Active Small Bowel Crohn 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.

Mucosal Healing and Clinical Efficacy of Adalimumab in Small Intestinal Crohn's Disease (SIMCHA Study): Final Results From a Prospective, Open-Label, Single-Arm Study.

Endoscopic healing is a key treatment target in inflammatory bowel disease; few data are available on the clinical and endoscopic efficacy of biological therapy in upper gastrointestinal Crohn's disease. This study aimed to investigate small bowel mucosal healing and clinical efficacy of adalimumab therapy by video capsule endoscopy in patients with endoscopically active upper gastrointestinal Crohn's disease. This prospective, open-label, single-arm study included Crohn's disease patients with moderate-severe endoscopic proximal small bowel involvement, defined by a Lewis score >790. Patients were treated with adalimumab monotherapy for 24 weeks. Co-primary outcomes were endoscopic healing, defined as Lewis score <350, and endoscopic response, defined as >50% decrease in Lewis score. Secondary outcomes included clinical (Harvey-Bradshaw index <4) and biomarker remission (fecal calprotectin <250 μg/g, and C-reactive protein <5 mg/L). A total of 59 Crohn's disease patients were screened; 17 patients have met eligibility criteria and were enrolled. Endoscopic healing was observed in 8 patients (47.1%) and endoscopic response in additional 5 patients (29.4%) at 24 weeks. Median Lewis score was significantly decreased compared to baseline (1912 vs. 337, P = .0005). Eleven of 13 patients (84.6%) with clinical activity achieved clinical remission (baseline: 13/17 vs. week 24: 2/17, P < .0001). Nine of 10 patients with elevated C-reactive protein achieved normal C-reactive protein after treatment and the median C-reactive protein significantly decreased from 7.4 to 1.6 mg/L, P = .032. In contrast, no change was observed in fecal calprotectin pre- and posttreatment. Adalimumab induced endoscopic healing and clinical remission in patients with active small bowel Crohn's disease, with approximately half of the patients achieving endoscopic healing.

Efficacy of biosimilar infliximab CT-P13 among inpatients with severe steroid-refractory colitis.

In this study, we evaluate the efficacy and safety of the biosimilar infliximab, CT-P13, in the treatment of inpatients with severe steroid-refractory colitis. A retrospective cohort study of adult colitis patients (UC or isolated Crohn's colitis) admitted to the University of Chicago inflammatory bowel disease inpatient service between January 2018 and December 2018 for management of severe colitis refractory to IV steroids who received CT-P13 were included in the study. Patients diagnosed with active small bowel Crohn's disease were excluded. CT-P13 was given as a single infusion of 5 to 10 mg/kg. A comprehensive review of their electronic medical records was performed, and demographic, clinical, laboratory, and endoscopic data were extracted. The primary endpoint was colectomy-free survival. Twenty-one patients with severe steroid-resistant colitis were included. Twelve patients had ulcerative colitis, seven patients had a diagnosis of indeterminate colitis, and two patients had a diagnosis of Crohn's colitis. The median age was 32.2 years. The median disease duration was 4.3 years, and the median follow-up time was 5.9 months. Patients had a median CRP of 23. All patients had moderate to severe disease on endoscopy. Colectomy-free survival was 76% at 3 months and 70% at 6 months. No severe adverse events were reported in this patient cohort. A significant proportion of patients with severe colitis failing IV steroids responded to induction therapy with CT-P13. Colectomy-free survival rates were similar to previous randomized trials using originator infliximab as induction therapy in severe steroid-refractory colitis.

