Small Bowel Patency Research Articles

Pro-motility Preparation Protocol May Reduce the Rates of Failed Patency Capsule Among Patients with Crohn's Disease in Clinical Remission.

Patency capsule (PC) ingestion is commonly used to minimize capsule retention in high-risk patients with Crohn's disease (CD). However, false-positive rates remain high, precluding the use of video capsule endoscopy (VCE). We aimed to compare the efficacy of two preparation protocols in reducing failed PC rates in patients with CD. This bi-center retrospective case-control study included adult patients with small-bowel CD in clinical remission who underwent PC ingestion. The pro-motility group followed a low-residue diet, then a clear fluid diet, and took bisacodyl after ingestion, while the control group followed only a clear fluid diet. The primary outcome was failed PC, defined as the absence of PC excretion or presence on abdominal X-ray at 30 h post-ingestion. Multivariable logistic regression was used to identify predictors of failed PC. Among 273 patients (83 in the pro-motility group, 190 controls), the pro-motility group was older (median 36 [27-48] vs. 31 [24-43], p = 0.012) and had a lower rate of B2/3 disease phenotype (32.5 vs. 53.1%, p = 0.002) compared to controls. The pro-motility group also had a lower failed PC rate (12.0 vs. 24.7%, p = 0.023). Longer disease duration (adjusted odds ratio (AOR) 1.053, 95% confidence interval (CI) 1.016-1.091, p = 0.005) increased the odds of failed PC, while the pro-motility protocol was protective (AOR 0.438, 95% CI 0.200-0.956, p = 0.038), outweighing the influence of B2/3 disease phenotype (AOR 1.743, 95% CI 0.912-3.332, p = 0.093). The pro-motility preparation protocol could substantially improve the success rates of the small-bowel patency test in patients with CD undergoing PC ingestion, potentially reducing the risk of capsule retention and associated complications.

P315 Comparable un-passed patency capsule rates among Crohn’s disease patients during Clinical remission using different preparation protocols

Abstract Background Patency capsule (PC) ingestion has been proven to be a useful tool in assessing small-bowel patency before ingestion of capsule endoscope. However, false positive results of un-passed PC due to colonic hypomotility/constipation, may wrongfully preclude the use of CE in this population. Therefore, we aimed to evaluate the efficacy of intense bowel-preparation protocol before PC ingestion versus standard clear fluid-diet to reduce un-passed PC rates in patients with Crohn’s disease (CD) in clinical remission. Methods This was a bicenter cohort of adult patients (≥18 years-old) with small-bowel CD (L1/L3) in clinical remission, who underwent PC ingestion before CE procedure. Each center regularly follows a different preparation protocol. Patients in the intense-protocol group adhered to a low-residue diet followed by a clear fluid diet for 12 hours and fasting for 12 hours before ingestion. During capsule ingestion they were also given 10mg of Bisacodyl. Drinking and eating were resumed after 2- and 4-hours post-ingestion, respectively. Clear fluids were consumed by the control group. Propensity-score matching (PSM) in a 1:1.75 ratio was performed with adjustment for age, sex, CD-duration>1year and B2/B3 disease-phenotype, with regards to the intense preparation-protocol. The primary outcome was defined as un-passed PC (i.e., the absence of PC excretion in the stool or its presence in the abdomen by abdominal X-ray within 30 hours from ingestion). Results 269 patients were included (intense group-79, control group-190). The cohort following the PSM comprised of 212 patients (intense group-77, control group-135). Current biologic use was less common in the intense-protocol group compared to the controls (37.7% vs. 61.2%, p=0.001). Un-passed PC rates were 13.0% (10/77 patients) vs. 19.3% (26/135 patients) in the intense-protocol and the control groups, respectively (p=0.242). On univariable analysis longer disease-duration (OR 1.042, 95% CI 1.002-1.085, p=0.040) was the only variable to be associated with un-passed PC. Age≥40 was associated with increased risk for un-passed PC as well, however only borderline significance was achieved (OR 1.917, 95% CI 0.927-3.967, p=0.085). Upon multivariate logistic regression analysis, there was no clinico-demographic/disease-related variable that was independently associated with the probability for un-passed PC. Of 269 patients, there was a single subsequent CE retention in the control group, which has resolved spontaneously (0.4%). Conclusion Intense-preparation protocol based on low-residue diet and laxatives was not superior to clear fluid diet alone, for reducing the rates of un-passed PC and for increasing successful patency test of small-bowel, among CD patients in clinical remission.

