Intestinal Crohn Research Articles

P672 A tertiary multicenter cohort of patients with chronic intestinal pseudo-obstruction and Crohn’s disease: a rare association with a high prevalence of monogenic disorders

Abstract Background Chronic intestinal pseudo-obstruction (CIPO) is a rare condition that is not commonly associated with Crohn’s disease (CD). We performed a cohort study aiming at identifying clinical, immunological and genetic features as well as response to conventional CD treatments of patients co-affected with CIPO and CD. Methods We conducted an observational retrospective cohort study in two tertiary CIPO and IBD centers. Patients with parenteral nutrition-dependent CIPO and features of CD including large intestinal or perianal ulcers, strictures, abscesses and fistula with pathology findings compatible with CD, were included. We used flow-cytometry and targeted-next generation sequencing to identify immune defects and monogenic causes in 129 predefined genes responsible for monogenic enteropathies Results Eight unrelated patients were studied. 5 had a myogenic phenotype and 3 had a neurogenic form with histological exam for all patients. CD involved small bowel in all cases whereas one patient had ileocolonic involvement. Two patients had perianal complex fistula. Seven patients had a stricturing form and 1 had an inflammatory-only behavior. No patient had a penetrating form. All patients were diagnosed with CIPO prior to CD. Median age at CIPO diagnosis was 11.5 years old (IQR 0,31.5) while it was 22.5 (IQR 19,29) at CD diagnosis. At CD diagnosis, mean fecal calprotectin level was 551 ug/g (range 390 - 1200) and citrulline averaged 23.6 umol/l (range 15–35 umol/l). Histopathological analyses of intestinal specimens revealed ulcerations for half of the patients, increase in intraepithelial lymphocytes in 3, granuloma and cryptitis in 1 patient. Abnormalities in peripheral lymphocytes’ subsets were found in 2 patients. 5 patients were ultimately diagnosed with monogenic forms of enteropathy: 2 in ACTG2, with an autosomal dominant inheritance, 1 with a STAT1gain of function, (GOF) and two with recessive inheritance: TYMP. All patients received steroids with clinical response in 2. 6 patients received antiTNF, with only one sustained remission. Two patients received vedolizumab and 2 were treated with ustekinumab. Except for antiTNF in 1 patient, common CD treatments did not lead to any improvement. Of note, antiJAK therapy in a patient with STAT1GOF failed to induce remission. Conclusion Herein is described the first cohort of extensively genetically and immunologically explored patients co-affected with CIPO and CD. Immune defects were common and monogenic forms were found with a high prevalence. Rates of response to biologic treatment were very low. Identification of monogenic cause through immunological and genetic explorations is warranted in patient with CIPO-CD association as it could lead to targeted therapy and genetic counseling.

Intestinal Tuberculosis or Crohn's Disease: A Diagnostic Challenge Case Report

Background and Aim: Crohn's disease is a chronic idiopathic disease in the category of gastrointestinal tract inflammation without any obvious reason. Clinical signs include abdominal pain, and diarrhea, which may be accompanied by a fistula or intestinal obstruction. Differential diagnosis of Crohn's disease and intestinal tuberculosis is a complex and difficult challenge. Case presentation: The patient was a 70-year-old woman who had been hospitalized due to fistulas with 4 years of discharge in the left inguinal and gluteal area. The patient's vital signs were stable, and she did not report any fever, chills, or gastrointestinal symptoms. Diagnostic tuberculosis procedures were performed for this patient and despite the lack of evidence in favor of intestinal tuberculosis, experimental tuberculosis treatment was started for him. Despite 10 months of anti-tuberculosis treatment, the symptoms and fistulas of the patient did not recover in 2016. On spiral computed tomography scan of the lung and mediastinum without injection, the presence of cardiomegaly, evidence of ground glass was seen along with an increased thickness of the interlobular septa in the middle lobe of the right lung and ground-glass opacities at the base of both lungs. Since the patient had typical intestinal tuberculosis symptoms, discharge cultivation and smear were performed and it did not grow on Mycobacterium tuberculosis bacillus acid staining. The patient underwent biopsy with MR Enterography, and Crohn's diagnosis was confirmed. The patient was treated with Metronidazole, Ciprofloxacin, and a combination of Azathioprine and Infliximab. Conclusion: According to the rare case reported, advanced diagnostic measures should be taken in dealing with patients with intestinal tuberculosis or Crohn disease

