Crohn's Terminal Ileitis Research Articles

The Diagnostic Accuracy of Colon Capsule Endoscopy in Inflammatory Bowel Disease-A Systematic Review and Meta-Analysis.

Colon capsule endoscopy (CCE) has regained popularity for lower gastrointestinal investigations since the COVID-19 pandemic. While there have been systematic reviews and meta-analyses on colonic polyp detection using CCE, there is a lack of comprehensive evidence concerning colonic inflammation. Therefore, this systematic review and meta-analysis aimed to assess the diagnostic accuracy of CCE for colonic inflammation, predominantly ulcerative colitis (UC) and Crohn's disease (CD). Methods: We systematically searched electronic databases (EMBASE, MEDLINE, PubMed Central, and Cochrane Library) for studies comparing the diagnostic accuracy between CCE and optical endoscopy as the standard reference. A bivariate random effect model was used for the meta-analysis. Results: From 3797 publications, 23 studies involving 1353 patients were included. Nine studies focused on UC, and ten focused on CD. For UC, CCE showed a pooled sensitivity of 92% (95% CI, 88-95%), a specificity of 71% (95% CI, 35-92%), and an AUC of 0.93 (95% CI, 0.89-0.97). For CD, the pooled sensitivity was 92% (95% CI, 89-95%), and the specificity was 88% (95% CI, 84-92%), with an AUC of 0.87 (95% CI, 0.76-0.98). Overall, for inflammatory bowel disease, the pooled sensitivity, specificity, and AUC were 90% (95% CI, 85-93%), 76% (95% CI, 56-90%), and 0.92 (95% CI, 0.94-0.97), respectively. Conclusions: Despite the challenges around standardised disease scoring and the lack of histological confirmation, CCE performs well in diagnosing inflammatory bowel disease. It demonstrates high sensitivity in both UC and Crohn's terminal ileitis and colitis and high specificity in Crohn's disease. Further studies are needed to evaluate the diagnostic accuracy of other colonic inflammatory conditions.

Role of the Mesentery in Crohn's Terminal Ileitis.

Despite the longstanding awareness of the presence of mesenteric alterations in Crohn's disease, the functional and clinical consequences of these alterations remain a topic of debate. Guidelines advise a limited resection without resection of the adjacent mesentery to prevent short bowel syndrome and postoperative complications. However, recently mesenteric resection has been proposed as an alternative to reduce recurrence rates in Crohn's disease patients. Here, we evaluate the data available on this topic in terminal ileitis, both from a fundamental research point of view and clinical perspective.

Nodular lymphoid hyperplasia of terminal ileum: how to avoid overdiagnosis of Crohn's terminal ileitis in MR enterography?

To investigate the magnetic resonance enterography (MRE) characteristics of nodular lymphoid hyperplasia (NLH) and Crohn's terminal ileitis (CTI). Of 1552 MREs from November 2011 to July 2018, 61 individuals with biopsy-proven NLH (n = 24) and CTI (n = 37, 27 with active CTI) were selected based on the inclusion criteria. NLH cases were also followed up for median (range) of 40 (21-61) months. Two board-certified radiologists, blind to clinical data and diagnosis, reviewed MRE in consensus. Conventional, morphological, enhancement, and diffusion parameters were assessed. Mann-Whitney, χ2, and logistic regression analyses were conducted. No NLH patient developed inflammatory bowel disease or lymphoproliferative disorders during the follow-up. Serosal surface irregularity (65% vs. 8%), pseudo-diverticula (27% vs. 0), and mesenteric fat involvement (38% vs. 4%) were more frequent in CTI than NLH (p < 0.01), while mucosal nodularity was more prevalent in NLH (71%) than CTI (19%) (p < 0.001). The upstream luminal diameter (15.0 vs. 12.5mm, p = 0.015) and mural thickness (6.0 vs. 4.0mm, p < 0.001) of the terminal ileum showed higher values in CTI than NLH. Unlike enhancement and diffusion parameters, morphological features (mucosal nodularity, serosal surface irregularity, and mesenteric fat involvement) could distinguish NLH from CTI regardless of CTI activity.

Does laparoscopic intracorporeal ileocolic anastomosis decreases surgical site infection rate? A propensity score-matched cohort study.

Foreshortened mesentery or thick abdominal wall constitutes a rationale for laparoscopic intracorporeal ileocolic anastomoses (ICA). The aim of this study was to compare intracorporeal to extracorporeal ICA in terms of surgical site infections in patients with Crohn's ileitis and overweight patients with right colon tumors. This was a prospective propensity score-matched cohort study enrolling consecutive patients with Crohn's terminal ileitis and overweight patients with right colon tumors undergoing elective laparoscopic right colon resection with intracorporeal or extracorporeal ICA. Propensity score matching with a 1:1 ratio was employed to compare diagnosis-matched patients for age, BMI, ASA, and previous abdominal surgery. Overall, 453 patients were enrolled: 233 intracorporeal vs. 220 extracorporeal. Propensity score matching left 195 intracorporeal and 195 extracorporeal patients comparable for age (p = 0.294), gender (p = 0.683), ASA (p = 0.545), BMI (p = 0.079), previous abdominal surgery (p = 0.348), and diagnosis (p = 0.301). Conversion rates (5.1 vs. 3.6%; p = 0.457) and intraoperative complications (1 vs. 2.1%; p = 0.45) were similar. Overall morbidity (5.1 vs. 12.8%; p = 0.008) and re-intervention rates (3.1 vs. 8.7%; p = 0.029) were significantly higher in extracorporeal patients. Anastomotic leak rates (0.5 vs. 1.5%; p = 0.623) did not differ. Incisional SSI rate was significantly higher in extracorporeal patients (p = 0.01). Laparoscopic intracorporeal ICA reduced incisional SSI rates as compared to its extracorporeal counterpart.

