Capsule Endoscopy In Crohn's Disease Research Articles

Correlation between different scoring indexes of capsule endoscopy and disease activity in Crohn's disease

Objective To investigate the correlation between capsule endoscopy Crohn's disease activity index (CECDAI), capsule endoscopy Lewis score, simplified Crohn's disease activity index (sCDAI), C reactive protein (CRP), erythrocyte sedimentation rate (ESR) and Crohn's disease (CD) activity. Methods From April 2009 to April 2014, 120 patients having received capsule endoscopy examination and diagnosed as CD were collected. The data of CRP and ESR were analyzed. The CD severity was scored by CECDAI, Lewis score and sCDAI. Spearman correlation was performed to analyze the correlation between CECDAI, Lewis score, sCDAI, CRP and ESR. Results Among all the patients, CECDAI had a good correlation with Lewis score (r=0.645, P 0.05). sCDAI had a good correlation with CRP and ESR (r=0.438 and 0.429, both P 0.05). Conclusions Lewis score, sCDAI, CRP and ESR can reflect disease activity of CD patients in a certain degree. CECDAI is the most suitable index in evaluating the disease activity of CD patients. Therefore, it is necessary to attach importance to capsule endoscopy examination. Key words: Crohn disease; CECDAI; Lewis score; SCDAI; C-reactive protein

Endoscopic Scores for Evaluation of Crohn's Disease Activity at Small Bowel Capsule Endoscopy: General Principles and Current Applications

The small bowel is affected in the vast majority of patients with Crohn's Disease (CD). Small bowel capsule endoscopy (SBCE) has a very high sensitivity for the detection of CD-related pathology, including early mucosal lesions and/or those located in the proximal segments of the small bowel, which is a major advantage when compared with other small bowel imaging modalities. The recent guidelines of European Society of Gastrointestinal Endoscopy (ESGE) and European Crohn's and Colitis Organisation (ECCO) advocate the use of validated endoscopic scoring indices for the classification of inflammatory activity in patients with CD undergoing SBCE, such as the Lewis Score or the Capsule Endoscopy Crohn's Disease Activity Index (CECDAI). These scores aim to standardize the description of lesions and capsule endoscopy reports, contributing to increase inter-observer agreement and enabling a stratification of the severity of the disease. On behalf of the Grupo de Estudos Português do Intestino Delgado (GEPID) – Portuguese Small Bowel Study Group, we aimed to summarize the general principles and clinical applications of current endoscopic scoring systems for SBCE in the setting of CD, covering the topic of suspected CD as well as the evaluation of disease extent (with potential prognostic and therapeutic impact), evaluation of mucosal healing in response to treatment and evaluation of post-surgical recurrence in patients with previously established diagnosis of CD.

Mo1578 Usefulness of Evaluating Small Intestinal Mucosa With Capsule Endoscopy in Clinically Inactive Crohn's Disease

In Japan, patency capsule (PC) was approved on July 2012. Using PC, Capsule Endoscopy (CE) enables non-invasive visualization of small intestine in Crohn's disease (CD). CD patients can be managed according to CE findings in addition to symptoms and laboratory findings. Aims: We aimed to examine the usefulness of evaluating small intestinal mucosa with CE in CD.

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.

Capsule Endoscopy (CE) Can Improve Outcomes in Crohnʼs Disease: An Evaluation of Pre- and Post-treatment CE