Exploring Mucin as Adjunct to Phage Therapy

Conventional phage therapy using bacteriophages (phages) for specific targeting of pathogenic bacteria is not always useful as a therapeutic for gastrointestinal (GI) dysfunction. Complex dysbiotic GI disorders such as small intestinal bowel overgrowth (SIBO), ulcerative colitis (UC), or Crohn’s disease (CD) are even more difficult to treat as these conditions have shifts in multiple populations of bacteria within the microbiome. Such community-level structural changes in the gut microbiota may require an alternative to conventional phage therapy such as fecal virome transfer or a phage cocktail capable of targeting multiple bacterial species. Additionally, manipulation of the GI microenvironment may enhance beneficial bacteria–phage interactions during treatment. Mucin, produced along the entire length of the GI tract to protect the underlying mucosa, is a prominent contributor to the GI microenvironment and may facilitate bacteria–phage interactions in multiple ways, potentially serving as an adjunct during phage therapy. In this review, we will describe what is known about the role of mucin within the GI tract and how its facilitation of bacteria–phage interactions should be considered in any effort directed at optimizing effectiveness of a phage therapy for gastrointestinal dysbiosis.

Primary Hyperparathyroidism with a Predominant Lesion of the Gastrointestinal Tract

Primary hyperparathyroidism is a common pathology, but it is fact that doctors of various specialties run against difficulties in diagnosinging. The variety of clinical manifestations causes a long period of diagnosis and, late start of treatment. The main symptoms of this pathology are described taking into account the pathogenesis. The most common laboratory markers of hyperparathyroidism are incrising level of parathyroid hormone and hypercalcemia. Imaging examination methods are used to establish primary hyperparathyroidism. Targeted ultrasound examination of the parathyroid glands should be performed in all patients with suspected calcium metabolism disorders.This article presents a clinical case of primary hyperparathyroidism with predominant gastrointestinal symptoms. The patient was twice admitted to the hospital with various clinical manifestations of damage to the gastrointestinal tract. Erosive gastritis, terminal ileitis, chronic pancreatitis, and cholelithiasis were identified. A differential diagnosis was made with small intestine lymphoma and Crohn’s disease. In addition, there were General cerebral symptoms in the form of lethargy, rapid exhaustion. Due to severe electrolyte disorders, the patient was observed in the intensive care unit. Due to the development of mechanical jaundice, endoscopic retrograde cholangiopancreatography with papillosphincterotomy was performed. Based on hypercalcemia, elevated parathyroid hormone levels, and visualization of parathyroid gland formation, the diagnosis of primary hyperparathyroidism was established based on ultrasound data. An adenomectomy of the left lower parathyroid gland was performed. in the surgical department. The patient was discharged with positive dynamics in the form of improvement in General health, cessation of pain, regress of vomiting, expansion of motor activity. Betimes diagnosis and treatment of primary hyperparathyroidism, on the example of the described case, leads to complete relief of symptoms and improvement of the quality of life of patients.

Colonic Crohn's disease - decision is more important than incision: A surgical dilemma.

The most common localization for intestinal Crohn’s disease (CD) is the terminal ileum and ileocecal area. It is estimated that patients with CD have one in four chance of undergoing surgery during their life. As surgery in ulcerative colitis ultimately cures the disease, in CD, regardless of the extent of bowel removed, the risk of disease recurrence is as high as 40%. In elective surgery, management of isolated Crohn’s colitis continues to evolve. Depending on the type of surgery performed, colonic CD patients often require further medical or surgical therapy to prevent or treat recurrence. The elective surgical treatment of colonic CD is strictly dependent on the localization of disease, and the choice of the procedure is dependent of the extent of colonic involvement and previous resection. The most common surgical options in colonic CD are total proctocolectomy (TPC) with permanent ileostomy, segmental bowel resection, subtotal colectomy. TPC completely removes all colonic and rectal disease and avoids the use of a potentially diseased anus. We will review current options for the elective surgical treatment of colonic CD, based on the current literature and our own personal experience.