Tu1239 Outcome of Early Surgery Versus Aggressive Medical Therapy in Patients With Newly Diagnosed Limited Inflammatory/Obstructive (A2/3L1B1/2) Terminal Ileitis: A Two-Year, Prospective, Single-Center, Pilot Study

Background: Data are scarce regarding the outcome of ‘curative' early surgery (ES) versus ‘aggressive medical therapy' [AMT, azathioprine (AZA) and anti-TNF biologics] for limited mixed inflammatory-obstructive Crohn's terminal ileitis (LMI/OTI). EST achieves removal of the affected segment and induces prolonged remission reserving immunosuppressives for patients at high-risk for post-operative recurrence. AMT can induce and maintain remission of CD but may be associated with serious adverse events and cannot guarantee long-term avoidance of surgery. Aim: To assess prospectively in a single-center pilot study the 2-year outcome of EST vs AMT in consecutive patients with LMI/OTI (phenotype A2/3L1Β1/2). Methods: Eligible were patients with newly diagnosed active (CDAI>180) LMI/OTI CD (despite treatment with 9mg/d budesonide for 6-8 weeks) and at high-risk for post-operative recurrence. LMI/OTI was defined as the combination of: a) raised inflammatory indices (leukocytes, platelets, CRP), b) involvement of ≤ 25cm terminal ileum, characterized by a narrow lumen, ulcerated but slightly distensible bowel wall with pre-stenotic dilatation although not purely stricturing disease at enteroclysis or MRI enterography, and c) inability to pass the colonoscope to the proximal unaffected ileum. After a thorough discussion, enrolled patients opted for AMT or EST (laparoscopic or open). EST patients received AZA (2.5mg/kg) for post-operative prophylaxis starting 14 days after surgery. AMT patients received standard doses of AZA and anti-TNF agents. Patients were followed for 2 years by physical examination and laboratory tests at bimonthly visits. Endoscopy was performed at 6, 12, and 24 months. Primary end-points were endoscopic remission (Rutgeerts score ≤1) for EST and avoidance of surgery for AMT. Results: Between 2007 and 2011, 17 patients [7M:10F, mean age 24(18-67) years, 12 smokers] consented to undergo EST and 17 patients [8M:9F, age 26(17-68) years, 13 smokers] received AMT. 2 years after EST, 3/17 (18%) patients had endoscopic recurrence and switched to biologics; 82% patients were in endoscopic remission. On AMT, 10/17 (59%) patients underwent surgery for complications (bowel obstruction and/or abscess, n=5), lack of efficacy (n=3) or adverse events to therapy (n=2); seven patients were in clinical remission (3 in deep remission). Conclusion: In this pilot study in consecutive CD patients selected by the A2/3L1B1/2 phenotype, EST appears to offer a better 2-year outcome than AMT. However, decisions should be taken on a caseto-case basis considering patient's age, life expectations, disease activity, relative degree of

Ileocecal Strictureplasty for Crohn’s Disease: Long‐Term Results and Comparison with Ileocecal Resection

The aim of the present study was to evaluate strictureplasty as the first choice for surgical treatment for Crohn's terminal ileitis. Between 1996 and 2000 we performed Finney-shaped ileocecal strictureplasty (ICS), doubling up the diseased terminal ileum, in 14 patients affected by Crohn's disease (group A). We compared the postoperative and long-term outcomes of these patients with those of 14 similar patients who underwent ileocecal resection with ileocolonic anastomosis during the same period (group B). No postoperative morbidity or mortality was recorded in group A, whereas two patients of group B had a pelvic hematoma and cholestatic hepatopathy, respectively. The mean hospital stay after surgery was 9.9days (range 7-13days) in group A and 7.4days (range 6-10days) in group B. After a median follow-up of 120months (range 103-147months), five patients of group A had a symptomatic recurrence: A stricture at the site of the ICS was present in four of them, but only one required surgery; symptoms were controlled by medical therapy in the other three. The fifth symptomatic patient was reoperated for multiple jejunoileal recurrence of the disease above the ICS. Group B patients have been followed for a mean of 108months (range 90-140months). Four of the patients had a preanastomotic recurrence, with subocclusive symptoms and mild malnutrition treated with medical therapy. Our results indicate that there are no significant differences between ICS and resection in terms of outcome and clinical relapse of Crohn's terminal ileitis.

Acute suppurative appendicitis

A case is presented of acute suppurative appendicitis occurring with Crohn's disease. The association is rare (only five other cases described), but if diagnostic uncertainty exists, laparotomy should be performed early. If, at laparotomy for suspected appendicitis, Crohn's terminal ileitis is incidentally found, the appendix should be removed.