P441 Efficacy of biosimilar infliximab CT-P13 among inpatients with severe steroid-refractory colitis

Abstract Background The infliximab biosimilar CT-P13 has been reported to have similar clinical effect compared with its originator. In this study, we evaluated the efficacy and safety of CT-P13 in the treatment of inpatients with severe steroid-refractory colitis. Methods Adult colitis patients (UC or isolated Crohn’s colitis; Montreal classification E2-3, or L3, respectively) admitted to the University of Chicago IBD inpatient service between January 2018 and December 2018 for management of severe colitis refractory to IV steroids who received CT-P13 were included in the study. Patients diagnosed with active small bowel Crohn’s disease were excluded. CT-P13 was given as a single or several infusions of 5 to 10 mg/kg. For all patients, demographic, clinical, laboratory, and endoscopic data were attained by a comprehensive review of their electronic medical records. The primary endpoint was colectomy-free survival. Results Twenty-one patients, 14 with ulcerative colitis and seven with Crohn’s colitis, were included. Fourteen (66%) of patients were female. The median age was 32.2 years (IQR 24.1–43.2). The median disease duration was 4.3 years (IQR 2–10.3), and the median follow-up time was 5.9 months (IQR 1.8–9.1). Patients had a median CRP of 23 (IQR 6–74). All patients had moderate to severe disease on flexible sigmoidoscopy. Three patients (14%) underwent colectomy during their index hospitalisation. Colectomy free survival was 76% at three months and 70% at six months (Figure 1). No severe adverse events were reported in this patient cohort. Conclusion A significant proportion of patients with severe colitis failing IV steroids responded to induction therapy with CT-P13. Colectomy free survival rates were similar to previous randomised trials using originator infliximab as induction therapy in severe steroid-refractory colitis. CT-P13 was effective and safe in hospitalised patients with severe steroid-refractory colitis.

P029 ACCURACY OF FECAL CALPROTECTIN IN DETECTING SMALL BOWEL CROHN’S DISEASE: A META-ANALYSIS AND SYSTEMATIC REVIEW

Identifying active small bowel Crohn’s Disease (CD) is often challenging due various reasons. The location of Crohn’s disease and often the disease process itself make direct visualization difficult. Fecal calprotectin (FCP) is a well-established marker of mucosal inflammation. Several studies have confirmed FCP’s utility in colonic inflammation; however, the diagnostic accuracy in active small bowel inflammation had yet to be established. The aim of the present study is to update the previous meta-analysis of FCP and its diagnostic accuracy in detecting active small bowel Crohn’s disease. A comprehensive search was performed using PubMed/OVID studies. Studies from 2010 until 2018 addressing patients with suspected or known CD and evaluated with noninvasive testing with FCP and confirming disease with video capsule endoscopy or imaging were included. Studies in which a 2 X 2 table with true positives, false negatives, false positives and true negative values could be constructed were included. Meta-analysis for the diagnostic accuracy of fecal calprotectin in diagnosing active small bowel CD was performed by calculating pooled estimates of sensitivity, specificity, likelihood rations, and diagnostic odds ratios. Pooling was conducted by both fixed and random effects models. Data was extracted from 17 studies which met the inclusion criteria. In CD patients, pooled sensitivity of fecal calprotectin was 76.50% (95% CI: 73.00 – 79.00) in diagnosing small bowel Crohn’s disease. Fecal calprotectin had a pooled specificity of 71.10% (95% CI: 68.00 – 73.00) for detecting active small bowel Crohn’s disease. The diagnostic odds ratio, of having active small bowel disease with elevated FCP was 12.28 (95% CI: 6.55 – 23.01). The positive likelihood ratio of FCP was 3.093 (95% CI: 2.16 – 4.41), and the negative likelihood ratio was 0.30 (95% CI: 0.21 – 0.43). Fecal calprotectin has moderate diagnostic accuracy for detecting active small bowel CD. Our results suggest a fecal calprotectin of at least 50 µg/g has moderate sensitivity and specificity. These values are proportional to the fecal calprotectin level.

