Small Bowel Crohn's Disease Patients Research Articles

Diffusion weighted imaging to predict longer term response in Crohn's disease patients commencing biological therapy: Results from the MOTILITY Trial.

Predicting longer term response to biological therapy for small bowel Crohn's disease (SBCD) is an unmet clinical need. Diffusion-weighted MR imaging (DWI) may indicate disease activity, but its predictive ability, if any, is unknown. We investigated the prognostic value of DWI for one year response or remission (RoR) in SBCD patients commencing biologic therapy, including incremental value over C-reactive protein (CRP) and faecal calprotectin (FC). A subset of participants in a prospective, multicentre study investigating the predictive ability of motility MRI for one-year RoR in patients starting biologic therapy for active SBCD, underwent additional DWI at baseline and post-induction (12-30 weeks). CRP and FC were collected in a subgroup. RoR at one year was evaluated using clinical and morphological MRE parameters. We calculated sensitivity and specificity to predict RoR and Quality of life (QoL) at one year, comparing apparent diffusion coefficient (ADC) value, Clermont score and CRP using multivariable logistic regression. 25 participants were included (mean 36.9 years, 32% female). ADC changes and Clermont score had poor sensitivity (30.0% [95%CI: 6.7-65.2] and 40.0% [95%CI: 12.2-73.8] respectively) and poor-to-modest specificity (50.0 [95%CI: 27.2-72.8] and 65.0% [95%CI: 40.8-84.6]) for RoR. None of Clermont score, CRP or FC predicted QoL. DWI has inadequate sensitivity and specificity for RoR at one year. There is no significant incremental prognostic value of DWI over CRP and FC to predict RoR and/or QoL at one year. Early post-induction DWI has no prognostic value for RoR at one year.

Does HLA-DQA1*05 carriage have a greater impact on the outcome of infliximab therapy for isolated small-bowel Crohn's disease?

Carriage of HLA-DQA1*05 is thought to increase the formation of anti-tumour necrosis factor alpha (TNF-α) antibodies, reducing the drug efficacy in Crohn's disease (CD) patients. However, little data are currently available for small-bowel Crohn's disease (SB-CD). A specific assessment of the impact of HLA-DQA1*05 on the clinical response to treatment with infliximab (IFX), a TNF-α antagonists, in SB-CD patients is necessary. We conducted a single-center retrospective study that included 106 SB-CD patients treated with IFX. The serum samples were collected for antibodies to infliximab (ATI) testing and HLA-DQA1*05 genotyping. Double-balloon enteroscopy (DBE) was performed following the IFX treatment, with endoscopic outcomes evaluated using the partial simple endoscopic score for CD (pSES-CD), whereas the clinical response was assessed with the Crohn's disease activity index (CDAI). Multivariate logistic regression and multivariate COX regression analyses were employed to analyze the correlation of the HLA-DQA1*05 genotypes with other clinical variables. In this study, 30.2% of SB-CD patients carried the HLA-DQA1*05 allele, which significantly increased their risk of ATI generation (odds ratio [OR]=2.337, p=.043), but it was not associated with the clinical response to IFX and drug persistence (OR=2.356, p=.145; OR=0.457, p=.249). The endoscopic remission rates were 40.6% (13/32) and 55.4% (41/74) in HLA-DQA1*05 carriers and non-carriers, respectively. HLA-DQA1*05 was not associated with endoscopic remission (OR=0.684, p=.414). The HLA-DQA1*05 variant is identified as a significant risk factor of ATI formation in Chinese patients with SB-CD, but is not associated with the clinical response of IFX treatment and endoscopic remission of SB lesions.

Evaluation of Deep Remission with Through-The-Scope Catheter-Based Endoscopic Ultrasound during Double Balloon Enteroscopy in Small Bowel Crohn’s Disease