A Logistic Regression Model for Predicting the Risk of Subsequent Surgery among Patients with Newly Diagnosed Crohn’s Disease Using a Brute Force Method

Surgery avoidance is an important goal in Crohn’s disease (CD) treatment and predicting the risk of subsequent surgery is important to determine adequate therapeutic strength for patients with newly diagnosed CD. Herein, we aimed to construct a prediction model for the risk of subsequent surgery based on disease characteristics at the patients’ initial visit. We retrospectively collected disease characteristic data from 93 patients with newly diagnosed CD. A logistic regression model with a brute force method was used to maximize the area under the receiver operating characteristic curve (auROC) by employing a combination of potential predictors from 14 covariates (16,383). The auROC remained almost constant when one to 12 covariates were considered, reaching a peak of 0.89 at four covariates (small-bowel patency, extensive small-bowel lesions, main lesions, and the number of poor prognostic factors), and it decreased with increasing covariate size. The most significant predictors were small-bowel patency, extensive small-bowel lesions, and age or major lesions. Therefore, this prediction model using covariates may be helpful in determining the likelihood that a patient with newly diagnosed CD will require surgery, which can aid in appropriate treatment selection for high-risk patients.

The why, when and how of small bowel and panenteric capsule endoscopy in Crohn’s disease

Small bowel capsule endoscopy (SBCE) is a tool used for Crohn’s disease (CD) diagnosis and monitorization, which aids in appropriate clinical decision-making, especially in the switch of treatment or withdrawal and influencing reclassification of unclassified inflammatory bowel disease. Compared to cross-sectional imaging, namely intestinal ultrasound and magnetic resonance enterography, SBCE has a superior diagnostic yield in proximal small bowel inflammatory activity, which has been associated with greater morbidity. The risk of capsule retention is higher in patients with established CD with suspected stenosis and those with suspected CD with obstructive symptoms, known stenosis or previous small bowel resection. In these situations, SBCE should be administered only after small bowel patency has been evaluated. There is evidence that the pan-enteric capsule (PEC) has a higher diagnostic yield than ileocolonoscopy in detecting terminal ileum mucosal defects. Future research should evaluate the PEC place in CD algorithms as it offers a non-invasive approach, which is especially important in a long-term follow-up, likely diminishing the disease burden.

P418 Does capsule endoscopy impact clinical management in established Crohn’s Disease?

Abstract Background Capsule endoscopy (SBCE) has developed a relevant role in different indications in patients with established Crohn’s Disease (CD). However, evaluation of its impact in clinical management in CD specific modification strategies has been scarce. The purpose of our study was to question therapeutic impact of SBCE in an 11-year real-life cohort of established CD patients. Methods Retrospective single center study including all consecutive patients with CD submitted to SBCE from January 2008 to December 2019. Small bowel patency was evaluated with patency capsule in selected patients. A conclusive procedure was defined as the one that allowed clinical decision-making. Mucosal inflammation was graded as mild (few aphtoid ulcers), moderate (multiple aphtoid ulcers/isolated deep ulcers) or severe (multiple deep ulcers/stenosis). Therapeutic impact was defined as a change in CD related treatment including escalation, de-escalation, dose adjustment or referral to surgery recommended based on SBCE results within the next 3 months after the SBCE. Patients were assigned to four groups regarding CE indication: staging, flare, post-op and remission (fig 1). Results From the 432 CE performed, 378 (87.5%) were conclusive and allowed clinical decision-making. SBCE results guided changes in 51.3% of patients: 199 (46.1%) with escalation and 23 (5.3%) with de-escalation of treatment. Active disease was present in 310 (71.8%) patients; 131 (30.3%) presented mild, 126 (29.2%) moderate and 53 (12.3%) severe activity. Disease activity demonstrated by SBCE correlated with therapeutic changes. With mild activity 24.1% increased therapy, whereas 77.8% and 84.9% increased therapy with moderate or severe disease, respectively (p<0.001). De-escalation was conducted in 12.8% patients with mucosal healing and 6.1% with mild disease but not in moderate or severe activity (p<0.001). Treatment before and after SBCE is shown in the table. Conclusion SBCE is a safe and useful tool when approaching established CD patients guiding therapeutic management in a real-life setting. Its positive impact does not limit to treatment escalation but also helps to de-escalate in patients who can benefit from it.