PWE-016 Faecal Calprotectin Has an Acceptable Sensitivity for Detecting Small Bowel Crohn’s Disease: Results from Real World Clinical Practice: Abstract PWE-016 Table 1

Introduction Faecal calprotectin ‘FC’ is a quick, non-invasive and inexpensive test proven to correlate well with colonic inflammation. It is used in our institution to also exclude active small bowel Crohn’s disease ‘CD’ although its reliability in such cases has recently been questioned. Using a higher cut-off FC value may exclude active disease in those with known inflammatory bowel disease with a higher specificity and reduce the number of false positives. 1,2 The aim of this study was to assess whether FC compared to gold standard magnetic resonance enterography ‘MRE’ can reliably be used in small bowel CD as a screening tool to select those needing further investigation. Methods Data from all CD patients who had undergone MRE to assess for active small bowel CD between January 2012 to November 2015 were reviewed. Patients with a known or new diagnosis of ileal or ileo-caecal crohn’s (Montreal classification L1 phenotype) or ileo-colonic crohn’s (L3 phenotype) with endoscopic and histologically-proven quiescent colonic disease were included. Data was analysed using Mann-Whitney U testing. Results 194 MREs were performed for investigation of possible small bowel CD during the study period. 64 patients were included for analysis; L1 disease = 90.6% (58 patients), L3 = 9.4% (6 patients). 50% were female. The median age was 48 years (range 17–76 years). Median time between FC and MRE was 30 days (range 0–180 days). 35 patients (54.7%) were Montreal disease behaviour B1, 24 patients (37.5%) with B2 and 5 patients (7.8%) with B3. 4 patients (6%) had peri-anal involvement. 26 patients (41%) had previous Crohn’s-related resectional surgery. 39 patients (60.9%) had evidence of active small bowel CD at MRE. The median FC in the active CD group was 246 mg/kg (IQR 556) and 49 mg/kg for the inactive small bowel disease group (IQR 177.5); p Table 1 shows results for sensitivity, specificity, positive predictive value ‘PPV’ and negative predictive value ‘NPV’ of different FC cut-off values in detecting any degree of small bowel activity at MRE. Conclusion In this study we compared FC results to MRE to exclude or confirm active small bowel CD in real-world clinical practice. This data demonstrates that by using a cut-off value of 50 mg/kg, an acceptable sensitivity for detecting active small bowel CD is achievable. However, at this cut-off value, specificity is low; nevertheless using FC will still reduce demand for MRE. References 1 F. Fasci-Spurio, A. Chiappini, V. Buonocore, S. Cannizzaro, Z. Maddalena, F. Maccioni, P. Vernia. (2014) Faecal calprotectin concentrations in Crohn’s patients with ileal disease location: correlations with disease activity as seen by MRI enterography. European Crohn’s and Colitis Organisation . 2 MF Hale, K Drew, ME McAlindon, AJ Lobo, R Sidhu. (2015). PTU-054 Faecal calprotectin in patients with suspected small bowel crohn’s disease: correlation with small bowel capsule endoscopy. Gut 2015 ;64:A83. doi:10.1136/gutjnl-2015-309861.169 Disclosure of Interest None Declared

PWE-060 Capsule Endoscopy in The Investigation and Management of Small Bowel Crohn’s Disease

Introduction Capsule endoscopy (CE) is increasingly being used to visualise the small intestine in patients with known or suspected Crohn’s disease. The aim of this study was to review the use of CE for this purpose over a two year period in a medium sized DGH following the creation of a new CE service. Methods Electronic records of all patients undergoing CE between 1 st April 2013 and 31 st March 2015 were reviewed. Patients who underwent the procedure to investigate for possible small bowel Crohn’s disease (based on clinical, biochemical and/or endoscopic suspicion) or to assess previously diagnosed Crohn’s disease we identified. Record was also made of contemporaneous faecal calprotectin results and ileal appearances at colonoscopy. Results Twenty-four patients underwent CE to investigate possible small bowel Crohn’s disease. Of these, 11 (46%) had CE findings supportive of Crohn’s disease. 5 of these 11 patients had contemporaneous faecal calprotectin measurement of which 4 (80%) were positive. Eight of these 11 patients had contemporaneous ileal intubation of which 7 (88%) showed evidence of ileitis. Of the 13 patients with normal CE findings, 8 had faecal calprotectin measurement of which only 1 (12%) was positive. Eleven of the 13 patients had contemporaneous ileal intubation of which 4 (36%) showed mild ileitis. Ten patients underwent CE to assess known small bowel Crohn’s disease. CE was normal in 4 cases and showed evidence of active small bowel Crohn’s in 6 cases. Of the 4 patients with normal CE findings, 2 had faecal calprotectin measurement of which both were normal and 3 had ileal intubation which showed no evidence of inflammation in all cases. Of the 6 patients with CE findings suggestive of active small bowel Crohn’s, 5 had faecal calprotectin measurement of which 4 (80%) were normal and all 6 had ileal intubation which showed ileitis in 4 (67%). Conclusion In patients with suspected small bowel Crohn’s disease CE findings supported this diagnosis in nearly half of patients and CE findings correlated well with faecal calprotectin measurement and ileal appearances at colonoscopy. However, in patients undergoing CE to assess known small bowel Crohn’s, CE showed active disease in 57% of patients with normal faecal calprotectin measurement although there was better correlation between CE findings and ileal appearances at colonoscopy. This suggests that CE is an informative test in both the investigation and ongoing management of small bowel Crohn’s disease, and may be a more sensitive test of small bowel Crohn’s disease than faecal calprotectin. Disclosure of Interest None Declared

