel Crohn's disease (CD) with variable results. To compare the overall diagnostic accuracy in assessing the activity of small bowel and complications. MEDLINE, EMBASE and Cochrane databases were searched for studies on the accuracy of MRE and CTE, as compared with a pre-defined reference standard. Pooled sensitivity, specificity, the weighted area under the curve (AUC), incremental yield (IY) and other diagnostic indices were evaluated. A total of 290 CD patients from six different studies were analysed. The pooled sensitivity and specificity for MRE in detecting active small bowel CD was 87.9% [95% confidence interval (CI), 81.8-92.5] and 81.2% (95% CI: 71.9-88.4) respectively. The AUC under the summary receiver-operating characteristic (sROC) of MRE was 0.905 (SEM 0.03, standard error of the mean). Likewise, the pooled sensitivity and specificity of CTE in detecting active small bowel CD was 85.8% (95% CI: 79.2-90.9) and 83.6% (95% CI: 75.3-90.1) with the AUC of 0.898. The AUC of MRE in detecting fistula, stenosis and abscess was 0.936, 0.931 and 0.996, respectively, compared to 0.963, 0.616 and 0.899 of CTE. No statistically significant IY for MRE vs. CTE was found (fixed model, P > 0.05). Magnetic resonance enterography has a diagnostic effectiveness comparable to computed tomography enterography, thus may serve as a radiation-free alternative for evaluation of patients with Crohn's disease.

Obstructive Small Bowel Crohn's Disease in Balloon Enteroscopy

Crohn's disease (CD) is a lifelong, chronic inflammatory intestinal disorder that is characterized by episodes of inflammatory activity that may be followed by periods of clinical remission. Active small bowel CD may involve severe limitations of the patient, i.e., severe abdominal pain from intestinal stenosis, malnutrition from intestinal inflammation, anemia from chronic blood loss, and in some patients repeated bowel resections resulting in devastating short bowel syndrome.In this case report, a 32-year-old man with known CD was admitted to the emergency department with abdominal pain, constipation, nausea, and vomiting. Double-balloon enteroscopy was performed to investigate the small bowel, and isolated CD of the small intestine with several high-grade strictures was detected. This article is part of an expert video encyclopedia.

Crohn's disease affecting the small bowel is associated with reduced appetite and elevated levels of circulating gut peptides

Appetite disturbance is an important nutritional issue in Crohn's disease (CD), but the biological basis is unclear. Satiety signals such as polypeptide YY (PYY) and glucagon-like peptide-1 (GLP-1) are produced by enteroendocrine cells (EEC). In animal models, upregulation of EEC plays a mechanistic role in feeding disturbance and weight loss. We recently showed increased EEC activity in tissue from active small bowel CD. This study investigated EEC products in plasma in CD, and appetite-related symptoms. Active CD patients and a healthy reference group were studied. Gut peptide responses to a mixed nutrient test meal were measured by ELISA. Symptoms were assessed by visual analogue score. A patient subset was re-studied in remission. CD subjects displayed reduced appetite (p<0.0001) before and after eating. Total PYY was increased 2.2-fold (p=0.04) and correlated with nausea (p=0.036) and bloating (p=0.037) scores only in small bowel CD. Postprandial plasma ghrelin levels were also elevated. Leptin correlated with body mass index (p=0.0001) and weight loss (p=0.01). GLP-1 and GIP were not elevated. In remission, postprandial PYY and ghrelin reverted to control levels. Enhanced EEC responses may directly and adversely affect appetite in CD patients through increased gut-brain signalling.