Evaluation of deep remission in Crohn's disease (CD) can be challenging when the disease is confined to the small intestine. The aim of this study was to evaluate the effectiveness of through-the-scope (TTS) endoscopic ultrasound (EUS) during Double-balloon enteroscopy (DBE) in distinguishing small-bowel CD patients in endoscopic remission from those with active disease. Patients who underwent DBE-EUS were divided into groups of endoscopic remission and endoscopic activity according to segmental Simple Endoscopic Score for Crohn's Disease (SES-CD). Thickness of small intestinal wall layers and other parameters were evaluated by EUS. EUS using the ultrasonic catheter probe via DBE showed that the total wall thickness (TWT) and submucosal thickness (SMT) of the small intestine in the active group were significantly greater than those in the remission group (TWT 3.84±1.02 vs 2.42±0.25mm, SMT 1.23±0.34 vs 0.79±0.13mm, respectively, p<0.001). Cut-off values of 2.65 mm for TWT and 0.95 mm for SMT can distinguish active small-bowel CD from inactive disease (Sensitivity 91.5%, Specificity 80.8% and Sensitivity 70.2%, Specificity 88.6%, respectively). The correlation analysis revealed a significant positive correlation between TWT and SES-CD (r=0.930, p<0.001). Furthermore, TWT was strongly correlated with FC (r=0.861, p<0.001) and CDAI (r=0.805, p<0.001). Similar results were observed for SMT. EUS using an ultrasonic catheter probe during DBE is effective in evaluation of both mucosal and transmural healing in small-bowel CD patients. DBE-EUS could become an important tool in the management of patients with small-bowel CD.

The Epidemiology and Clinical Management of Short Bowel Syndrome and Chronic Intestinal Failure in Crohn's Disease in Italy: An IG-IBD Survey.

Limited data exist on the epidemiology and clinical management of short bowel syndrome (SBS) and chronic intestinal failure (CIF) in Crohn's disease (CD). This study aimed to evaluate these aspects in Italy. Members of the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) were invited to complete a cross-sectional web survey. A subgroup analysis examined the influence of different clinical settings on SBS and CIF management in CD. A total of 47/128 (36.7%) IG-IBD centers participated. Among them, 31.9% were teduglutide (TED) prescribers, and 48.9% were academic centers. The median estimated prevalence of CIF among small bowel CD patients was 1%, and it was significantly higher in academic centers (2.0% [IQR 1-5%] vs. 0.13% [IQR 0-1%], p = 0.02). Seventy-eight percent of centers managed fewer than 10 SBS and CD patients. Routine small bowel measurement and nutritional assessment were performed in only 15% and 42.6% of centers, respectively. TED was prescribed by 12 centers to 35 patients, with a treatment success rate exceeding 50% in 81.8% of centers. The estimated prevalence of CIF in CD patients with small bowel involvement in Italy is 1%. The diagnosis and management practices for SBS and CIF are suboptimal, and TED use is limited.

Single-balloon Enteroscopy for Evaluation of Small Bowel Crohn Disease Strictures: Peripheral Blood Lymphocytes As a Risk Factor for Strictures.

Few reports have focused on single-balloon enteroscopy (SBE) for evaluation of small bowel Crohn disease (CD) strictures. The aim of this study was to analyze the relationships between peripheral blood inflammatory markers and small bowel CD strictures observed by SBE. CD patients who underwent SBE between January 2016 and December 2020 were enrolled. The clinical characteristics and peripheral blood inflammatory markers were collected and analyzed to screen for predictive factors significantly associated with small bowel CD strictures. A total of 221 CD patients underwent SBE. The lymphocyte (LC) counts in peripheral blood were significantly lower in the active group (n=178) than in the inactive group (n=43) according to the simple endoscopic score for CD (SES-CD), P =0.011, and was correlated with the SES-CD ( r =-0.134, P =0.047). The LC levels were significantly lower in the stricture group (n=116) than in the nonstricture group (n=105) based on whether small bowel strictures developed, P =0.000, and LC was a risk factor for strictures in the multivariate analysis [hazard ratio (HR), 2.332; 95% CI, 1.102-4.937; P =0.027]. In the subgroup analysis, LC levels notably decreased after stricture aggravation ( P =0.000). Forty-seven patients who underwent small bowel resection underwent SBE at 6 to 12 months after surgery. The LC level was significantly lower in the postoperative patients with strictures ( P =0.025), and LC (HR, 4.444; 95% CI, 1.265-15.617; P =0.020) was a risk of postoperative strictures by univariate analysis, but the age at diagnosis (HR, 6.462; 95% CI, 1.272-22.560; P =0.022) was an independent risk factor by multivariate analysis. Peripheral blood LC levels were correlated with SES-CD and gradually decreased as the intestinal stricture increased in small bowel CD patients. The LC level was also significantly lower in the postoperative CD patients with strictures. The level of LC was a risk factor for small bowel strictures. These results suggest that peripheral blood LC could be a novel marker of small bowel CD strictures to guide CD diagnosis and therapy.

