Established Crohn's Disease Research Articles

P032 Clinical Usefulness of Double Balloon Enteroscopy in Patients With Established or Suspected Small Bowel Crohn's Disease.

The diagnosis of isolated small bowel Crohn's disease (CD) can be challenging. Symptoms are non-specific and both imaging and capsule endoscopy (CE) may be misleading as several diseases may mimic CD. Double balloon enteroscopy (DBE) allows a more extensive endoscopic and histologic evaluation of the small bowel. Our aim was to describe the diagnostic utility and impact of DBE on management of patients with known CD and in patients with suspected/rule-out CD. Retrospective review of our institution's DBE database from February 2009 to May 2013. Adult patients referred for DBE for further evaluation of known or suspected CD (due to symptoms, abnormal imaging and/or CE) were included. Patient demographics, clinical characteristics, imaging and CE results, prior DBE, indication for DBE, DBE findings, DBE adverse events, pathology findings, final diagnosis, treatment prior and post DBE and follow-up DBE were abstracted from the electronic medical record. A total of 108 patients were included, 61 (56%) females, mean age 52 years (range 20-83). Indications for DBE included: disease activity assessment/therapeutic in 10 patients with established diagnosis of CD and for diagnostic purposes in 98 patients with suspected CD (31 patients due to abnormal imaging, 29 due to abnormal CE and 26 due to both abnormal imaging and CE). Upper, lower, bidirectional upper and lower, and stomal DBE were performed in 21, 24, 62 and 1 patients, respectively. DBE revealed active disease in 8/10 patients with known CD with one patient undergoing dilation of a stricture. Changes in management were recommended for all patients with active disease - start thiopurine (2), optimize thiopurine dose (1), start biologics (3) change biologics (1), systemic steroids (1) and budesonide (1). The patient who underwent stricture dilation ultimately required surgery. A definitive diagnosis of CD (both endoscopic and histologic) was reached in only 39/98 (40%) patients who were referred for suspected CD. Changes in management were recommended in 32/39 (82%) patients. Interestingly, 24/98 patients had been diagnosed with CD at outside institutions and were recommended to initiate therapy for CD. Of these, CD was confirmed in only 15/24 (63%) patients. Adverse events included perforation in 1 patient (1%) who required surgical management and mouth swelling/abrasion in 3 patients (3%). Follow-up DBE to re-assess disease activity was performed in 10/49 (20%) patients with definitive diagnosis of CD, average time between procedures 4.5 years (range 0.7-11.6). One patient with CD was diagnosed with lymphoma 2.4 years after initial DBE. Changes in management were recommended in 6 patients: de-escalation of therapy (3, two underwent surgery), start thiopurine and/or biologic (2) and switch biologics (1). No complications were seen at follow-up DBE. DBE is a useful technique to confirm a diagnosis in patients who have suspected CD and can help establish a diagnosis of several diseases that may mimic CD on CT scan or CE. Additionally, DBE in patients with established diagnosis of small bowel CD is an effective tool to assess disease activity and guide therapy. Serious complications are infrequent.

Does capsule endoscopy impact clinical management in established Crohn's disease?

BackgroundCapsule endoscopy (SBCE) has developed a relevant role in patients with established Crohn's Disease (CD). However, evaluation of the impact in clinical management has been scarce. AimsTo evaluate therapeutic impact of SBCE in an 11-year real-life cohort of known CD patients. MethodsRetrospective single center study including all patients with established CD submitted to SBCE procedure from 01/01/2008 to 31/12/2019. Patency capsule was used in selected patients. Small bowel mucosal inflammation was quantified using Lewis score. Therapeutic impact was defined as a change in CD-related treatment recommended based on SBCE results. Patients were assigned to four groups regarding SBCE indication: staging, flare, post-op and remission. ResultsFrom the 432 SBCE performed 87.5% were conclusive. Active disease was present in 63.7 of patients; 41.6% mild inflammation and 21.9% moderate-to-severe activity. A change of management was guided by SBCE in 51.3% of procedures: 199 (46.1%) escalation and 23 (5.3%) de-escalation, with significant changes in all groups. Escalation increased with disease activity: 57.8% in mild and 89.5% in moderate-to-severe disease. De-escalation was conducted in 13.9% procedures with mucosal healing and 1.1% with mild disease. ConclusionSBCE is a useful tool for guiding therapeutic management in CD patients both for treatment escalation and de-escalation.

Tag-less patency capsule for suspected small bowel stenosis: Nationwide multicenter prospective study in Japan.