Multiple sclerosis in the context of TNF blockade and inflammatory bowel disease

In August 1999, a 26-year-old Caucasian woman presented with abdominal pain, diarrhoea and weight loss. Active small bowel Crohn's disease (CD) was diagnosed on barium follow-through and confirmed histologically following ileal resection in October 1999. Subsequent radiological and endoscopic investigations demonstrated extensive small bowel and foregut involvement with stricturing disease. Despite treatment with 6-mercaptopurine (6-MP) (1.25 mg/kg/day) and corticosteroids, control of disease activity was suboptimal and four further laparotomies were required. (or stricturoplasties and adhesiolysis). Between January and July 2004, she had received four infliximab (Remicade®, Schering-Plough) (5 mg/kg) infusions with limited efficacy. In June 2007 the humanized anti-tumour necrosis factor (TNF) agent, adalimumab (Humira®, Abbott Ltd.), was commenced (80 mg loading dose, then 40 mg every second week) with good clinical effect. In October 2007, she presented with ‘pins and needles’ affecting the fingertips of her left hand and the right side of her face. These symptoms evolved over 2 weeks to include parasthesias affecting her left arm and intermittent diplopia. Her left hand became clumsy and her left leg weak. In addition to adalimumab she was also treated with mercaptopurine, ketamine, gabapentin, esomeprazole, folic acid and loperamide. Her mother suffered from rheumatoid arthritis. Clinical examination revealed bilateral internuclear ophthalmoplegia with associated horizontal nystagmus. There was reduced sensation to light touch and pin prick in the left upper and lower limbs. There was mild pyramidal weakness on the left arm and leg with finger–nose ataxia, predominantly right-sided. Reflexes were brisk throughout and there was an upgoing left plantar response. She was afebrile and demonstrated no signs of sepsis. Haematological and biochemical parameters including full blood count, renal and thyroid function, vitamin B12, folate and C reactive protein were normal. Rheumatoid factor, anti-nuclear and anti-neutrophil cytoplasmic antibodies were negative. MRI scanning of the central nervous system (CNS) demonstrated a number of white matter lesions …

Impact of capsule endoscopy on management in patients with established crohn's disease-experience from a single tertiary centre

IntroductionCapsule endoscopy (CE) has developed a pertinent role in the management of patients with Crohn's disease, however there is a paucity of literature assessing the long term impact of CE....

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.

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.

Strictureplasty for active Crohn's disease

Several studies over the last 20 years have confirmed the safety and efficacy of strictureplasty in the treatment of obstructive Crohn's disease. However, almost all of these studies use strictureplasty to treat fibrotic strictures: limited resection being preferred to treat active disease strictures. One study dating from 1986 used strictureplasty to treat purely active disease strictures, with disappointing results. No other similar studies have been published. We investigate the complication and recrudescence rates together with the intervention-free intervals in patients undergoing strictureplasty for active disease strictures. A retrospective review of 14 patients who underwent strictureplasty either in isolation or in combination with limited resection for active small bowel Crohn's disease between 1996 and 2004 was undertaken. A total of 73 strictureplasties were carried out. There was no operative mortality; however, one patient subsequently died from metastatic small bowel adenocarcinoma arising from existing Crohn's disease. One patient subsequently developed complications directly attributed to strictureplasty and required further surgery. Three patients developed recrudescent disease and required further surgery in the form of either strictureplasty, limited resection or both. All patients undergoing strictureplasty with resection and over 70% of patients undergoing strictureplasty alone were intervention-free at 41 months. With extended follow-up, the same proportion of patients would remain intervention-free at 70 months or longer. The use of strictureplasty in active disease strictures is well tolerated and has similar, if not better, recurrence and complication rates when compared with limited resection in patients with similar disease profiles.