Panenteric capsule endoscopy versus ileocolonoscopy plus magnetic resonance enterography in Crohn’s disease: a multicentre, prospective study

IntroductionCrohn’s disease diagnosis and monitoring remains a great clinical challenge and often requires multiple testing modalities. Assessing Crohn’s disease activity in the entire gastrointestinal (GI) tract using a panenteric capsule...

Magnetic Resonance Enterography and Capsule Endoscopy in Patients Undergoing Patency Capsule for the Evaluation of Small Bowel Crohn's Disease: A Korean Clinical Experience.

Objective Studies comparing magnetic resonance enterography (MRE) and capsule endoscopy (CE) for the assessment of small bowel (SB) Crohn's disease (CD) are scarce in Korea. In addition, there is no Korean experience of patency capsule (PC) examination prior to CE. The primary aim of this study was to compare diagnostic yields of MRE and CE for the assessment of SB CD. Secondary objectives were to compare the detection rate of proximal SB lesions by each modality in the Montreal classification and evaluate the safety and feasibility of PC in Korean CD patients. Methods MRE was performed as the first examination to assess SB CD. PC examination and CE were then performed. Diagnostic yields of active SB disease by MRE and CE were then analyzed. Results Disintegration of the patency capsule was shown in 5 patients out of 26 patients, who did not undergo CE. These 5 patients were accounted as negative CE findings. Overall, MRE and CE detected 80.8% and 65.4% of active SB lesions of CD in 26 patients, respectively (P = 0.212). MRE and CE detected 0% (0/26) and 19.2% (5/26) (P = 0.051) of jejunal lesions, 30.8% (8/26) and 42.3% (11/26) (P = 0.388) of proximal ileal lesions, and 80.8% (21/26) and 53.8% (14/26) (P = 0.039) of terminal ileal lesions, respectively. According to the Montreal classification, MRE and CE independently detected proximal disease (L4) in 30.8% (8/26) and 53.8% (14/26) (P = 0.092), respectively. Conclusions The diagnostic yields of MRE and CE for the assessment of SB CD including proximal SB lesions were similar. MRE is a more objective tool for detecting clinically relevant stricture than PC although PC examination could be performed safely before CE to prove the patency of SB. This trial is registered with KCT0004305.

Assessment of small bowel mucosal healing by video capsule endoscopy for the prediction of short-term and long-term risk of Crohn's disease flare: a prospective cohort study

The optimal monitoring strategy for predicting disease course in Crohn's disease remains undefined. We aimed to evaluate the accuracy, safety, and tolerability of an intensive monitoring strategy designed to predict the future course of Crohn's disease in patients with quiescent disease. In a prospective observational cohort study, we recruited patients older than 18 years with quiescent (for 3-24 months) Crohn's disease involving the small bowel with confirmed small bowel patency from three tertiary medical centres in Israel. Enrolled patients underwent baseline magnetic resonance enterography (MRE) and patency capsule, clinical or biomarker assessment every 3 months, and video capsule endoscopy (VCE) at baseline and every 6 months for 2 years or until a clinical flare (the primary outcome, defined as an increase in the Crohn's disease activity index score by 70 points or more) or disease worsening necessitating treatment intensification. We assessed the ability of the different Crohn's disease monitoring methods used to predict the occurrence of a flare during the 24-month follow-up period. Of 90 screened patients, 29 were excluded (17 because of non-patent small bowel). Of the 61 patients enrolled between July 3, 2013, and Feb 1, 2015, 17 (28%) had a flare during the 24-month follow-up. No clinicodemographic parameter predicted future flare. A baseline VCE Lewis score of 350 or more identified patients with future flare (area under the curve [AUC] 0·79, 95% CI 0·66-0·88; p<0·0001; hazard ratio 10·7, 3·8-30·3). C-reactive protein at baseline had an AUC of 0·73 (0·6-0·84; p=0·0013) for predicting flare. The AUC of baseline faecal calprotectin for the prediction of flare occurring within 2 years was 0·62 (0·49-0·74; p=0·17), but progressively improved for shorter timespans and reached an AUC of 0·81 (0·76-0·85) for the prediction of flare occurring within 3 months. Of four MRE-based indices, only MRE global score correlated with 2-year flare risk (AUC 0·71, 0·58-0·82; p=0·024). During follow-up, a Lewis score increase of 383 points or more from baseline predicted imminent disease exacerbation within 6 months (AUC 0·79, 0·65-0·89; p=0·011). The safety and tolerability of the 231 VCEs ingested was excellent, with none being retained. In patients with quiescent Crohn's disease involving the small bowel, faecal calprotectin predicts short-term flare risk, whereas VCE predicts both short-term and long-term risk of disease exacerbation. If corroborated by additional studies, protocols incorporating VCE could expand the scope of available methods for monitoring disease activity and predicting outcomes in small bowel Crohn's disease. The Leona M & Harry B Helmsley Charitable Trust.