The PillCam patency capsule (PPC) is an Agile tag-less patency capsule used to evaluate gastrointestinal (GI) patency. We determined the appropriate use of PPC to preclude subsequent small bowel capsule endoscopy (SBCE) retention. This prospective multicenter study consecutively enrolled patients indicated for SBCE with suspected or established small bowel stenosis. Excretion of an intact PPC or its radiologic visualization in the large bowel was considered GI patency. Primary and secondary study endpoints were SBCE retention rates in patients with confirmed patency and identification of factors associated with patency and SBCE retention, respectively. Of 1096 patients enrolled in the study, patency was confirmed in 976 (89.1%). PPC excretion occurred in 579 patients. Of the remaining 517 patients, patency was confirmed using imaging modalities in 401 (77.5%). SBCE retention occurred in five (0.51%) of 963 patients who underwent SBCE: 1.0% in established Crohn's disease (CD) patients, 0% in suspected CD, 0% in tumors, and 1.6% in patients with obscure GI bleeding, for which PPC localization had been radiographically misinterpreted. The non-confirmation of patency was associated with established CD, stenosis identified using imaging modalities, abdominal fullness, serum albumin levels <4.0g/dL, and previous small bowel obstruction (adjusted odds ratios: 4.21, 2.60, 2.47, 2.12, and 2.00; 95% confidence intervals: 2.62-6.78, 1.62-4.17, 1.43-4.27, 1.32-3.40, and 1.15-3.47, respectively). The PillCam™ patency capsule helped preclude SBCE retention in most patients, but its accurate localization was essential for cases without excretion (Study registered the University Hospital Medical Information Network, #UMIN000010513).

Restoration of Maxillary Arch Using Smooth Surface Dental Implants in a Case of Aggressive Periodontitis with Established Crohn's Disease: A Special Case File

Restoration of Maxillary Arch Using Smooth Surface Dental Implants in a Case of Aggressive Periodontitis with Established Crohn's Disease: A Special Case File

Capsule Retention in Crohn's Disease: A Meta-analysis.

The main factor that limits wider utilization of capsule endoscopy (CE) in Crohn's disease (CD) is the potential risk of retention. The aim of this systematic review was to evaluate capsule retention rates in adult and pediatric CD and determine if retention risk is reduced in established CD (ECD) with patency capsule (PC) or magnetic resonance/computed tomography (MR/CT) enterography. Studies of CD patients undergoing CE that reported retention were identified. Pooled estimates for retention rates and relative risk in ECD to suspected CD (SCD) were calculated. All hypothesis tests were 2-sided; statistical significance was set at a P value of <0.05. In the overall CD cohort, retention rates were 3.32% (95% confidence interval [CI], 2.62%-4.2%): 4.63% (95% CI, 3.42%-6.25%) and 2.35% (95% CI, 1.31%-4.19%) in ECD and SCD, respectively. Retention rates were 3.49% (95% CI, 2.73%-4.46%) and 1.64% (95% CI, 0.68%-3.89%) in adult and pediatric CD, respectively. Retention risk in adult ECD was 3.4 times higher than SCD, but there was no difference in retention risk in pediatric ECD compared with SCD. Retention rates in ECD were decreased after patency capsule (2.88%; 95% CI, 1.74%-4.74%) and MR/CT enterography (2.32%; 95% CI, 0.87%-6.03%). In comparison with older literature, this meta-analysis demonstrates lower CE retention rates in SCD and ECD. Retention rates in pediatric CD were lower than in adult CD. Retention rates in adult ECD were higher than SCD, but there were no differences between pediatric ECD and SCD. Retention rates in ECD were lower after negative PC or MR/CT enterography.

The role of small bowel endoscopy for Crohn's disease.

The review discusses the roles of small bowel capsule endoscopy and deep enteroscopy in patients with Crohn's disease. It highlights recent advances in the field and identifies areas where evidence is lacking. Small bowel capsule endoscopy has an important role in the follow-up of patients with Crohn's disease after escalation of therapy and in the postoperative assessment period following surgical resection. Device-assisted enteroscopy offers the therapeutic advantage of small bowel dilatation, which may result in a reduction in the number of surgical resections required, thus avoiding long-term complications, such as short bowel syndrome and malabsorption. Capsule endoscopy has an established role in the diagnosis and management of small bowel Crohn's disease. It is used in the setting of suspected Crohn's disease when ileocolonoscopy is negative and for the assessment of extent of small bowel disease in established Crohn's disease. It is relatively well tolerated because of the provision of patency capsule endoscopy to minimize the risk of inadvertent capsule retention. Device-assisted enteroscopy aids with the diagnosis of Crohn's disease as it enables histology to be taken from inflamed areas within the small bowel. Therapeutic procedures can be carried out during device-assisted enteroscopy including dilatation of Crohn's disease-related strictures and retrieval of retained capsules.