Polymeric nutrition as the primary therapy in children with small bowel Crohn's disease.

Recent studies in adults have shown that polymeric (whole protein) diets are as effective as semi-elemental and elemental formulae for the induction of remission in small bowel Crohn's disease. Whole protein diets are more palatable and cheaper. There have been no studies confirming efficacy in children. We report our experience with seven children with active small bowel Crohn's disease given a casein-based, polymeric feed rich in TGF-beta 2 (Specific Polymeric Diet; Nestle-Clintec; Vevey, Switzerland) as complete nutrition for 8 weeks. Initial and follow-up assessments were performed. All children showed a significant improvement in disease activity, with C-reactive protein returning to normal, an increase in serum albumin and a good weight gain. Initial and follow-up ileal biopsies were assessed and showed reduced mucosal inflammation in six of seven children, with complete healing in two. In an uncontrolled descriptive study we have shown that a polymeric (whole protein) diet is a therapeutic option for small bowel Crohn's disease in children. By comprehensive follow-up we have demonstrated clinical and biochemical remission, with an improved endoscopic appearance and a reduction of mucosal inflammation in the terminal ileum.

Postheparin plasma diamine oxidase values in the follow up of patients with small bowel Crohn's disease.

Measurement of postheparin plasma diamine oxidase (PHD) activity has been proposed to assess mucosal integrity in several diseases of the small intestine. In Crohn's disease, PHD values identify a group of patients with predominantly small bowel mucosal damage. To determine the role of mucosal involvement in the progression of small bowel Crohn's disease and whether different PHD values can predict different outcomes the changes in PHD values in 41 patients with small bowel Crohn's disease admitted consecutively to our department were investigated. The test was performed during periods of active disease and after either medical or surgical treatment had resulted in improvement. PHD values were significantly lower than in normal subjects (normal range 3.7-7.7 U/ml). In 35 patients with active disease (Crohn's disease activity index (CDAI) greater than 150) two groups were identified by choosing a cut off value of 2 U/ml: 93% of the 15 patients with PHD values lower than 2 U/ml (mean (SD) 1.36 (0.46) U/ml) relapsed at least once in the following year, while only the 20% of the 20 whose values were higher than 2 U/ml (mean (SD) 3.69 (1.50)) relapsed in the same period. The data were statistically significant (Yates's corrected chi 2 = 15.63; p less than 0.0001). The positive and negative predictive values of the test were 93% and 80%, respectively. During relapses, PHD values were consistently lower than previous values, and increased significantly after effective medical or surgical treatment. In the six patients in whom there were no changes in disease activity (CDAI persistently less than 150), there was no change in PHD values. This test may be useful for identifying Crohn's disease patients who are likely to relapse. Furthermore, the data indicate that mucosal damage is common in active small bowel Crohn's disease and improves at least in part after treatment.

Improvement of abnormal lactulose/rhamnose permeability in active Crohn's disease of the small bowel by an elemental diet.

Intestinal permeability to sugar has been used as an objective measure of small bowel integrity to assess the efficacy of an elemental diet as the sole treatment or Crohn's disease of the small bowel. Fourteen children aged 11-17 years with active small bowel Crohn's disease were given an elemental diet for six weeks. Investigations with iso-osmolar oral test solutions before and after this treatment showed that all 14 children had abnormally raised lactulose/L-rhamnose permeability ratios, which fell significantly after the elemental diet. This change coincided with marked clinical improvement, as assessed by a disease activity index score.

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.