Diagnostic accuracy of small intestine ultrasonography using an oral contrast agent in Crohn’s disease: Comparative study from the UK

To evaluate the usefulness of small intestine contrast-enhanced ultrasonography (SICUS) using an oral contrast agent in routine clinical practice by assessing the level of agreement with the established techniques, small bowel follow-through (SBFT) and computed tomography (CT), and diagnostic accuracy compared with the final diagnosis in the detection of small bowel Crohn's disease (CD) and luminal complications in a regional centre. All symptomatic known or suspected cases of CD who underwent SICUS were retrospectively reviewed. The level of agreement between SICUS and SBFT, CT, histological findings, and C-reactive protein (CRP) level was assessed using kappa (κ) coefficient. Sensitivity was demonstrated using the final diagnosis as the reference standard defined by the outcome of clinical assessment, follow-up, and results of investigations other than SICUS. One hundred and forty-three patients underwent SICUS of these 79 (55%) were female. Eighty-six (60%) were known to have CD and 57 (40%) had symptoms suggestive of intestinal disease with no previous diagnosis. Forty-six (55%) of the known CD patients had had at least one previous surgical resection. The sensitivity of SICUS in detecting active small bowel CD in known CD and undiagnosed cases was 93%. The kappa coefficient was 0.88 and 0.91 with SBFT and CT, respectively. SICUS detected nine patients who had one or more small bowel strictures and six patients with a fistula all detected by SBFT or CT. SICUS is not only comparable to SBFT and CT but avoids radiation exposure and should be more widely adopted in the UK as a primary diagnostic procedure and to monitor disease complications in patients with CD.

Diagnostic accuracies of MR enterography and CT enterography in symptomatic Crohn's disease

Objective. In patients, with symptomatic Crohn's disease (CD), valid information about the presence or absence of small bowel disease activity and stenosis is clinically important. Such information supports decisions about medical or surgical therapy and can be obtained with MR enterography (MRE) or CT enterography (CTE). Materials and methods. A total of 50 patients with symptomatic pre-existing CD and a demand for small bowel imaging to support changes in treatment strategy were included in this prospective and blinded study. MRE and CTE were performed on the same day in alternating order and subsequently compared with the gold standard: pre-defined lesions at ileoscopy (n = 30) or surgery with (n = 12) or without (n = 3) intra-operative enteroscopy. Results. A total of 35 patients had active small bowel CD (jejunum 0, ileum 1, (neo)-terminal ileum 34) and 20 had small bowel stenosis. The sensitivity and specificity of MRE for detection of small bowel CD was 74% and 80% compared to 83% and 70% with CTE (p ≥ 0.5). MRE and CTE detected small bowel stenosis with 55% and 70% sensitivities, respectively (p = 0.3) and 92% specificities. Conclusions. MRE and CTE have comparable diagnostic accuracies for detection of small bowel CD and stenosis. In symptomatic patients with CD and high disease prevalence, positive predictive values are favorable but negative predictive values are low. Consequently, MRE and CTE can be relied upon, if a positive result is obtained whereas a negative enterography should be interpreted with caution.

Enteroendocrine cells and appetite dysregulation in Crohn's disease

IntroductionLoss of appetite and malnutrition in active Crohn's disease (CD) are important problems. The biological mechanisms underpinning appetite loss are unclear. Enteroendocrine cells (EEC) form a pivotal part of the...

Dipeptidyl peptidase IV expression in a cellular and human model of intestinal inflammation

IntroductionDipeptidyl peptidase IV (DP IV) is a serine protease. It modulates the physiological activity of satiety inducing hormones such as glucagon like peptide 1 (GLP-1) and polypeptide YY (PYY). It...

Detection of Small Bowel Inflammation Characteristic of Crohnʼs Disease in Spondyloarthropathy by Capsule Endoscopy Compared to Ileocolonoscopy: Preliminary Results of the Space Study