Correlation of the endoscopic findings for small and large bowels in pediatric patients with established Crohn's disease.

Small bowel capsule endoscopy can detect subtle mucosal lesions in pediatric patients with Crohn’s disease, and our aim was to evaluate its application in established ileocolonic Crohn’s disease. Colonic inflammation was evaluated with the colonic Simple Endoscopic Score for Crohn’s Disease (SES-CD) (excluding the score of the terminal ileum). Small bowel inflammation was evaluated with the Lewis score and/or Capsule Endoscopy Crohn’s Disease Activity Index (CECDAI). A Lewis score <135 was defined as small bowel inactive. A colonic SES-CD of 0 (colonic inactive group) was observed in 22/42 procedures (52.4%), and active small bowel lesions were observed in 11/22 procedures (50.0%). The Lewis score was lower in the colonic inactive group compared to the colonic active group. Correlations between the colonic SES-CD, the Lewis score and CECDAI were weak. The Lewis score and CECDAI in the colonic inactive group had significant correlation with fecal calprotectin levels. We suggest that Crohn’s disease patients without both colonic active lesions and elevation of fecal calprotectin levels may not need to receive small bowel capsule endoscopy due to low incidence of lesions in small bowel.

Su1221 Fecal Calprotectin Correlates With Small Bowel Inflammatory Activity Detected by Capsule Endoscopy in Patients With Established Crohn's Disease

Su1221 Fecal Calprotectin Correlates With Small Bowel Inflammatory Activity Detected by Capsule Endoscopy in Patients With Established Crohn's Disease

1076 A Simple, Validated Ultrasonographic Score for the Detection of Inflammation in Established Crohn's Disease

1076 A Simple, Validated Ultrasonographic Score for the Detection of Inflammation in Established Crohn's Disease

Video Capsule Endoscopy of the Small Bowel for Monitoring of Crohn's Disease.

Video capsule endoscopy has revolutionized our ability to visualize the small bowel mucosa. This modality is a valuable tool for the diagnosis of suspected small bowel Crohn's disease, and it is increasingly used for the monitoring of disease activity in patients with established small bowel Crohn's. The purpose of the current article was to review the literature pertaining to the utilization of capsule endoscopy in established Crohn's disease, for monitoring of mucosal healing, postoperative recurrence, disease classification, and other indications.

Contrast-Enhanced Cross Sectional Imaging and Capsule Endoscopy: New Perspectives for a Whole Picture of the Small Bowel

Small bowel evaluation is a challenging task and has been revolutionized by high-quality contrasted sectional imaging (CT enterography - CTE) and magnetic resonance enterography (MRE) as well as by small bowel capsule endoscopy (SBCE).The decision of which technique to employ during the investigation of small bowel diseases is not always simple or straightforward. Moreover, contraindications may preclude the use of these techniques in some patients, and although they are noninvasive procedures, may present with various complications.SBCE plays a crucial role in the investigation of both obscure gastrointestinal bleeding and Crohn's disease, but it is also useful for surveillance of patients with Peutz-Jeghers syndrome, while CTE is very accurate in small bowel tumours and in established Crohn's Disease, and its use in patients presenting with gastrointestinal bleeding is increasing. MRE, an expensive and not widely available technique, is essential for the study of patients with Crohn's Disease, and presents an attractive alternative to SBCE in Peutz-Jeghers syndrome surveillance.These diagnostic modalities are often not competitive but synergistic techniques. Knowing their characteristics, strengths and limitations, indications, contraindications and potential complications, as well as the adaptation to local availability and expertise, is essential to better select which procedures to perform in each patient, both safely and effectively, in order to optimize management and improve patient outcomes.

Mo1577 Predictive Model of Small Bowel Disease Detected in Capsule Endoscopy in Patients With Established Crohn's Disease