CT or MR Enterography to Assess Response During Vedolizumab Therapy for Small Bowel Crohn's Disease.

To describe response to therapy of small bowel (SB) Crohn's disease (CD) at CT or MR enterography (CTE/MRE) in patients on vedolizumab. Patients with SB CD who underwent CTE/MRE exams greater than 12 months apart on vedolizumab therapy were included. Length (in cm) and inflammation severity (EMBARK score) of inflamed SB segments were assessed. Changes in inflammation length of 3.4cm or greater or inflammation severity of 2 EMBARK points or greater was categorized as response or progression, as appropriate, with development of newly inflamed segments, strictures, or penetrating complications also indicating progression. Patients not meeting the criteria for response or progression were categorized as having stable disease. Of 36 SB CD patients, the large majority had prior surgery (86%; 31), anti-TNF use (92%; 33), and internal penetrating (78%; 28) disease. Thirty-two patients had paired baseline and follow-up CTE/MRE exams without interval surgery, with clinical response observed in 24/32 (75%). Based on imaging response criteria, 22% (7/32; 95% CI: 9%-40%) had response, 50% (16/32; 95% CI: 32%-68%) were stable, and 28% (9/32; 95% CI: 14%-47%) had disease progression. Fifty-six percent of (18/32; 95% CI: 38%-74%) patients had clinical improvement with response or stable disease by imaging. Patients with stable disease had shorter median baseline lengths of SB inflammation (P = .012). Proportion of patients with colonic inflammation, perianal disease, or penetrating complications did not change. Most patients on vedolizumab for over 12 months demonstrated response or stable SB disease when using objective cross-sectional radiologic imaging criteria using CTE/MRE.

Usefulness of the capsule endoscopy Crohn's disease activity index in assessing the necessity of early additional treatment in patients with Crohn's disease in clinical remission.

The Capsule Endoscopy Crohn's Disease Activity Index (CECDAI) was recently reported as a new scoring system to evaluate the mucosal lesions of patients with Crohn's disease (CD). We investigated whether CECDAI is useful for assessing the necessity of early additional treatment in patients with CD in clinical remission.Twenty-one patients with small intestinal CD in clinical remission underwent capsule endoscopy (CE). The CECDAI and Lewis score (LS) were used to evaluate the intestinal lesions. We analyzed the correlations between several biomarkers and CECDAI or LS and examined the changes in therapeutic regimens based on the CECDAI.CE identified intestinal abnormalities in most CD patients in clinical remission: 81.0% and 85.7%, as assessed using CECDAI and LS, respectively. A significant positive correlation was observed between the CDAI and LS (P = .025), as well as between CDAI and CECDAI (P = .014) in these cases. Compared to LS, CECDAI scores were more evenly distributed. No significant correlations were observed between endoscopic scores and serum markers, including CRP, hemoglobin, and albumin levels. Additional treatment was performed significantly more often in patients with moderate-severe disease activity (CECDAI ≥5.8) (P = .012) than in those with normal (CECDAI <3.5) and mild (3.5≤CECDAI<5.8) disease activity. Resection of the small intestine did not affect the small bowel transit time or CE score.CECDAI is useful in evaluating mucosal lesions in small bowel CD patients in clinical remission and helps in assessing the requirement for additional treatment for these patients, including those who undergo intestinal resection.

Radiological Response Is Associated with Better Outcomes and Should Be Considered a Therapeutic Target in Crohn's Disease.

The aim of the study was to identify factors associated with a radiological response and to assess the impact of radiological improvement in long-term outcomes in small bowel (SB) Crohn's disease (CD) patients. We performed a retrospective study from June 2011 to June 2017 in the tertiary center, Claude Huriez Hospital in Lille, France. All SB CD patients, who underwent two magnetic resonance enterographies (MRE) 3-12months apart, with at least 1-year follow-up after the second MRE, were included. Signs of radiological inflammation were identified by two expert radiologists in CD. Patients were classified as radiological responders (RR) and non-responders (NR). Hospitalization rates, adjustment of treatment, and surgical or endoscopic interventions were assessed and compared between RR and NR. Factors associated with a radiological response were also studied using the Cox model. One hundred and fifteen SB CD patients were included with a median follow-up of 17months (IQR 11.6-28.3). There were 54 (47%) RR and 61 (53%) NR. The risk of surgical or endoscopic intervention was higher in NR than RR (p = 0.04), and the median delay until a surgical or endoscopic intervention was shorter in NR (p = 0.04). Multifocal disease, a hypersignal on diffusion-weighted or dynamic contrast-enhanced imaging, a stricture, or a fistula was significantly associated with a decreased probability of a radiological response (p < 0.05). This study shows that a radiological response is associated with a decreased risk of surgical or endoscopic intervention and should be considered as a therapeutic target in CD patients.