Evaluation of Small-Bowel Patency in Crohn’s Disease: Prospective Study with a Patency Capsule and Computed Tomography

Background and Purpose: Patency capsule (PC) examination is usually performed – previously to capsule endoscopy – to evaluate small-bowel patency in patients with established Crohn’s disease (CD). The reported PC retention rate is significantly higher than expected. Our aims were to assess small-bowel patency, to determine the precise location of the retained PC in patients with CD, and to determine the false positive rate of evaluation with a radiofrequency identification tag (RFIT) scanner. Methods: This is a prospective single-center study including CD patients with clinical indication for small-bowel capsule endoscopy. PillCam® PC examination was performed on all patients to assess small-bowel patency. On all patients with a positive identification of the PC using an RFIT scanner, 30 h after ingestion, an abdominal CT was performed in order to identify its precise location. Results: Fifty-four patients were included. The PC retention rate, according to evaluation with the RFIT scanner, was 20% (in 11 patients) 30 h after ingestion. These patients were then submitted to abdominal CT, which revealed that there was small-bowel retention in 5 cases (9%). Higher CRP levels, penetrating disease, and a history of abdominal surgery were associated with an increased risk of PC retention (p = 0.007, p = 0.011, and p = 0.033, respectively). On multivariate analysis, there was an independent association between small-bowel PC retention and CRP levels >5 mg/dL (OR = 15.5; p = 0.03). Discussion: The small-bowel PC retention rate (9%) was considerably lower than those found in previous reports. Our results show that, with this protocol, the false-positive cases of RFIT scans or plain abdominal X-rays may be avoided. This may contribute to more extensive application of capsule endoscopy without the risk of small-bowel retention.

Utility of video capsule endoscopy for longitudinal monitoring of Crohn’s disease activity in the small bowel: a prospective study

This prospective, multicenter study evaluated small-bowel capsule endoscopy (CE) for the longitudinal assessment of mucosal inflammation in subjects with Crohn's disease (CD). Subjects with known CD underwent clinical evaluation with ileocolonoscopy and CE at baseline and 6-month follow-up. Small-bowel patency was confirmed before CE at both time points. The Simple Endoscopic Score for CD (SES-CD) was used for ileocolonoscopy, and the Lewis score and the CE CD Endoscopic Index of Severity (CECDEIS) were used for CE. Clinical scoring indices included the Physician Global Assessment (PGA), CD Activity Index (CDAI), and Harvey-Bradshaw Index (HBI). Laboratory markers including C-reactive protein, fecal calprotectin, and erythrocyte sedimentation rate were collected at baseline and follow-up. Correlation between endoscopic scores and clinical parameters were measured using Spearman tests. A total of 74 subjects were enrolled, of whom 53 (72%) completed endoscopic procedures at baseline and 6-month follow-up. The SES-CD ileocolonoscopy score correlated with the Lewis score (P< .001, ρ= .59) and CECDEIS capsule score (P= .002, ρ= .48). None of the 3 endoscopic scores correlated with PGA, CDAI, HBI, C-reactive protein, erythrocyte sedimentation rate, or fecal calprotectin. Approximately 85% of subjects had proximal small-bowel inflammation identified on CE. There were no CE-related adverse events. There was high correlation between CE and ileocolonoscopy scores for the assessment of mucosal disease activity over time; however, there were no correlations between endoscopic scores and clinical parameters. The use of serial CE for the assessment of small-bowel CD is feasible and valid. (Clinical trial registration number: NCT01942720.).