Introduction: The role of Capsule Endoscopy (CE) in patients with established Crohn's Disease (CD) is not fully determined. Identification of predictive factors of small bowel disease may help the selection of patients that could benefit from CE. Aims and Methods: Evaluate whether clinical parameters, biomarkers, laboratory and endoscopic findings correlate with the presence of small bowel lesions in patients with CD. A transversal and multicentric study was carried out including patients with CD submitted to CE between 2003 and 2013. Data was analyzed using Pearson Chi-Square, Fischer's exact test, Mann-Whitney, Kruskal-Wallis and logistic regression as appropriate. Lewis score was calculated in all procedures. Results: One hundred and ninety patients with established CD were included, being 57% female. According to Montreal classification, 75% had diagnosis between 17 and 40 years-old (A2), 43% had ileal disease (L1) and the majority (75%) had non-stricturing non-penetrating disease (B1). Hemoglobin levels were significantly lower (p=0.006) in patients with higher Lewis score (>790) comparing with those with lower scores, although those differences were clinically insignificant (median 13.1 vs 13.9 g/dL). Similarly, albumin was lower (41 vs 45 mg/dL, p<0.001) and C-Reactive Protein was higher (7.65 vs 3.40 mg/L, p<0.001) in patients with Lewis score higher than 790. The presence of small bowel disease diagnosed by CE was significantly related with the need of steroids in the first 6 months after diagnosis (OR 3.088; CI 95% 1.3207.223), the presence of ileal disease at colonoscopy (OR 4.680; CI 95% 1.969-11.123) and history of weight loss (OR 2.763; CI 95% 1.205-6.335). Albumin levels were inversely related to the presence of small bowel disease (OR 0.843; CI 95% 0.761-0.934). Multivariate logistic regression showed that albumin levels (OR 0.745; CI 95% 0.616-0.901) and ileal disease (OR 13.369; CI 95% 2.287-78.163) were independently related to small bowel disease (AUROC=0.806 (0.7120.900), with a sensitivity and specificity of 79% with a cutoff of 0.77). Disease behaviour, early need of azathioprine or biologics, C-reactive protein levels, hemoglobin, abdominal pain and diarrhea were not predictive of small bowel disease. Conclusion: Predictive factors for small bowel disease diagnosed at CE in patients with CD include early need of steroids, ileal disease at colonoscopy, weight loss and lower albumin levels. Regarding those with positive findings at CE, lower hemoglobin and albumin levels and higher C-reactive protein were related with more serious disease. This data may help the selection of patients with CD in which CE could be more useful.

336 PAtency Capsule in Patients With Established Crohn's Disease Undergoing Videocapsule Endoscopy of the Small Bowel

Video capsule endoscopy (VCE) is invaluable in diagnosis of small bowel (SB) pathology. Capsule retention is a major concern in patients with Crohn's disease (CD). Patency capsule (PC) was designed to evaluate SB patency before VCE but, the actual benefit of PC in CD is unclear. The aim of this study was to evaluate the clinical impact of PC administration on capsule retention risk in patients with established CD.

Su1184 Small Bowel Imaging in Crohn's Disease: Measuring the True Accuracy of Proximal and Distal Small Intestinal Disease Activity Using Total Enteroscopy in Patients With Established and Suspected Crohn's Disease

Su1184 Small Bowel Imaging in Crohn's Disease: Measuring the True Accuracy of Proximal and Distal Small Intestinal Disease Activity Using Total Enteroscopy in Patients With Established and Suspected Crohn's Disease

Tu1149 Clinical Impact and Safety of Capsule Endoscopy in Patients With Established Crohn's Disease -A Multicenter Cross-Sectional Study

readers using the MaRIA index and CDEIS, respectively. A MaRIA subsegment score >11 and CDEIS >8 were used as selection criteria demonstrating active disease for inclusion into a study of moderate to severely active CD. Results: A total of 19 patients were enrolled across the six centers. Using ileocolonoscopy as the standard reference, MRE without enema identified deep ulcers in the colon with 58% sensitivity, 73% specificity; MRE with enema had similar sensitivity, 58% but better specificity, 80%. For enrollment into a trial for moderate to severely active CD, the CDAI identified 6 patients. Of these, only 3 patients had active disease confirmed by either MRE or Ileocolonoscopy. One of these three patients had an abscess identified by MRE. The remaining three patients had no objective evidence of disease by MRE or ileocolonoscopy. Using MRE, 12 subjects were identified for inclusion into a trial of which 3 would have been excluded from a clinical trial due to presence of an abscess or abdominal extramedullary hematopoeisis. Two of the remaining 9 subjects did not have identifiable disease on ileocolonoscopy. Using ileocolonoscopy, 6 subjects were identified of whom 2 patients would have been excluded by MRE due to an abscess. Overall, MRE selected 7 patients with active disease compared with 4 and 2 patients by CDEIS and CDAI who would be appropriate to include in a CD clinical trial. Conclusions: In comparison to endoscopy and the CDAI, MRE better enriches for patients with more appropriate levels of disease for inclusion in a clinical trial with therapeutic intervention.