Purpose: Capsule endoscopy has been demonstrated to be superior to standard endoscopic and radiographic modalities in diagnosing small bowel Crohn's disease (CD), especially for subtle mucosal lesions. However, its utility in tracking treatment response via mucosal healing has not been fully established. The aim of this study is to assess small bowel mucosal healing based on the Capsule Endoscopy Crohn's Disease Activity Index (CECDAI, Dig Dis Sci (2008) 53:1933-27) after initiation or escalation of therapy.Table: Table. Change in CECDAI Pre- and Post-Treatment CEMethods: Retrospective review of CE in patients with suspected and known small bowel nonstricturing CD. CEs were read by two highly experienced readers who were not the managing IBD physicians at a tertiary referral center. Results: 2,190 capsule endoscopies were performed between October, 2001-October, 2012. One hundred fifty eight subjects underwent ≧ 2 capsule endoscopies during that time interval. Of those 158 subjects, 28 had known or suspected CD, for a total of 65 CE. Of those 28 subjects, 17 had known CD (60.7%), seven had suspected CD (25%), three had IBD-U (10.7%), and one had UC (3.6%). 7/11 (63.6%) with suspected CD or IBD-U were re-classified as CD and treated as such after pre-treatment CE. Indications for CE included abdominal pain (35%), extent of CD (20%), diarrhea (19%), growth failure (10%), anemia (8%), gastrointestinal bleed (4%), weight loss (2%), pouchitis (1%), and extraintestinal manifestations of CD (1%). The median age was 32 years old (range: 8-70), there were no capsule retentions, and 48/65 (73.8%) of capsules reached the cecum. The median time interval between pre- and post-treatment CE was 27 months (range: 1-81). CE results lead to escalation of therapy or switching of biologic agents in 15/28 (53.6%). There was a statistically significant difference in the CECDAI between the pre- and post-treatment CE (8.2 versus 4.1, p=0.0250.) However, there was no difference in pre- and post-treatment CRP (0.66 mg/dl vs 0.43 mg/dl, p=.21). Conclusion: CE was able to re-classify disease phenotype in >60% of those patients with suspected Crohn's disease or IBD-U, thereby potentially changing both the management and the natural outcome of small bowel Crohn's disease. More importantly, CE demonstrated mucosal healing in 70% of patients after escalation of therapy with a nonstricturing phenotype, positively changing disease outcomes and achieving a therapeutic goal. A prospective study is needed for confirmation. Disclosure - Neel K. Mann - Grant Support: Given Imaging.

Capsule endoscopy in the diagnosis of Crohn&amp;rsquo;s disease

Crohn’s disease is a chronic inflammatory disorder affecting any part of the gastrointestinal tract, but frequently involves the small and large bowel. Typical presenting symptoms include abdominal pain and diarrhea. Patients with this disorder may also have extraintestinal manifestations, including arthritis, uveitis, and skin lesions. The PillCam™SB capsule is an ingestible disposable video camera that transmits high quality images of the small intestinal mucosa. This enables the small intestine to be readily accessible to physicians investigating for the presence of small bowel disorders, such as Crohn’s disease. Four meta-analyses have demonstrated that capsule endoscopy identifies Crohn’s disease when other methods are not helpful. It should be noted that it is the best noninvasive procedure for assessing mucosal status, but is not superior to ileocolonoscopy, which remains the gold standard for assessment of ileocolonic disease. Mucosal healing along the small bowel can only be demonstrated by an endoscopic procedure such as capsule endoscopy. Achievement of long-term mucosal healing has been associated with a trend towards a decreased need for hospitalization and a decreased requirement for corticosteroid treatment in patients with Crohn’s disease. Recently, we have developed and validated the Capsule Endoscopy Crohn’s Disease Activity Index (also known as the Niv score) for Crohn’s disease of the small bowel. The next step is to expand our score to the colon, and to determine the role and benefit of a capsule endoscopy activity score in patients suffering from Crohn’s ileocolitis and/or colitis. This scoring system will also serve to improve our understanding of the impact of capsule endoscopy, and therefore treatment, on the immediate outcome of this disorder. As the best procedure available for assessing mucosal status, capsule endoscopy will provide important information about the course and outcome of Crohn’s disease.