Diagnostic challenge between Crohn's disease and intestinal tuberculosis in chronic diarrhea with ulcerated jejunal stenosis: a case report

Intestinal tuberculosis and Crohn's disease are a diagnostic challenge because of the clinical, radiological and endoscopic similarity. The histological and microbiological findings are positive in less than 50%, which delays the correct treatment, putting the patient at risk. We reported a 34-year-old immunocompetent patient with 4 years of malabsorptive diarrhea, weight loss, nocturnal diaphoresis, abdominal pain and an ulcer with stenosis in the jejunum was found; she mpirical antituberculosis treatment with clinical improvement. Later the culture was positive for M. tuberculosis.

Effect of Crohn's Disease on Villous Length and CYP3A4 Expression in the Pediatric Small Intestine.

Changes in absorptive capacity and first‐pass metabolism in the small intestine affect oral drug bioavailability. Characterization of such changes as a consequence of inflammation is important for developing physiologically‐based pharmacokinetic (PBPK) models for inflammatory bowel disease. We sought to elucidate the impact of small intestinal Crohn’s disease (CD) on villous length and CYP3A4 expression in children. Freshly frozen duodenal and terminal ileum (TI) biopsies from 107 children (1–19 years) with and without CD were evaluated for active inflammation. Villous length and CYP3A4 mRNA/protein expression were compared among regions of active and inactive inflammation in CD and controls. A twofold reduction in villous length was observed in inflamed duodena and ilia of children with CD, but in the absence of regional inflammation, villi in CD were comparable in length to controls. Expression of CYP3A4 mRNA correlated significantly with villous length in the TI (P = 0.0003), with a trend observed in the duodenum that did not reach statistical significance. In the presence of active inflammation, a significant decrease in CYP3A protein expression was confirmed in the duodenum, where protein expression also correlated significantly with villous length across diagnoses (P < 0.0001). Our findings suggest that previous observations of decreased CYP3A4 expression and function in inflamed intestine may not be due solely to downregulation by inflammatory cytokines, but also to villous blunting and subsequent loss of surface area for protein expression. This information is relevant for PBPK model development and could aid with dose adjustment decisions for oral CYP3A4 substrates administered during CD flare (e.g., budesonide).

Systematic reporting of computed tomography enterography/enteroclysis as an aid to reduce diagnostic dilemma when differentiating between intestinal tuberculosis and Crohn's disease: A prospective study at a tertiary care hospital.

Background and AimCrohn's disease (CD) and intestinal tuberculosis (ITB) have similar symptomatology and overlapping features on imaging, endoscopy, and histopathology. It is important to differentiate ITB from CD to initiate correct medical management. This prospective study aimed to characterize imaging features on computed tomography enteroclysis/enterography (CTE) that help in differentiating ITB from CD.MethodsA total of 300 consecutive patients who underwent CTE with the suspicion of small bowel diseases were evaluated. CTE findings were documented on a detailed “CTE case record form” and were correlated with other investigations like endoscopy, histopathological and microbiological examination, and improvement on empirical therapy to arrive at a final diagnosis. Only confirmed cases of ITB/CD were included for further analysis.ResultsFinal diagnoses revealed that 61 patients had ITB, 24 had CD, 90 patients had a final diagnosis not related to ITB/CD, and 125 had no bowel‐related diseases. The sensitivity of CTE (ITB vs CD, 90.2 vs 91.6%) was higher than the sensitivity of ileocolonoscopy (ITB vs CD, 87 vs 83.3%). A homogenous pattern of bowel wall thickening and confluent bowel involvement were significantly more common in ITB. Stratified bowel wall thickening with mucosal hyperenhancement, skip lesions in the bowel, and a comb sign were significantly more common in CD. Stratified bowel wall enhancement with an intervening layer of fat was specifically (P < 0.001) seen in patients with CD, and necrotic (P = 0.002) and calcified (P = 0.055) lymph nodes were specifically seen in patients with ITB.ConclusionWe propose a systematic approach to the radiological differentiation of ITB from CD.