Small bowel capsule endoscopy for management of Crohn's disease: A retrospective tertiary care centre experience

The role of small bowel capsule endoscopy in the management of established Crohn's disease is uncertain. A retrospective study of small bowel capsule endoscopy tests performed in a referral centre from 2008 to 2011; 77 tests were performed in patients with known Crohn's disease. Six patients were excluded due to capsule test retention. Patients were classified into 4 indication groups: unexplained anaemia (G1, n = 6); discrepancy between clinical symptoms and morphology (G2, n = 25), full assessment of Crohn's disease location (G3, n = 37) and evaluation of mucosal healing (G4, n = 3). Twenty-seven (38%) patients had no lesions, 32 (45%) moderate and 12 (17%) severe lesions. Endoscopic lesions were found in 4/6 (67%) G1 patients, 11/25 (44%) G2 and 28/37 (76%) G3 (p < 0.03). Three months after endoscopy was performed, 38/71 patients experienced a change in their treatment that was significantly associated with the severity of endoscopic lesions and with test indications; in 60%, 20% and 58% of patients from G1, G2 and G3, respectively (p < 0.01). Small bowel capsule endoscopy resulted in management changes in the majority of patients with established Crohn's disease.

PTU-151 Small bowel ultrasound: diagnostic yield in established small bowel Crohn's disease

IntroductionCrohn's disease is an intestinal inflammatory disorder which frequently involves the small intestine. Accurate localisation of disease is important to direct targeted therapy. Video capsule endoscopy (VCE) has revolutionised clinical...

969 Balloon-Assisted Enteroscopy Versus Computed Tomography Enterography for Evaluation of Small-Bowel Lesions in Patients With Suspected and Established Crohn's Disease

969 Balloon-Assisted Enteroscopy Versus Computed Tomography Enterography for Evaluation of Small-Bowel Lesions in Patients With Suspected and Established Crohn's Disease

972 Small Bowel Ultrasound: Diagnostic Yield in Established Small Bowel Crohn's Disease

Introduction Crohn9s disease is an intestinal inflammatory disorder which frequently involves the small intestine. Accurate localisation of disease is important to direct targeted therapy. Video capsule endoscopy (VCE) has revolutionised clinical assessment of small intestinal Crohn9s disease. Small bowel ultrasound (SB USS) is a rapid, inexpensive, interactive and non-invasive alternative method for assessing small bowel Crohn9s disease, which is in routine use only at selected UK institutions. We evaluated the diagnostic yield of SB USS in VCE determined Crohn9s disease. Methods A retrospective assessment of patients who had undergone VCE in 2008–2010 was carried out. Patients investigated for suspected small bowel Crohn9s disease, or who had findings of small bowel Crohn9s on VCE were included, if they had also had a SB USS within 12 months. VCE findings were graded as mild (aphthous ulcers only), moderate (aphthous ulcers with mucosal distortion) or severe (aphthous ulcers with mucosal distortion and strictures/stenosis). SB USS was graded positive or negative for small bowel Crohn9s disease. Both assessments were single operator. Either investigation could predate the other. Results were expressed as sensitivity, specificity, positive and negative predictive value (PPV and NPV) of SB USS compared with VCE for detection of small bowel Crohn9s. Sub-analysis of SB USS findings for VCE-defined severity of small bowel Crohn9s disease was carried out. Results 196 VCE procedures were reviewed, of which 22 fulfilled the inclusion criteria. 10 patients had SB Crohn9s on VCE; this was detected in four patients by SB USS (sensitivity 40%). 12 patients had no evidence of SB Crohn9s on VCE; none of these had SB USS findings of Crohn9s disease (specificity 100%). Of 18 patients with no evidence of SB Crohn9s on SB USS, VCE findings of Crohn9s disease were apparent in 6 patients (negative predictive value 67%); however, all patients with positive findings of Crohn9s disease on SB USS had evidence of SB Crohn9s on VCE (positive predictive value 100%). Sub-analysis for severity of inflammation on VCE was carried out. Of four patients with positive findings at SB USS, 3 were severe and one moderate on VCE. One patient with severe Crohn9s on VCE was missed by SB USS; however, the patient9s body habitus was unfavourable. Conclusion SB USS has excellent positive predictive value (100%) and specificity (100%) for detection of SB Crohn9s disease, with only moderate negative predictive value (67%). In addition, all detected cases were moderate or severe, which may complicate VCE. It therefore seems a safe, quick, relatively cheap initial investigation in expert hands, which may obviate more costly, invasive investigations. A prospective evaluation of these diagnostic modalities should be carried out. Competing interests None declared.

Mo1525 Diagnostic Yield and Impact of Capsule Endoscopy (CE) on Management of Patients With Suspected and Established Crohns Disease (CD)

Mo1525 Diagnostic Yield and Impact of Capsule Endoscopy (CE) on Management of Patients With Suspected and Established Crohns Disease (CD)