When Crohn′s disease is in remission, more patients complete capsule endoscopy study but less lesions are identified

Background and Aims:Wireless capsule endoscopy (WCE) is used in Crohn's disease (CD) to define disease extent. We aimed to define WCE detection rate of small bowel ulcerative lesions and completion rate in CD patients.Patients and Methods:A total of 102 consecutive CD patients, who successfully passed patency capsule, were matched to 102 controls. WCE was performed in both patients (in acute phase and CD clinical remission) and controls.Results:Eighty-six (84%) controls versus 62 (61%) patients in the acute phase (P = 0.003) and 96 (94%) in remission (P = 0.02) completed WCE study. Gastric passing time was 48 ± 66 min in controls, 66 ± 82 min in CD acute phase (P = 0.03) and 30 ± 21 min in remission (P = 0.07). Small bowel passing time was 276 ± 78 min in controls, 299 ± 78 min in the acute phase of CD (P = 0.04) and 248 ± 89 min in remission (P = 0.01). Mean capsule endoscopy Crohn's disease activity index (CECDAI) score was 14 ± 6 in acute small bowel CD, 12 ± 7 in acute small-large bowel CD (P = 0.08) and 2 ± 2 in both CD types while in remission (P = 1.00). Small bowel ulcerative lesions in the acute phase were more frequently in distal small bowel. Aphthous ulcers were frequent a month after entering clinical remission and tend to disappear gradually later on. No ulcerative lesions were present in deep remission. Patency capsule is rather safe to exclude small bowel obstruction.Conclusions:(1) A high percentage of patients with active CD do not complete small bowel study with WCE. (2) Small bowel ulcerative lesions in clinical remission were less severe, although at least 6 months are needed in order for them to disappear.

Tu1258 Role of Capsule Endoscopy in the Evaluation of Different Segments of the Small Bowel in Crohn's Disease: Correlation of Clinical Parameters, Biomarkers, Endoscopy, and Lewis Score

INTRODUCTION: The recent paradigm shift of the treatment of Crohn's disease (CD) and the ability of capsule endoscopy (CE) to detect early lesions in the small bowel has highlighted its importance in CD. AIMS & METHODS: Classify inflammatory activity and evaluate the correlation of demographics, clinical parameters, biomarkers, and endoscopy with the Lewis score (LS) in each tertile in patients with CD submitted to CE. A transversal and multicentric study was carried out in which the LS was systematically determined in 87 CE of patients diagnosed with CD between 2003 and 2010. Laboratory workup was analyzed at the date of diagnosis and the date of CE, and endoscopic findings closest to the date of CE were registered. Correlations were calculated using the Pearson's test and stratified according to each tertile. RESULTS: Of the 87 patients included, 62% were female. According to the Montreal classification, most patients were diagnosed between the ages 17 and 40 years (A2, 74%), with ileo-colonic location (L3, 43%), and non-stricturing, non-penetrating phenotype (B1, 69%). During the first 6 months after diagnosis 61% of the patients required steroids, 16% were immunossupressed with azathioprine, and 6% needed anti-TNF therapy. Inflammatory activity was considered moderate/severe (LS>790) in 34% of patients. The frequency of involvement of the first 2 tertiles was 28% in patients with LS > 135. In the first tertilecorrelations were found between LS and sideropenia (p=0.001) and low levels of total serum proteins (p=0.004) at thedate of diagnosis, and serum albumin (p=0.039) and C-reactive protein levels at CE (p=0.033). There was a correlationbetween the LS and a high platelet count in the second tertile (p_diagnosis =790) in the first tertile was associated with lesions in the cecum and ascending colon (p=0.033), transverse colon (p=0.028), and rectum (p=0.002. CONCLUSION: The LS has a positive correlation with biomarkers and objectively characterizes small bowel involvement in CD. This is the first time that the LS was systematically evaluated and stratified according to the different tertiles in CD in which a correlation between the upper digestive tract disease and biomarkers and endoscopic findings was found, underlining the importance of CE in CD.

Tu1259 The Short Health Scale is a Quick and Reliable Measure of Health Status in English Speaking Patients With Ulcerative Colitis