Characteristics and prognosis of isolated small-bowel Crohn's disease.

Previous studies suggest that Crohn's disease (CD) with both small bowel and colon involvement is more serious than colonic CD. However, clinical features of isolated small-bowel CD have not been fully investigated. In this retrospective case-control study, 89 patients were divided into two groups according to capsule endoscopy, ileocolonoscopy, and enhanced computed tomography results. The case group was isolated small-bowel CD (n = 50) and the control group was CD with both small bowel and colon involvement (n = 39). We collected data of the patients and analyze it. In univariate analysis, isolated small-bowel CD group had higher percentage of stricture, Lewis score, platelet, plateletcrit and lower Harvey-Bradshaw index, high-sensitivity C-reactive protein, and erythrocyte sedimentation rate. In multivariable analysis, it had lower Harvey-Bradshaw index (p = 0.000), which meaned relatively mild symptoms. However, it had higher Lewis score (p = 0.007), which meaned more serious small-bowel inflammation. The Kaplan-Meier survival curve also suggested that isolated small-bowel CD patients were more likely to accept partial small intestinal resection surgery (p = 0.029). Isolated small-bowel CD is easily overlooked for milder clinical symptoms and relatively limited lessions, but severe small-bowel histological injury results in owing worse clinical outcomes. Clinicians should pay more attention to the isolated small-bowel CD and take aggressive intervention during therapy.

Defining the Celiac Disease Transcriptome using Clinical Pathology Specimens Reveals Biologic Pathways and Supports Diagnosis

Celiac disease is provoked by gluten exposure, but the complete pathogenic process in the duodenum and the loss of tolerance to gluten is not well understood. We aimed to define the core celiac transcriptomic signature and pathologic pathways in pre-treatment formalin-fixed paraffin-embedded (FFPE) duodenum biopsies used for clinical diagnosis. We use mRNAseq to define pre-treatment diagnostic duodenum gene expression in 54 pediatric celiac patients and non-celiac controls, and we validate our key findings in two independent cohorts of 67 adults and pediatric participants that used fresh frozen biopsies. We further define similar and divergent genes and pathways in 177 small bowel Crohn disease patients and controls. We observe a marked suppression of mature epithelial metabolic functions in celiac patients, overlapping substantially with the Crohn disease signature. A marked adaptive immune response was noted for the up-regulated signature including interferon response, alpha-beta, and gamma-delta T-cells that overlapped to some extent with the Crohn disease signature. However, we also identified a celiac disease specific signature linked to increased cell proliferation, nuclear division, and cell cycle activity that was localized primarily to the epithelia as noted by CCNB1 and Ki67 staining. Lastly, we demonstrate the utility of the transcriptomic date to correctly classify disease or healthy states in the discovery and validation cohorts. Our data supplement recently published datasets providing insights into celiac pathogenesis using clinical pathology FFPE samples, and can stimulate new approaches to address this highly prevalent condition.

Prediction of disease activity of Crohn's disease through fecal calprotectin evaluated by balloon-assisted endoscopy.

Fecal calprotectin (FC) is a useful marker for assessing the activity of intestinal inflammation. However, most studies have used ileocolonoscopy to evaluate the association of FC with intestinal inflammation, and it is not clear whether FC is useful for the evaluation of small-bowel Crohn's disease (CD). This study aimed to determine the usefulness of FC for predicting intestinal inflammation evaluated by balloon-assisted endoscopy (BAE), which can visualize the deep small intestine. This was a cross-sectional, observational study involving 69 CD patients, 39 of whom had only small-bowel disease. The extended simplified endoscopic activity score for Crohn's disease (eSES-CD) was calculated based on the findings of BAE. Mucosal healing was defined as an eSES-CD of 0. In all CD patients, FC levels were correlated with the eSES-CD (r=0.663, P<0.001). The cutoff value to predict mucosal healing was 92mg/kg, with a sensitivity of 94%, specificity of 88%, positive predictive value of 98%, negative predictive value of 64%, and the area under the curve of 0.91. Even in small-bowel CD patients, FC levels were correlated with the eSES-CD (r=0.607, P<0.001). The cutoff value was 92mg/kg, with a sensitivity of 87%, specificity of 88%, positive predictive value of 96%, negative predictive value of 64%, and area under the curve of 0.85. Fecal calprotectin showed a significant correlation with the intestinal inflammation evaluated with BAE even in patients with only small intestinal disease. FC is useful for the evaluation of CD including both the small and large intestines.