16741 Pediatric patients with orofacial granulomatosis likely to develop intestinal Crohn disease

Orofacial granulomatosis (OFG) is a rare mucocutaneous disorder characterized by persistent granulomatous perioral inflammation in the absence of systemic disease. There is continued debate regarding whether OFG is a distinct clinical disorder or a manifestation of orofacial Crohn disease (CD) given indistinguishable clinical and histologic features. We aimed to determine if there is a relationship between a diagnosis of biopsy-proven OFG in the absence of systemic disease and the subsequent diagnosis of intestinal CD in a pediatric patient population. A retrospective chart review from 2000 to 2018 at a single tertiary pediatric hospital was performed. Seven patients met inclusion criteria of receiving a diagnosis of OFG in the absence of previous or concurrent diagnosis of inflammatory bowel disease. Four patients were subsequently diagnosed with intestinal CD during the study period with a median time to diagnosis of 36 months (range 4-72 months). The remaining three patients have no diagnosis of intestinal CD to date with a median follow-up time of 3 months (range 2-17 months). Similar to previous studies, our case series demonstrates that pediatric patients diagnosed with OFG are likely to receive a subsequent diagnosis of intestinal CD. At minimum, Gastroenterology evaluation is warranted with long-term monitoring for any signs of intestinal CD.

S2302 Empiric Anti-Tuberculosis Treatment as a Way to Help Solve Diagnostic Challenges Between Intestinal Tuberculosis and Crohn’s Disease—A Case Presentation

S2302 Empiric Anti-Tuberculosis Treatment as a Way to Help Solve Diagnostic Challenges Between Intestinal Tuberculosis and Crohn’s Disease—A Case Presentation

Pediatric patients with orofacial granulomatosis likely to subsequently develop intestinal Crohn's disease: Brief Report.

Orofacial granulomatosis (OFG) is an uncommon chronic granulomatous condition presenting as perioral inflammation in the absence of systemic disease. There is continued debate regarding whether OFG is a distinct clinical disorder or a manifestation of orofacial Crohn's disease. Our retrospective review identified 7 patients diagnosed with OFG between 2000 and 2018 at a tertiary pediatric hospital. Four of the 7 patients subsequently developed Crohn's disease with a median delay of 3.1years (range 0.4-6.9years). This indicates that gastroenterology evaluation with long-term monitoring for intestinal Crohn's disease is warranted.

Femoral Vein Wall Thickness Measurement May Be a Distinctive Diagnostic Tool to Differentiate Behçet's Disease with Intestinal Involvement and Crohn's Disease.

Behçet's disease (BD) and Crohn's disease (CD) cannot be easily differentiated in young adults presenting with nonspecific gastrointestinal (GI) manifestations due to similar extraintestinal manifestations. We recently showed that increased common femoral vein (CFV) thickness is a distinctive feature of BD, rarely present in other inflammatory or vascular diseases with a specificity higher than 80% for the cutoff value of ≥ 0.5mm. We suggest that CFV thickness measurement with ultrasonography (US) can be a diagnostic tool for BD. To assess the diagnostic performance of CFV thickness measurement in the differential diagnosis of BD and CD. Patients with BD (n = 69), CD (n = 38), and healthy controls (HC) (n = 38) were included in the study. Bilateral CFV thickness was measured with Doppler US. Both right and left CFV thicknesses were significantly higher in BD compared to HC and CD (for right: 0.76mm vs 0.33mm, for left: 0.78mm vs 0.35mm, p < 0.001 for both). CFV thicknesses in CD were similar to HC (p > 0.05 for both). CFV thickness was also similar between BD patients with and without GI involvement (p = 0.367). The diagnostic cutoff values of ≥ 0.5mm for CFV thickness performed well against to both CD and HCs for discrimination of BD. The sensitivity and specificity rates were > 85% for both HC and CD. Positive and negative predictive values in our tertiary clinical setting were > 90%. We found significantly lower CFV thickness in CD compared to BD. Our results suggest that CFV wall thickness measurement is a distinctive diagnostic tool for the differentiation of BD and CD and can be helpful in daily practice for the differentiation of two diseases.