INTRODUCTION: The recent paradigm shift of the treatment of Crohn's disease (CD) and the ability of capsule endoscopy (CE) to detect early lesions in the small bowel has highlighted its importance in CD. AIMS & METHODS: Classify inflammatory activity and evaluate the correlation of demographics, clinical parameters, biomarkers, and endoscopy with the Lewis score (LS) in each tertile in patients with CD submitted to CE. A transversal and multicentric study was carried out in which the LS was systematically determined in 87 CE of patients diagnosed with CD between 2003 and 2010. Laboratory workup was analyzed at the date of diagnosis and the date of CE, and endoscopic findings closest to the date of CE were registered. Correlations were calculated using the Pearson's test and stratified according to each tertile. RESULTS: Of the 87 patients included, 62% were female. According to the Montreal classification, most patients were diagnosed between the ages 17 and 40 years (A2, 74%), with ileo-colonic location (L3, 43%), and non-stricturing, non-penetrating phenotype (B1, 69%). During the first 6 months after diagnosis 61% of the patients required steroids, 16% were immunossupressed with azathioprine, and 6% needed anti-TNF therapy. Inflammatory activity was considered moderate/severe (LS>790) in 34% of patients. The frequency of involvement of the first 2 tertiles was 28% in patients with LS > 135. In the first tertilecorrelations were found between LS and sideropenia (p=0.001) and low levels of total serum proteins (p=0.004) at thedate of diagnosis, and serum albumin (p=0.039) and C-reactive protein levels at CE (p=0.033). There was a correlationbetween the LS and a high platelet count in the second tertile (p_diagnosis =790) in the first tertile was associated with lesions in the cecum and ascending colon (p=0.033), transverse colon (p=0.028), and rectum (p=0.002. CONCLUSION: The LS has a positive correlation with biomarkers and objectively characterizes small bowel involvement in CD. This is the first time that the LS was systematically evaluated and stratified according to the different tertiles in CD in which a correlation between the upper digestive tract disease and biomarkers and endoscopic findings was found, underlining the importance of CE in CD.

Validation of the Capsule Endoscopy Crohn’s Disease Activity Index (CECDAI or Niv score): a multicenter prospective study

The Capsule Endoscopy Crohn's Disease Activity Index (CECDAI or Niv score) was devised to measure mucosal disease activity using video capsule endoscopy (VCE). The aim of the current study was to prospectively validate the use of the scoring system in daily practice. This was a multicenter, double-blind, prospective, controlled study of VCE videos from 62 consecutive patients with isolated small-bowel Crohn's disease. The CECDAI was designed to evaluate three main parameters of Crohn's disease: inflammation (A), extent of disease (B), and stricture (C), in both the proximal and distal segments of the small bowel. The final score was calculated by adding the two segmental scores: CECDAI = ([A1 × B1] + C1) + ([A2 × B2] + C2). Each examiner in every site interpreted 6 - 10 videos and calculated the CECDAI. The de-identified CD-ROMs were then coded and sent to the principal investigator for CECDAI calculation. The cecum was reached in 72 % and 86 % of examinations, and proximal small-bowel involvement was found in 56 % and 62 % of the patients, according to the site investigators and principal investigator, respectively. Significant correlation was demonstrated between the calculation of the CECDAI by the individual site investigators and that performed by the principal investigator. Overall correlation between endoscopists from the different study centers was good, with r = 0.767 (range 0.717 - 0.985; Kappa 0.66; P < 0.001). There was no correlation between the CECDAI and the Crohn's Disease Activity Index or the Inflammatory Bowel Disease Quality of Life Questionnaire or any of their components. A new scoring system of mucosal injury in Crohn's disease of the small intestine, the CECDAI, was validated. Its use in controlled trials and/or regular follow-up of these patients is advocated.

Small bowel Crohn’s disease: MR enteroclysis and capsule endoscopy compared to balloon-assisted enteroscopy

New modalities are available to visualize the small bowel in patients with Crohn’s disease (CD). The aim of this study was to compare the diagnostic yield of magnetic resonance enteroclysis (MRE) and capsule endoscopy (CE) to balloon-assisted enteroscopy (BAE) in patients with suspected or established CD of the small bowel. Consecutive, consenting patients first underwent MRE followed by CE and BAE. Patients with high-grade stenosis at MRE did not undergo CE. Reference standard for small bowel CD activity was a combination of BAE and an expert panel consensus diagnosis. Analysis included 38 patients, 27 (71%) females, mean age 36 (20–74) years, with suspected (n = 20) or established (n = 18) small bowel CD: 16 (42%) were diagnosed with active CD, and 13 (34%) by MRE with suspected high-grade stenosis, who consequently did not undergo CE. The reference standard defined high-grade stenosis in 10 (26%) patients. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value of MRE and CE for small bowel CD activity were 73 and 57%, 90 and 89%, 88 and 67%, and 78 and 84%, respectively. CE was complicated by capsule retention in one patient. MRE has a higher sensitivity and PPV than CE in small bowel CD. The use of CE is considerably limited by the high prevalence of stenotic lesions in these patients.