Fecal calprotectin reflects endoscopic activity in patients with small-bowel Crohn's disease according to double-balloon endoscopy findings.

ABSTRACTFecal calprotectin (FC) has drawn attention as a biomarker in the evaluation of Crohn’s disease (CD). However, few reports have provided a detailed examination of the relationship between small-bowel CD lesions and FC levels. The present study aimed to examine the entire small bowel using double-balloon endoscopy (DBE) and to determine the relationship between the endoscopic activity in small-bowel CD and FC levels. Twenty small-bowel CD patients, who underwent DBE, were prospectively enrolled. Endoscopic evaluation was based on the simple endoscopic score for CD, with the small bowel divided into four regions. This score was defined as the double-balloon endoscopic score for CD (DES-CD). Furthermore, to focus on mucosal membrane damage, we used the partial DES-CD (pDES-CD), in which presence of stenosis was excluded from DES-CD. DES-CD revealed a correlation with FC (γ = 0.691, P = 0.001) and C-reactive protein (CRP) (γ = 0.631, P = 0.003) levels. Furthermore, pDES-CD showed a correlation with the FC level (γ = 0.747, P < 0.001), erythrocyte sedimentation rate (γ = 0.492, P = 0.028), and the CRP level (γ = 0.605, P = 0.005). CD Activity Index and endoscopic score showed no correlation. Our results revealed a correlation between the endoscopic activity in small-bowel CD and FC levels. Furthermore, pDES-CD showed a strong correlation with FC levels. This may be because FC levels were elevated due to mucosal membrane damages, rather than stenoses.

Predictors of Durability of Radiological Response in Patients With Small Bowel Crohn’s Disease

The long-term significance of radiological transmural response (TR) as a treatment goal at the first follow-up scan in small bowel Crohn's disease (CD) has been previously shown. We examined the durability of a long-term strategy of treating to a target of radiological TR and the influence of baseline predictors on the maintenance of TR. Small bowel CD patients between January 1, 2002, and December 31, 2014, were identified with serial computed tomography enterography (CTE)/magnetic resonance enterography (MRE) before and after initiation of therapy or on maintenance therapy. Overall TR (inflammatory lesions with/without strictures) w1as characterized by abdominal radiologists in up to 5 small bowel lesions per patient at each serial scan until last follow-up or small bowel resection, as response, partial response, or nonresponse. The rate of conversion between TR states and transition to surgery, including the effect of baseline patient/disease characteristics, was examined using a multistate model (mstate R-package). CD patients (n = 150, 705 CTE/MRE) with a median of 4 CTE/MRE during 4.6 years of follow-up, 49% with ileal-only distribution, had 260 examined bowel segments. Conversion from response to partial response/nonresponse was 37.4% per year of follow-up with no transitions seen directly from response to surgery. Current smoking status (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.1-4.3) and internal penetrating disease at baseline scan (HR, 2.2; 95% CI, 1.2-4.1) were associated with a 2-fold increased risk of transition from partial response/nonresponse to surgery. Achievement and maintenance of radiological response is associated with avoidance of small bowel surgery. Continued follow-up with CTE/MRE is recommended to identify loss of response, especially in current smokers and patients with internal penetrating disease at baseline CTE/MRE.

Role of capsule endoscopy and fecal biomarkers in small-bowel Crohn's disease to assess remission and predict relapse