Purpose: Spondyloarthropathies (SpA) are associated with clinical IBD in 10-15% of cases. A higher percentage of SpA patients have subclinical gut inflammation, documented by endoscopic, serologic, or histologic findings. HLA B27 seems to be less present in SpA-IBD association than in idiopathic SpA, but there is evidence for the association between gut inflammation in SpA and Crohn's disease (CD) related CARD 15 mutations. Capsule endoscopy (CE) has a higher detection rate for small bowel (SB) inflammation, compared to ileo-colonoscopy (IC) and imaging modalities. The aim is to determine the prevalence of IBD in SpA patients, comparing CE and IC. Methods: To date 15 (10 M) of 80 projected SpA patients (all HLA B27+), with (n=12) or without (n=3) digestive symptoms underwent SB CE, followed by IC and biomarkers (CRP, Hgb). Their age range was 22-63 years. CE was scored by the Lewis index (Gralnek, et al. Aliment Pharmacol Ther 2008). IC was performed blinded to CE results. Results: CE revealed findings consistent with active SB CD in 8 cases (53.3%). IC was positive in 50% of the CD cases to date, and in none of the 7 cases with normal CE. The sensitivity, specificity, positive and negative predictive values of the CRP were: 57%, 71.4%, 66.7%, and 62.5%. Values for Hgb were: 14.3%, 84.6%, 33.3% and 71.4%, respectively. Conclusion: These preliminary results show that CE of the SB is superior to IC in detecting CD in patients with known SpA. Neither the CRP nor Hgb appear to be reliable screening tests for the co-existence of these inflammatory disorders. Serological and genetic marker analyses are pending, in order to determine their predictive value in a larger cohort in this ongoing study. Disclosure: Dr Seidman is a consultant and a member of the speakers' bureau for Given Imaging Inc and for Abbott Laboratories (Canada). Abbott Laboratories provided financial support for this study. Given Imaging provided support in kind (capsules).

Validation of a lower radiation computed tomography enterography imaging protocol to detect Crohnʼs disease in the small bowel

The purpose was to validate a lower radiation dose computed tomography enterography (CTE) imaging protocol to detect the presence of Crohn's disease (CD) in the small bowel using two different reference standards and to identify a prediction model based on CTE signs for the presence of active CD. This retrospective study included patients with known or suspected CD who underwent CTE between January and October 2006 according to a lower radiation dose protocol. Two gastrointestinal radiologists blindly and independently classified each CTE as being active or inactive. Reference standards included ileocolonoscopy ± biopsy and a comprehensive clinical reference standard (retrospectively created by a gastroenterologist, also including history, physical, follow-up course, and subsequent endoscopy, imaging, or surgery). Logistic regression was used to identify CTE findings that predicted the presence of active CD based on the combined clinical reference standard. In all, 137 patients underwent CTE and ileocolonoscopy. Using an endoscopic reference standard, the sensitivity of CTE to detect active CD for the two readers was 81% and 89%, respectively. Using the clinical reference standard, the sensitivity of CTE to detect active CD was 89% and 98%, respectively. For both readers the sensitivity of CTE increased by 8%-9% when using the comprehensive reference standard. Multivariate analysis showed that a combination of mural thickness and hyperenhancement best predicted active CD (area under the curve [AUC] = 0.92-0.93, P < 0.0001). Lower radiation dose CTE exams are sensitive for the detection of active small bowel CD. The combination of mural thickness and hyperenhancement are the best radiologic predictors of active CD.

Quality, clinical influence and tolerance of computed tomography enteroclysis in patients with suspected small bowel disease

Computed tomography enteroclysis (CTE) may be superior to other small bowel imaging techniques, detecting subtle mucosal lesions and extraluminal pathology. This study aimed to define the technical success, clinical influence and tolerance of CTE in patients with suspected small bowel disease. CTE scans of 42 consecutive patients (aged 21-78 years, 12 men) were reviewed by a single radiologist for technical adequacy and diagnosis. A panel of gastroenterologists reviewed clinical information. At a telephone interview, tolerance of CTE was graded numerically from 1 (unbearable) to 10 (excellent) and descriptively as unbearable, fair, good or excellent. Good or optimal distension of small bowel was achieved in 98%. The entire small bowel was imaged in 88%. Eighteen patients had a normal small bowel, whereas 12 (29%) had active small bowel Crohn disease, 4 intussusception, 3 small bowel diverticula and 7 having other diagnoses. Mesenteric lymphadenopathy was evident in 11 and fat stranding in 5. CTE resulted in a new or altered diagnosis in 13 (31%) patients and identified more extensive Crohn disease in a further 8 (19%). A change in management plan was instituted in 18 (43%) patients, with subsequent clinically significant improvement in 12. 33 (85%) described the procedure as 'fair' or 'unbearable' rather than 'good' or 'excellent'. The median tolerance score was 3 out of 10. CTE provided high-quality images in nearly all patients and had an effect on diagnosis, management or outcome in most, but was not well tolerated.