Lewis Score Correlates More Closely with Fecal Calprotectin Than Capsule Endoscopy Crohn’s Disease Activity Index

Small-bowel capsule endoscopy (SBCE) is an invaluable imaging method for the small bowel. The Lewis score (LS) and the Capsule Endoscopy Crohn's Disease Activity Index (CECDAI) have been developed to standardize the reporting of small-bowel inflammation. Fecal calprotectin (FC) represents a highly reliable biomarker of intestinal inflammation. To assess the performance of the two SBCE inflammation scoring systems by correlating them with FC. Furthermore, to define threshold levels for CECDAI. Retrospective study; patients who underwent SBCE and had FC measurement shortly before or after SBCE. LS and CECDAI were calculated by a single reviewer and correlated [Spearman's (r ( s ))] with the FC results. Linear regression analysis was used to identify threshold levels for CECDAI. Forty-nine patients; three subgroups A, B and C (based on FC levels <100, 100-200, and ≥200 μg/g, respectively). LS appears to correlate with FC (r ( s ) = 0.448, p = 0.0014), unlike CECDAI, which does not demonstrate significant correlation (r ( s ) = 0.245, p = 0.089). Strongly positive correlation between FC and LS was observed in subgroup A (r ( s ) = 0.68, p = 0.0047), while in subgroups B and C, neither LS nor CECDAI showed correlation with FC. Significant correlation between LS and CECDAI was demonstrated (r ( s ) = 0. 6324, p < 0.0001). Linear regression analysis demonstrates that LS thresholds of 135 and 790 correspond with CECDAI levels of 3.8 and 5.8, respectively. LS performs better than CECDAI in describing small-bowel inflammation, especially at FC levels of <100 μg/g. Furthermore, CECDAI levels of 3.8 and 5.8 seem to correspond to LS thresholds of 135 and 790, respectively.

Small bowel video capsule endoscopy in Crohn’s disease: What have we learned in the last ten years?

Since its introduction in 2001, capsule endoscopy (CE) has become the most important advance in the study of small bowel disease, including Crohn's disease (CD). This technique has been demonstrated to be superior to all other current forms of radiological investigation in detecting mucosal abnormalities of small bowel nonstricturing CD. CE has proven to be extremely useful in diagnosing CD in patients with inconclusive findings from ileocolonoscopy and x-ray-based studies. Almost half of all patients with CD involving the ileum also present lesions in proximal intestinal segments, with the small bowel being exclusively involved in up to 30% of all CD cases. Despite the widespread use of CE, several questions concerning the utility of this technique remain unanswered. The lack of commonly agreed diagnostic criteria for defining CD lesions with the aid of CE may have had an influence on the variation in diagnostic results for CE reported in the literature. The utility of CE in monitoring CD and in guiding therapy has also been proposed. Furthermore, CE could be a useful second-line technique for patients with an established diagnosis of CD and unexplained symptoms. Finally, as no threshold for CD diagnosis has been agreed upon, a severity scale of mucosal disease activity has not been universally followed. None of the available activity indexes based on CE findings has been independently validated. This article discusses several cutting-edge aspects of the usefulness of CE in CD 10 years after its introduction as a sensible method to study the small intestine.