P290 Determination of small-bowel patency in Crohn’s disease - a prospective study

Patency capsule (PC) is usually performed to establish small-bowel patency, previously to capsule endoscopy (CE), in patients with an increased risk of CE retention. Notably, the reported patency capsule retention rate is significantly higher than the expected for Crohn’s disease (CD). Our aims were to assess small-bowel patency in CD patients, to determine the precise location of the retained PC, as well as to evaluate predictive factors for PC retention. Prospective single-centre study including CD patients with indication for small-bowel CE, between December 2015 and February 2017. PillCam® patency capsule was performed in all patients to access small-bowel patency; PC was ingested, after a 12-h fasting period, without previous bowel preparation. In all patients with a positive radiofrequency identification tag (RFIT) scanner identification of the PC, at 30 h after ingestion, an abdominal-CT was performed in order to determine its precise location. Fifty-four patients were included. 65% of patients were female and the mean age was 40.5 ± 11.1 years. Twelve (22%) patients had a known or suspected small-bowel stenosis detected by previous ileocolonoscopy or abdominal imaging. Twelve (22%) patients had a history of abdominal surgery (intestinal resection: n = 7). The PC retention rate at 30 h was 20% (11 patients). These patients were then submitted to abdominal-CT, which revealed a small-bowel retention only in 5 (9%) cases. Higher CRP levels, penetrating disease and a history of abdominal surgery were associated with increased risk of PC retention (p = 0.007, p = 0.011 and p = 0.033, respectively). On multivariate analysis, there was an independent association between small-bowel patency capsule retention and CRP levels >5mg/dL (OR = 15.5; p = 0.03). The PC small-bowel retention rate in CD was 9%, and even higher in patients with increased CRP levels. Our results show that, with this sequential CT protocol, the false positive cases of RFIT scanner or plain abdominal X-ray may be avoided. This may contribute to a more effective application of CE without the risk of small-bowel retention.

Clinical factors related to false-positive rates of patency capsule examination.

BackgroundRetention is the most common complication of capsule endoscopy (CE), and is reported to occur in 0–13% of cases. To avoid retention, a PillCam patency capsule (PC) is used in patients with suspected intestinal stenosis. However, a relatively low positive predictive value of the PC examination has been reported previously. The aims of this study were to clarify the accuracy of PC examination and to evaluate clinical factors related to cases of false-positive detection.MethodsWe performed a retrospective single-center study of 282 consecutive patients referred for PC examination. Patients in which the PC could not pass through the small bowel within 33 h were classified into the ‘no patency’ group. The ‘no patency’ group was investigated for evidence of significant stenosis upon further examinations, including CE, double-balloon endoscopy, and small bowel follow-through after PC examination. Clinical factors related to small bowel patency and false-positive cases were evaluated.ResultsWe included 161 male (57.1%) and 121 female (42.9%) patients with a mean age of 47.5 ± 17.7 years. Of the 282 patients enrolled, 27 patients exhibited ‘no patency’ upon PC examination. Multivariate analysis showed that clinical factors related to ‘no patency’ included Crohn’s disease, abdominal symptoms, stenosis upon imaging, and previous abdominal surgery. Upon further examination, nine cases in the ‘no patency’ group had significant stenosis. Sensitivity, specificity, and negative and positive predictive values of PC examination for detecting small bowel stenosis were 93.8%, 96.6%, 99.6%, and 62.5%, respectively, and the only clinical factor related to false-positive cases was constipation (p < 0.05).ConclusionWe found a relatively low positive predictive value of PC examination and that constipation was related to false-positive results. To extend the implications of CE indications, clinical study focusing on these results is expected.