Double-balloon enteroscopy in Crohn’s disease patients suspected of small bowel activity: findings and clinical impact

It is estimated that 10-30% of patients with Crohn's disease (CD) have small bowel (SB) involvement, but the exact frequency and clinical relevance of these findings is unknown. Double-balloon enteroscopy (DBE) enables endoscopic visualization of the SB. In this study we evaluated whether DBE is a feasible technique for detection of CD localized in the SB in CD patients with clinical suspicion of SB lesions and whether these findings have clinical impact. Retrospectively we analyzed 52 DBE procedures in 40 CD patients (16 males, mean age 40 years, mean duration of CD 15 years). Included patients had clinical suspicion of small bowel CD activity, including persistent abdominal discomfort (n = 27), iron deficiency anemia (n = 9) and/or hypomagnesemia (n = 4). Active small bowel CD was found in 24 (60%) patients, leading to a change in therapy in 18 patients (75%). After a mean follow-up of 13 months, 15 (83%) had persistent clinical improvement with a significant drop of mean CDAI from 178 to 90, after a mean follow-up of 13 months. DBE is a useful diagnostic tool for the evaluation of SB lesions in CD patients. The significance of these findings is emphasized by the fact that adjustment of therapy in the majority of these patients leads to significant and sustained clinical improvement.

Combining two imaging techniques is best to diagnose small-bowel Crohn's disease

In most patients with Crohn's disease, diagnostic gastrointestinal lesions are located in the small bowel, which is not easily accessible to direct investigation. This commentary focuses on an article by Solem et al., which compared the utility of four primary small-bowel imaging modalities (CT enterography, ileocolonoscopy, capsule endoscopy, and small-bowel follow-through) in diagnosis of active small-bowel Crohn's disease. Capsule endoscopy had lower diagnostic specificity than the other techniques. This result, in conjunction with the need to perform preliminary small-bowel radiography to detect asymptomatic, partial, small-bowel obstructions, makes capsule endoscopy a poor choice as a first-line test for Crohn's disease. We concur with Solem et al.'s opinion that a combination of two of the other available imaging methods is the best diagnostic option for small-bowel Crohn's disease, although the choice of which two to use should be based on the facilities and expertise that are available locally.

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

With the introduction of new techniques to image the small bowel, there remains uncertainty about their role for diagnosing Crohn's disease. To assess the sensitivity and specificity of capsule endoscopy (CE), CT enterography (CTE), ileocolonoscopy, and small-bowel follow-through (SBFT) in the diagnosis of small bowel Crohn's disease. Prospective, blinded trial. Inflammatory bowel disease clinic at an academic medical center. Known or suspected Crohn's disease. Exclusion criteria included known abdominal abscess and non-steroidal anti-inflammatory drug (NSAID) use. Partial small-bowel obstruction (PSBO) at CTE excluded patients from subsequent CE. Patients underwent all 4 tests over a 4-day period. Sensitivity, specificity, and accuracy of each test to detect active small-bowel Crohn's disease. The criterion standard was a consensus diagnosis based upon clinical presentation and all 4 studies. Forty-one CTE examinations were performed. Seven patients (17%) had an asymptomatic PSBO. Forty patients underwent colonoscopy, 38 had SBFT studies, and 28 had CE examinations. Small-bowel Crohn's disease was active in 51%, absent in 42%, inactive in 5%, and suspicious in 2% of patients. The sensitivity of CE for detecting active small-bowel Crohn's disease was 83%, not significantly higher than CTE (83%), ileocolonoscopy (74%), or SBFT (65%). However, the specificity of CE (53%) was significantly lower than the other tests (P < .05). One patient developed a transient PSBO due to CE, but no patients had retained capsules. Use of a consensus clinical diagnosis as the criterion standard-but this is how Crohn's disease is diagnosed in practice. The sensitivity of CE for active small-bowel Crohn's disease was not significantly different from CTE, ileocolonoscopy, or SBFT. However, lower specificity and the need for preceding small-bowel radiography (due to the high frequency of asymptomatic PSBO) may limit the utility of CE as a first-line test for Crohn's disease.