Value of a diagnostic criterion of capsule endoscopy for small bowel Crohn's disease

Objective To investigate the value of a diagnostic criterion of capsule endoscopy （CE） for small bowel Crohn＇s disease （CD）. Methods The clinical data of 50 patients with suspected CD who underwent CE from March 2003 to October 2008 were analyzed retrospectively. Diagnoses were made based on a criterion proposed by De Bona et al. Patients were grouped and followed up for 1 to 5 years. Results A total of 50 patients were enrolled and divided into 3 groups according to the results of CE. Group A includ- ed 25 patients as having small intestine CD on CE, in which 3 received surgery and was confirmed by pathol- ogy, and the other 22 got improved after treatments for CD. Group B was comprised of 15 patients who were clinically diagnosed as small intestinal CD and received experimental treatments, in which 13 patients im- proved and 2 others received surgery and were confirmed to be small intestine diverticula. Patients in group C （n = 10） were diagnosed as non-specific enteritis and received medication of Bifico and metronidazole for at least 3 months. All patients were followed up for 1 to 5 years and no recurrence was observed. Conclusion This diagnostic criterion of CE for small bowel CD enables early diagnosis of the disease. Key words: Diagnosis; Small intestinal Crohn＇s disease; Capsule endoscopy

Accuracy of the Patency Capsule to Exclude Small Bowel Strictures in Crohnʼs Disease: Is it Better to be Safe or Sorry?

Purpose: Capsule endoscopy (CE) is now a well established investigation for suspected Crohn's disease (CD). Its use in established CD has been limited, due in part to the relatively high risk (˜5%) of capsule retention. Barium radiography (SBFT) has not been found to be reliable to assure small bowel patency prior to CE in CD. The use of a patency capsule has thus been proposed as an alternate screening test for this purpose. Evacuation of the dummy capsule from the small bowel within a 30 h window indicates small bowel patency, whereas its retention beyond this time has been taken to imply a potential luminal stricture, contraindicating CE. The purpose of this study was to evaluate the clinical utility and safety of the patency capsule in established CD. Methods: Outcomes of consecutive CD cases referred for CE were reviewed before and after the systematic use of a patency capsule to screen for small bowel patency. Plain abdominal radiology (AxR) was used to localize the patency capsule 30 +/− 2 hr after ingestion. Results: Before the FDA approved introduction of the Agile patency capsule in 2006, we carried out small bowel CE in 31 CD patients without obstructive symptoms or any strictures seen on SBFT. Capsule retention occurred in 2 (6.7%) of these cases. Subsequently, 37 consecutive CD patients first underwent the patency capsule exam. Among these, 5 were denied CE because the patency capsule was localized to the small bowel radiologically 30 h after ingestion. Among the 32 others who underwent the CE exam, capsule retention occurred in 1 (3.2%) case. For the most recent 4 CD patients in whom the patency capsule position was deemed to be in the small bowel or its location was doubtful at 30 h, a second AxR was carried out at 48-60 h. In 3 of the latter, the repeat imaging showed that the patency capsule was eliminated intact from the small bowel. All 3 subsequently underwent a successful CE exam. CE was denied in the 1 remaining case with prolonged small bowel retention of the patency capsule. Conclusion: Subclinical intestinal stenoses are frequent in CD and conventional radiologic investigations have a low sensitivity for their detection. Use of a patency capsule use appears to reduce, but not completely eliminate the risk of capsule retention. However, the “safe” reliance on a 30 hour cut-off for patency capsule elimination from the small bowel may preclude a clinically worthwhile CE study. Further trials are required to validate the safety and clinical value of a delayed cut-off (˜48 hr) for intact patency capsule passage. Disclosure: Dr Ernest G Seidman- Consultant, member of Speaker's Bureau, and recipeint of research support from Given Imaging Inc. Given Imaging Inc. supplied a small number of patency capsules free of charge.

Assessment and Validation of the New Capsule Endoscopy Crohn’s Disease Activity Index (CECDAI)