Su1172 Evaluation of Small Bowel Patency in Crohn's Disease and Prospective Sudy With Patency Capsule and Computed Tomography

Su1172 Evaluation of Small Bowel Patency in Crohn's Disease and Prospective Sudy With Patency Capsule and Computed Tomography

P308 Safety of the given patency capsule in patients with Crohn's disease or suspected Crohn's disease

Background: Videocapsule endoscopy (VCE) is a non-invasive method for examining the small bowel. Nevertheless VCE retention is the most significant complication of these devices and may occur in any location of the gastrointestinal tract. A patency capsule (PC) is used to safely perform VCE, in patients with an increased risk of VCE retention. A recent report raised some concerns about PC safety in 2 patients with suspected CD, but there were some limitations since one of the PC expiry date was exceededhttps://planner.smart-abstract.com/ecco2017/submission/en/abstract/4483/content#. Our aim was to assess the safety of PC in patients with Crohn's disease (CD) or suspected CD, in routine clinical practice. Methods: Retrospective single-center study including patients with CD or suspected CD with clinical indication for VCE, between January 2011 and October 2016. PillCam PC (Given Imaging®) was performed in all patients to access small-bowel patency, without previous bowel preparation. PC detection was performed 30 hours after ingestion with radiofrequency identification (RFID) scanner. Patients with a positive identification of PC were considered to not have patency of the gastrointestinal tract and did not performed VCE. Symptomatic PC retention was defined as the presence of typical obstructive abdominal symptoms (i.e. postprandial colicky abdominal pain/bloating/vomiting). Results: During the period of the study, were performed 451 PC (60% women, with a mean age of 39±13 years). Fifty-eight per cent of cases had a suspected CD and 42% of cases had a previous diagnosis of CD. Twenty-seven per cent of cases had a known or suspected small-bowel stenosis detected by previous ileocolonoscopy or abdominal imaging and 26% of cases had a history of previous abdominal surgery. The retention rate 30h after PC ingestion was 27% (31% in patients with CD vs. 24% in patients with suspected CD, p>0.05). All 322 patients with confirmed small bowel patency performed VCE, without incidents. Six (1.3%) patients presented a symptomatic PC retention (5 with CD and 1 with suspected CD, p>0.05). Two (0.4%) cases (with CD) were admitted due to small-bowel obstruction, which was successfully managed with corticosteroids. Conclusions: The PC test has proven to be a safe modality for securing small bowel patency prior to capsule endoscopy, with reduced frequency of symptomatic retention, which occurred almost exclusively in patients with a previous diagnosis of CD.

Use of patency capsule in patients with established Crohn's disease.

Video capsule endoscopy (VCE) is invaluable in the diagnosis of small-bowel pathology. Capsule retention is a major concern in patients with Crohn's disease. The patency capsule was designed to evaluate small-bowel patency before VCE. However, the actual benefit of the patency capsule test in Crohn's disease remains unclear. The aim of this study was to evaluate the clinical impact of patency capsule use on the risk of video capsule retention in patients with established Crohn's disease. This was a retrospective, multicenter study of patients with established Crohn's disease who underwent VCE for clinical need. The utilization strategy for the patency capsule was classified as selective (only in patients with obstructive symptoms, history of intestinal obstruction or surgery, or per treating physician's request) or nonselective (all patients with Crohn's disease). The main outcome was video capsule retention in the entire cohort and within each utilization strategy. A total of 406 patients who were referred for VCE were included in the study. VCE was performed in 132 /406 patients (32.5 %) without a prior patency capsule test. The patency capsule test was performed in 274 /406 patients (67.5 %) and was negative in 193 patients. Overall, VCE was performed in 343 patients and was retained in the small bowel in 8 (2.3 %). In this cohort, the risk of video capsule retention in the small bowel was 1.5 % without use of a prior patency capsule and 2.1 % after a negative patency test (P = 0.9). A total of 18 patients underwent VCE after a positive patency capsule test, with a retention rate of 11.1 % (P = 0.01). Patency capsule administration strategy (selective vs. nonselective) was not associated with the risk of video capsule retention. Capsule retention is a rare event in patients with established Crohn's disease undergoing VCE. The risk of video capsule retention was not reduced by the nonselective use of the patency capsule. Furthermore, VCE after a positive patency capsule test in patients with Crohn's disease was associated with a high risk of video capsule retention.