Utility of Wireless Capsule Enteroscopy (WCE) in Evaluating Crohn's Disease Patients with Abdominal Symptoms

WCE is a new diagnostic modality for patients with suspected or known Crohn's disease (CD). Aim: To determine the frequency of small bowel (SB) disease and the distribution of SB lesions detected by WCE among symptomatic patients with known CD. Methods: Data of all established CD patients who underwent WCE between October 2001 and February of 2004 for symptoms suggestive of active disease were retrospectively reviewed. Symptoms included abdominal pain, gastrointestinal bleeding, diarrhea, and weight loss. All images were reviewed by a single experienced endoscopist and were analyzed with respect to type and location of SB lesions. The finding of multiple ulcerations (>3) on WCE was classified as active small bowel CD. The presence of ≤3 ulcerations was considered suggestive of active CD. Results: Ninety-seven WCE were performed on 88 symptomatic patients with documented CD. Forty-eight of 96 (50%) patients had findings diagnostic of active CD, and 10 (10%) patients had findings suggestive of active CD. Thirty-three (34%) patients had normal findings. Forty-four of 96 (46%) procedures showed lesions in more than one region of the SB. 23%, 34%, 42%, and 51% of the lesions were in the duodenum, jejunum, proximal ileum, and distal ileum, respectively. Only 5 cases showed lesions in the duodenum, jejunum, or proximal ileum without lesions in the distal ileum (Fisher's Exact p < 0.0001). The capsule reached the cecum in 64 of 96 (67%) procedures and showed active colonic ulcerations in 18 cases. Twenty-two patients had colonoscopy data within 90 days (mean 30 days) of WCE. While 55% had disease findings on WCE, only one patient (5%) had a single aphthous ulcer on colonoscopy. In 32 cases a small bowel follow through (SBFT) had been performed within 90 days of the WCE procedure (mean 30 days). WCE was superior to SBFT in detecting active Crohn's lesions (p = 0.05). Conclusion: WCE identified active SB lesions in half of CD patients experiencing abdominal symptoms. A surprisingly large number of lesions were seen in the more proximal parts of the SB, but they rarely existed in the absence of distal ileal lesions. Our limited data suggests that colonoscopy added little value to assess active disease in symptomatic patients. Therefore, WCE may be the preferred modality in evaluating CD patients presenting with symptoms. Prospective studies are needed to assess the utility of WCE as the primary tool for evaluating patients with symptomatic CD.

Intestinal permeability in children with Crohn's disease and coeliac disease.

Mannitol and lactulose were used as probe molecules to measure intestinal permeability in children with active small-bowel Crohn's disease and with untreated coeliac disease. Mannitol and lactulose were administered by mouth in a moderately hypertonic solution (580 mmol (mosmol)/l), and results were expressed as the ratio of the molecules excreted in urine over five hours. Patients with Crohn's disease had a sixfold increase in permeability (due to increased lactulose permeability) and those with coeliac disease a fivefold increase (due to decreased mannitol permeability). From these results the test offers potential as a noninvasive investigation in children with small-bowel disease.