Capsule endoscopy is a relatively new imaging tool for the detection of small bowel pathology. The assessment of the severity of Crohn's disease by capsule endoscopy is not standardized and is limited by interobserver variations in interpreting the findings. To develop, assess and validate a new, simple capsule endoscopy Crohn's disease activity index (CECDAI) in order to grade the severity of small bowel capsule endoscopy findings. The system involves dividing the small bowel into proximal and distal segments according to transit time and then rating each segment on the basis of three parameters: inflammation (A), extent of disease (B) and presence of strictures (C). The segmental score is calculated by multiplying the inflammation subscore by the disease-subextent score and adding the stricture subscore (A x B + C); the final score is calculated by adding the two segmental scores: CECDAI = (A1 x B1 + C1) + (A2 x B2 + C2). In the present study, four senior endoscopists (two with experience in capsule endoscopy interpretation) independently reviewed coded capsule endoscopy videos of 20 patients with Crohn's disease and rated them according to the CECDAI. Interobserver variability was analyzed by Spearman's correlation test. The CECDAI total scores for the 20 patients ranged from 0 to 26. The correlation for the total score assigned between every two observers was 0.867 (0.700-1.000 = strong degree association; WHO classification; P < 0.0001). The Kappa statistics for agreement among all observers for the subscores and total scores were as follows: A1, 0.31 +/- 0.05; B1, 0.25 +/- 0.05; C1 (no cases); A2, 0.51 +/- 0.05; B2, 0.57 +/- 0.05; C2, 0.27 +/- 0.07. All examiners reported that the system was simple to learn and apply. The CECDAI score may serve as a convenient, reliable and reproducible diagnostic and follow-up tool for use by experienced endoscopists in the evaluation of patients with Crohn's disease of the small bowel.

Role of capsule endoscopy in inflammatory bowel disease

Capsule endoscopy (CE) is an innovative technological breakthrough that for the first time provides a noninvasive method to obtain high-resolution imaging of the entire small bowel. Since its recent inception, the diagnostic utility of CE has become well established for the evaluation of diverse ulcerative and inflammatory disorders of the jejunum and ileum. The incredible resolution of its lens (0.1 mm) detects focal villous edema or atrophy, denuded, as well as ulcerated mucosal lesions missed by other imaging techniques. CE has been shown by meta-analysis to be a more sensitive method to investigate patients for small bowel Crohn's disease, with an incremental yield above 30% versus other imaging modalities. In patients with indeterminate colitis, CE is useful in distinguishing between ulcerative and Crohn's colitis. Among patients with established Crohn's disease, CE may be employed to determine: (1) the extent and severity of small bowel involvement, (2) postoperative recurrence, (3) post-therapy mucosal healing, and (4) whether active small bowel inflammatory lesions exist in the clinical setting of functional bowel disorder. Complications are rare and include capsule retention at stricture sites. The new patency capsule can diminish the risk of the latter problem in at-risk patients. CE can also serve as a guide to sites that require biopsies or dilatation by push or double-balloon enteroscopy. However, other causes of small bowel lesions may mimic Crohn's disease. A standard terminology system has thus been developed, and a CE Crohn's disease severity scoring index is currently undergoing validation studies.

The Risk of Retention of the Capsule Endoscope in Patients with Known or Suspected Crohn's Disease

Capsule endoscopy (CE) allows visualization of the mucosa of the entire small bowel and is therefore a potentially important tool in the evaluation of patients with known or suspected Crohn's disease (CD). However, small bowel strictures, which are not uncommon in Crohn's, are considered to be a contraindication to CE for fear of capsule retention. Our goal was to determine the risk of capsule retention in patients with suspected or known CD. We retrospectively reviewed the records of 983 CE cases performed at three private gastroenterology practices between December 2000 and December 2003, and selected those with suspected or proven Crohn's. A total of 102 cases were identified in which CE was used in patients with suspected (N = 64) or known (N = 38) CD. Only one of 64 patients (1.6%) with suspected CD had a retained capsule. However, in five of 38 (13%) patients with known Crohn's, the capsule was retained proximal to a stricture. Of the five cases of retained capsules, three strictures were previously unknown. In four cases, the obstructing lesions were resected without complications, leading to complete resolution of the patient's underlying symptoms. One patient chose not to undergo surgery and has remained without an episode of small bowel obstruction for over 38 months. Capsule retention occurred in 13% (95% CI 5.6%-28%) of patients with known CD, but only in 1.6% (95% CI 0.2%-10%) with suspected Crohn's. A retained capsule may indicate unsuspected strictures in Crohn's that may require an unexpected, but therapeutic, surgical intervention. Patients and physicians should be aware of these potential risks when using CE in CD.