Clinical usefulness of transabdominal ultrasonography prior to patency capsule for suspected small-bowel strictures

Objective: Patency capsule (PC) examination has made it possible to perform capsule endoscopy (CE) in patients with a suspected small-bowel stricture. However, PC has some drawbacks, so we assessed the usefulness of transabdominal ultrasonography (TUS) prior to PC in patients with suspected small-bowel strictures to avoid unnecessary PC examination. Patients and methods: Fifty-two patients who underwent TUS prior to PC were enrolled in this study. TUS findings were classified as follows: intestinal narrowing and distension at the oral side (Type A); extensive bowel wall thickening (Type B); focal bowel wall thickening (Type C) or no abnormality detected (Type D). We evaluated the TUS and PC findings for the detection of small-bowel strictures. Results: Double-balloon endoscopy (DBE) revealed small-bowel strictures in 13 of 50 patients (26%). TUS yielded Type B or C findings in 12 of 13 patients (92%), while PC revealed strictures in all 13 patients. In Crohn’s disease (CD) patients with Type B TUS findings, 8 of 9 (89%) had small-bowel strictures on DBE. However, only two of six non-CD patients (33%) with Type B TUS findings had small-bowel strictures. The incidence of Type B strictures was significantly higher in CD patients. Conclusions: CD patients with Type B TUS findings should not undergo PC or CE because of the high rate of small-bowel strictures. Non-CD patients diagnosed with Type B TUS strictures, as well as patients diagnosed with Type C or D strictures should undergo CE after confirming small-bowel patency using PC.

Clinical Utility of Patency Capsule in Pediatric Video Capsule Endoscopy

Introduction: Capsule Endoscopy retention is a concern among pediatric patients who undergo video capsule endoscopy. The patency capsule(PC) has been used to determine small bowel patency. An abdominal x-ray is often used to determine if the PC has passed through the small bowel within 30 hrs. We report our experience of the use of the agile patency capsule in pediatric capsule endoscopy. Methods: We retrospectively reviewed the use of the (PC) in our cohort of 528 pediatric patients undergoing capsule endoscopy. There were 86 patency capsules performed. Patients ingested the patency capsule 30 hours prior to obtaining an abdominal x-ray. The abdominal x-ray was read by radiologists and also by the gastroenterologist performing the capsule endoscopy study. The indications for the patency capsule evaluation included known Crohn's disease 38 (44.2%) and Ulcerative Colitis 5 (5.81%). Results: 86 patients underwent patency capsule study along with and abdominal x-ray prior to capsule endoscopy. In 40 (46.5%) of abdominal x-rays, the PC was not seen at 30 hours post ingestion, confirming complete passage throgh the GI tract. In 44 (51.2%) abdominal x-rays, the radiologist reported presence of the PC in the abdomen. In 27(31.4%) of these 86 x-rays where the PC was noted in the abdomen, the radiologist commented that the PC was in the colon. In 15 (17.4%) abdominal x-rays, the location of the PC was not specifically identified to be within the colon. Instead, it was reported to be in various locations such as the right lower quadrant. The gastroenterologist therefore was required to further interpret these x-ray studies to determine whether these 15 PCs were in the colon. In 2 (2.3%) abdominal x-rays studies, the radiologist interpreted the capsule to be in the distal ileum or cecal region. These PC's were confirmed by colonoscopy to be retained in the distal ileum. Capsule endoscopy was therefore not performed on these two patients. The remaining 84 patients sucessfully completed video capsule endoscopy. The patency capsule retention rate within the small bowel at 30 hours post injestion was found to be 2.3% of patency capsule studies. Conclusion: The patency capsule is useful in preventing capsule endoscope retention and often requires careful interpretation by both the radiologist and the gastroenterologist.Figure 1Figure 2

Detection of Small Bowel Mucosal Healing and Deep Remission in Patients With Known Small Bowel Crohn's Disease Using Biomarkers, Capsule Endoscopy, and Imaging.