Is the rise in Crohn's disease in India accompanied by a fall in intestinal tuberculosis? A single-center experience

IntroductionThe relationship between the incidence of intestinal tuberculosis (TB) and Crohn's disease (CD) is interesting, especially considering the striking similarity between the two conditions. Some studies from Asian populations suggested that the incidence of intestinal TB decreases when there is an increase in CD. AimTo compare the incidence trend between intestinal TB and CD over 15 years. MethodsMedical records of patients seen in the Division of Gastroenterology over 15 years (2005–2019) were reviewed. CD was diagnosed according to the Copenhagen criteria. Intestinal TB was diagnosed in the appropriate clinical situation if any one or more of the following was present: (1) positive TB MGIT culture; (2) positive Gene Xpert for TB; (3) suggestive histologic findings, with positive tissue acid-fast bacillus (AFB) on smear or with sustained response to anti-TB therapy. The incidence time trend of patients with CD and intestinal TB diagnosis was then studied year-wise. Results632 medical case records were accessed; 60 patients were excluded due to inadequate data or not fulfilling diagnostic criteria. The 572 patients included 224 with intestinal TB (median age 37 years, IQR 22; 125 [56%] females) and 348 with CD (median age 40 years, IQR 25; 159 [46%] females [p < 0.02 as compared to TB]). Thus, more patients with CD were seen during the study period, but there was no correlation between the incidence of the two conditions (r = 0.318; p = 0.25). ConclusionIn Indian patients in a single private-sector center, there was no inverse correlation between the incidence of intestinal TB and CD over 15 years.

Serial measurements of faecal calprotectin may discriminate intestinal tuberculosis and Crohn's disease in patients started on antitubercular therapy.

Response to antitubercular therapy (ATT) is often used to differentiate intestinal tuberculosis (ITB) from Crohn's disease. Role of non-invasive biomarkers to predict mucosal response to ATT is unclear. A prospective study to compare faecal calprotectin and serum C-reactive protein (CRP) levels at diagnosis, 2 and 6 months of ATT in patients with suspected ITB started on ATT was done. The patients were eventually divided into two groups: ITB or alternative diagnosis (OTH). Decline of calprotectin and CRP levels was used to compute area under the receiver operating characteristic (AUROC) to predict mucosal healing at 2 months. Thirty-seven patients (mean age: 34.95 ± 16.35 years, 23 males) were included and 28 (75.67%) were diagnosed as ITB while nine (24.32%) had alternative diagnosis (OTH). The median faecal calprotectin values of ITB and OTH groups at baseline, 2 months and 6 months were 216 and 282 µg/g (P = 0.466), 43 and 216 µg/g (P = 0.003), and 26 and 213 µg/g (P < 0.001), respectively. The median CRP values at baseline, 2 months and 6 months were 18 and 30 mg/L (P = 0.767), 4.7 and 15 mg/L (P = 0.025), and 3 and 10.85 mg/L (P = 0.068), respectively. The AUROC of percent decline in faecal calprotectin and serum CRP at 2 months for mucosal healing were 0.8287 [95% confidence inteval (CI) 0.6472-1] and 0.6018 (95% CI 0.4079-0.7957), respectively. Faecal calprotectin can help in assessing response to therapy in suspected ITB patients started on empirical ATT.