Capsule endoscopy (CE) is the most sensitive test to diagnose small-bowel Crohn's disease (CD). Conventional parameters poorly assess CD remission, and although fecal biomarkers assess colonic activity, their role in assessing remission is uncertain. We report CE findings in small-bowel CD patients in clinical remission compared with fecal biomarkers and standard clinical tools to determine mucosal remission and predict relapses. Forty-three adult small-bowel CD patients in clinical remission (Crohn's Disease Activity Index [CDAI]<150) were prospectively enrolled at 4 academic centers and followed clinically for 12 months. Baseline CE studies were scored using the Capsule Endoscopy Scoring Index (CESI or Lewis score). Baseline and endpoint fecal biomarkers were assayed. CE findings were normal in 17 patients (40%), mild inflammation in 19 (44%), and moderate to severe inflammation in 7 (16%). Of the 26 patients (60%) with mucosal inflammation on CE, 85% had elevated baseline fecal calprotectin and 77% elevated lactoferrin level. Calprotectin and lactoferrin were normal in all patients without inflammation and elevated in all with moderate to severe inflammation. CESI correlated significantly with calprotectin, lactoferrin, and S100A12 levels but not either CDAI or C-reactive protein. During follow-up, 14% of patients exhibited a clinical flare; all had mucosal inflammation at CE and 83% had elevated baseline calprotectin and lactoferrin levels. In small-bowel CD patients in clinical remission, many had ongoing mucosal inflammation assessed by CE and fecal biomarkers. Only some developed a clinical flare during medium-term follow-up. These findings suggest CE and fecal biomarkers are useful in monitoring small-bowel CD progress.

Radiological Response Is Associated With Better Long-Term Outcomes and Is a Potential Treatment Target in Patients With Small Bowel Crohn's Disease.

Crohn's disease (CD) management targets mucosal healing on ileocolonoscopy as a treatment goal. We hypothesized that radiologic response is also associated with better long-term outcomes. Small bowel CD patients between 1 January 2002 and 31 October 2014 were identified. All patients had pre-therapy computed tomography enterography (CTE)/magnetic resonance enterography (MRE) with follow-up CTE or MRE after 6 months, or 2 CTE/MREs≥6 months apart while on maintenance therapy. Radiologists characterized inflammation in up to five small bowel lesions per patient. At second CTE/MRE, complete responders had all improved lesions, non-responders had worsening or new lesions, and partial responders had other scenarios. CD-related outcomes of corticosteroid usage, hospitalization, and surgery were assessed using Kaplan-Meier survival analysis and multivariable Cox models. CD patients (n=150), with a median disease duration of 9 years, had 223 inflamed small bowel segments (76 with strictures and 62 with penetrating, non-perianal disease), 49% having ileal distribution. Fifty-five patients (37%) were complete radiologic responders, 39 partial (26%), and 56 non-responders (37%). In multivariable Cox models, complete and partial response decreased risk for steroid usage by over 50% (hazard ratio (HR)s: 0.37 (95% confidence interval (CI), 0.21-0.64); 0.45 (95% CI, 0.26-0.79)), and complete response decreased the risk of subsequent hospitalizations and surgery by over two-thirds (HRs: HR, 0.28 (95% CI, 0.15-0.50); HR, 0.34 (95% CI, 0.18-0.63)). Radiological response to medical therapy is associated with significant reductions in long-term risk of hospitalization, surgery, or corticosteroid usage among small bowel CD patients. These findings suggest the significance of radiological response as a treatment target.

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.

Assessment of capsule endoscopy scoring index, clinical disease activity, and C‐reactive protein in small bowel Crohn's disease

Small bowel Crohn's disease (SBCD) patients are frequently assessed by capsule endoscopy (CE), which enables direct visualization of small bowel mucosal abnormalities; however, the correlations between CE scoring index (CESI), C-reactive protein (CRP), and disease activity indices remain undefined. We aimed to determine correlations between the CESI, clinical disease activity indices, and CRP in SBCD patients. A prospective study was conducted between October 2008 and February 2011 on 58 established SBCD patients and suspected patients who received a definitive SBCD diagnosis during study. Patients underwent complete CE and were scored according to the CESI and Harvey-Bradshaw index (HBI). Statistical correlation among CESI, HBI, and CRP was assessed. Weak, but significant, correlations were found between CESI and HBI (r = 0.4, P < 0.01). The correlation between CESI and CRP was moderate (r = 0.58, P < 0.01). The median CRP value was significantly higher in patients with moderate to severe CESI compared with the mild group (22.60 ± 16.79 mg/L vs 11.88 ± 8.39 mg/L, P < 0.01). Changes between baseline and follow-up CESI failed to correlate with the delta-HBI or delta-CRP (both, P > 0.05). In this cohort of SBCD patients, clinical disease activity index was not reliable predictors of mucosal inflammation. CRP, however, might be a useful inflammatory marker for evaluating the moderate to severe CE activity in SBCD patients. Furthermore, therapy-induced clinical and biological improvement was not associated with repair of SBCD mucosal lesions.