Mucosal healing (MH) and deep remission (DR) are associated with improved outcomes in Crohn's disease (CD). However, most of the current data pertain to colonic MH and DR, whereas the evidence regarding the prevalence and impact of small bowel (SB) MH is scarce. The aim of this study was to to evaluate the prevalence of SBMH and DR in quiescent SBCD. Patients with known SBCD in clinical remission (CDAI<150) or with mild symptoms (CDAI<220) were prospectively recruited and underwent video capsule endoscopy after verification of SB patency. Inflammation was quantified using the Lewis score (LS). SBMH was defined as LS<135, whereas a significant inflammation was defined as LS>790. Clinico-biomarker remission was defined as a combination of clinical remission and normal biomarkers. DR was defined as a combination of clinico-biomarker remission and MH. Fifty-six patients with proven SB patency were enrolled; 52 (92.9%) patients were in clinical remission and 21 (40.4%) in clinico-biomarker remission. SBMH was demonstrated in 8/52 (15.4%) of patients in clinical remission. Moderate-to-severe SB inflammation was demonstrated in 11/52 (21.1%) of patients in clinical remission and in 1/21 (4.7%) of patients in clinical and biomarker remission. Only 7/52 (13.5%) patients were in DR. SB inflammation is detected in the majority of CD patients in clinical and biomarker remission. SBMH and DR were rare and were independent of treatment modality. Our findings represent the true inflammatory burden in quiescent patients with SBCD.

Prediction of patency capsule retention in known Crohn's disease patients by using magnetic resonance imaging

Evaluation of small-bowel patency is recommended before swallowing video capsule endoscopy to prevent capsule retention. This study aimed to evaluate the ability of magnetic resonance enterography (MRE) to predict patency capsule (PC) retention in patients with Crohn's disease and to identify the most predictive imaging features for retention. Fifty-seven patients prospectively underwent MRE and PC. Two radiologists predicted PC retention. Interrater reliability was determined by using Cohen's κ coefficient. The sensitivity, specificity, and positive and negative predictive values were calculated for the predictions. Evaluation of the imaging features was done using the t test and receiver-operating characteristics; t-tests were also performed on the clinical parameters. The κ value for interrater reliability was 0.58. The sensitivity, specificity, PPV, and NPV for the predictions by the 2 radiologists were 92.3%, 59%, 40%, 96.3%, and 100%, 52.3%, 38.2%, 100%, respectively. The maximal stricture length (9.7 ± 3.66 cm vs 7.0 ± 3.08 cm, P = .04) and the number of prestenotic dilations (1.9 ± 1.07 vs 1.0 ± 1.38, P = .03) were associated with PC retention. The area under the receiver-operating characteristic curves was 0.69 for the maximal stricture length and 0.751 for the number of prestenotic dilations. The phenotype of the disease was the only clinical parameter significantly correlated with PC retention. MRE has a high NPV and sensitivity for PC retention. When capsule retention is suggested by MRE, PC should be performed before the video capsule endoscopy examination. The maximal stricture length and the number of prestenotic dilations were found to be the most predictive imaging features for PC retention.

Small bowel patency assessment using the patency device and a novel targeted (limited radiation) computed tomography-based protocol.

Excretion of the patency capsule (PC) within a certain time frame may be used to demonstrate luminal patency prior to capsule endoscopy (CE). We aimed to determine how often further radiological imaging is needed to confirm luminal patency after PC, assess radiologists' ability to locate the PC on plain abdominal films, and evaluate the outcomes of a novel computed tomography (CT) protocol for PC localization. A study of the ability of radiologists to localize PC using plain abdominal films was performed. A novel protocol targeting a limited CT at the level of the PC identified on the "scout" film if retained 30 h post-ingestion was prospectively evaluated in 400 consecutive patients undergoing PC. In a study of the confidence with which radiologists could localize the PC on plain films, radiologists preferred abdominal CT to localize PCs identified on plain films in 74% of cases. In a protocol based on the use of a PC and targeted, limited CT scan to confirm small bowel patency in those failing to excrete the PC 30 h post-ingestion, the sensitivity, specificity, positive, and negative predictive value were 99.4%, 90.0%, 99.7%, and 81.0%, respectively. Crohn's disease was the only statistically significant predictor associated with higher risk of luminal stricture (P=0.001) in post-hoc analysis. Excretion of the PC 30 h post-ingestion reliably predicts safe CE passage. Plain abdominal radiology is unreliable and a scout film targeted, limited CT scan offers an accurate minimal radiation method of determining small bowel patency.