Apoptosis in peripheral blood lymphocytes in intestinal tuberculosis and Crohn’s disease: Implications to diagnostic differentiation

Intestinal tuberculosis (ITb) and Crohn's disease (CD) mimic each other often leading to misdiagnosis. We evaluated the difference between ITb and CD using the extent of apoptosis in peripheral blood lymphocytes. CD4+ cells as a percentage of the lymphocytes and viable, dead, total apoptotic, early apoptotic, and late apoptotic CD4+ cells were assessed in the peripheral blood by flow cytometry in healthy controls and patients with confirmed active ITb and CD prior to initiating therapy. Early apoptotic and total apoptotic cells were further expressed as a proportion of the percentage of CD4+ cells. The percentages of CD4+ cells (6.5 [3.0, 8.7] vs. 13.40 [10.15, 13.40]; p < 0.001), total apoptotic cells (0.13 [0.0, 0.22] vs. 0.08 [0.0, 0.21]; p = 0.045), early apoptotic (1.24 [0.55, 2.54] vs. 0.71 [0.40, 1.30]; p = 0.037), and the proportion of the latter two parameters (17.18 [5.61, 57.33] vs. 4.84 [2.71, 9.83]; p-value 0.039) and (17.18 [7.4, 67.50] vs. 5.51 [3.10, 11.03]; p-value 0.036) were significantly different between patients with ITb and CD. The best sensitivity, specificity, and positive and negative predictive values for the diagnosis of ITb were seen with the CD4+ cell percentage (82.6%, 82.4%, 86.4%, 77.8%, respectively) and the proportion of early apoptotic cells (73.9%, 70.6%, 77.3%, 66.7%, respectively). CD4+ cells as a percentage of peripheral blood lymphocytes and the proportion of early apoptotic CD4+ cells show promise to diagnostic differentiation betweenITb andCD.

Surgical technique for intestinal Crohn's disease

Surgery for intestinal Crohn's disease has been in constant evolution over the past four decades. The field has been changing due to a better understanding of the pathophysiology and the natural history of the disease and the dramatic advances in medical therapy. In order to understand the rationale behind the different anastomotic techniques and the indications for a resection versus a strictureplasty, we describe the essential steps of the surgical decision making process when approaching a patient with intestinal Crohn's disease, including the surgical indications, pre-operative patient optimization, the choice of different surgical techniques for resection and strictureplasty and the long term results. In this manuscript we summarize our personal opinion based on a thorough review of the literature and extensive personal experience.

Antitubercular Therapy Given to Differentiate Crohn's Disease From Intestinal Tuberculosis Predisposes to Stricture Formation.

Treatment trial with antitubercular therapy [ATT] is a common strategy in tuberculosis-endemic countries in case of a diagnostic dilemma between intestinal tuberculosis and Crohn's disease [CD]. Our aim was to determine the long-term clinical course of patients who received ATT before an eventual diagnosis of CD was made. We performed retrospective comparison between CD patients who received ≥6 months of ATT vs those who did not receive ATT. Outcomes assessed were change in disease behaviour during follow-up, requirement of surgery and medication use. In all, 760 patients with CD were screened for the study and, after propensity matching for location and behaviour of disease, 79 patients in each group were compared. Progression from inflammatory [B1] to stricturing/fistulising [B2/B3] phenotype was increased among CD patients who received ATT [B1, B2, B3: 73.4%, 26.6%, 0% at baseline vs: 41.8%, 51.9%, 6.3% at follow-up, respectively] as compared with those who did not receive ATT [B1, B2, B3: 73.4%, 26.6%, 0% at baseline vs: 72.2%, 27.8%, 0% at follow-up, respectively] with an odds ratio of 11.05[3.17-38.56]. The usage of 5-aminosalocylates, steroids, immunosuppressants and anti-tumour necrosis factor was similar between both the groups. On survival analysis, CD patients who received ATT had a lower probability of remaining free of surgery [45%] than those who did not [76%] at 14 years of follow-up (hazard ratio [HR] = 3.22, 95% confidence interval [CI], 1.46-7.12, p = 0.004]. Crohn's disease patients diagnosed after a trial with antitubercular therapy had an unfavourable long-term disease course with higher rate of stricture formation and less chance of remaining free of surgery.

Intestinal tuberculosis or Crohn's disease: a review of the diagnostic models designed to differentiate between these two gastrointestinal diseases.

Differentiating Crohn’s disease (CD) from intestinal tuberculosis (ITB) is a diagnostic dilemma, particularly in regions where ITB is prevalent and CD incidence is increasing, because both diseases can present quite similarly, and diagnostic tests to identify Mycobacterium tuberculosis in tissue samples have rather poor sensitivity. Studies that were conducted to determine the factors that differentiate CD from ITB identified some significant characteristics, but none of those characteristics are exclusive to either ITB or CD. Many diagnostic models or scoring systems that use one to several diagnostic parameters have been proposed to help distinguish these two intestinal diseases. Early models consisted of parameters common to routine clinical practice, such as clinical features, and endoscopic and pathologic findings. The later models also include more advanced diagnostic parameters like high-resolution imaging and serological testing. However, the number and types of parameters differ among diagnostic models, and the systems used to calculate scoring also vary from model to model. Enhanced awareness and understanding of the currently available diagnostic models will help physicians determine which model(s) is/are most suitable for differentiating CD from ITB in their clinical practice.

Oral lesions as first clinical manifestations of Crohn's disease in paediatric patients: a report on 8 cases.

Oro-facial granulomatosis is a descriptive term commonly encompassing a variety of conditions that exhibit similar clinical and microscopic features. It is generally used to describe persistent enlargement of the soft tissues of the oral and maxillofacial region. We report on the salient clinical features of 8 cases of Crohn's disease in paediatric patients (age range from 9 to 13 years old), with oral lesions as first clinical manifestations. The clinical presentation of oro-facial granulomatosis is highly variable but usually recurrent facial swelling, mainly in the lips with or without intraoral manifestations, is the single most common clinical sign at onset. The association with systemic conditions such as sarcoidosis and Crohn's disease has been widely reported in literature. In paediatric age, oro-facial granulomatosis may frequently represent an extra-intestinal manifestation of Crohn's disease and oral lesions can be the first sign of an unknown intestinal disease. The diagnosis in paediatric patients is challenging as oro-facial granulomatosis may precede Crohn's disease by several years, frequently remaining the only evident active focus of the disease. The detection of specific oral manifestations often preceded by painless gingival enlargement (diffuse lip and buccal mucosal swelling, oral cobblestoning, buccal sulcus ulceration and mucosal tags) and/or unspecific or ancillary ones (cheilitis, scaly perioral erythematous rashes and frank intraoral abscess formation, labial and tongue fissuring, glossitis and aphthous stomatitis) is mandatory for the early diagnosis of intestinal Crohn's disease.

Clinical value of capsule endoscopy in small intestinal diseases

Objective: To analyze the clinical value of capsule endoscopy (CE) in small intestinal diseases and to explore the correlation between the diagnosis and clinical characteristics. Methods: From June 2016 to April 2019, a total of 194 patients receiving CE were enrolled in the Department of Gastroenterology, Shanxi People's Hospital, including 68 patients with obscure gastrointestinal bleeding, 104 with chronic abdominal pain and 22 with diarrhea. Results: The detection rate of small intestinal lesions by CE was 53.6%(104/194), of which gastrointestinal bleeding was 66.2% (45/68), chronic abdominal pain was 53.8%(56/104), and diarrhea was 13.6%(3/22). The first three positive diagnostic criteria of CE for gastrointestinal bleeding were non-specific inflammation, small intestinal ulcer and vascular malformation. CE findings in patients with abdominal pain were non-specific inflammation, small intestinal ulcer and Crohn's disease; while the major endoscopic presentations in patients with diarrhea were small intestinal ulcer and non-specific inflammation. Logistic regression analysis suggested that the clinical manifestations and gender were correlated with positive diagnosis by CE (P<0.05), and the positive diagnostic rate of CE in female patients was significantly lower than that in male patients [31.6%(25/79) vs. 51.3%(59/115), P<0.05]. The diagnostic rates of CE in patients with gastrointestinal bleeding and chronic abdominal pain were similar [55.9%(38/68) vs. 41.4%(43/104)], which was significantly higher than those with diarrhea [9.1%(2/22), P<0.05]. Conclusions: Capsule endoscopy has a high detection rate for small intestinal diseases, which could be the first choice in patients with unexplained gastrointestinal bleeding. Male patients and gastrointestinal bleeding are predictors of positive findings by CE.