Small Bowel Radiography Research Articles

Pyogenic granuloma of the ileum depicted by small-bowel radiography, capsule endoscopy and double balloon endoscopy

An 86-year-old woman was admitted because of occult obscure astrointestinal bleeding (OGIB). Capsule endoscopy (CE) showed polypoid lesion in the middle small bowel (Fig. 1A). Doubleontrast small bowel radiography revealed a semi-pedunculated olypoid lesion in the ileum, measuring 7 mm in size (Fig. 1B). ased on the radiographic findings, retrograde double balloon ndoscopy (DBE) was performed. The lesion was reddish in colour, nd the surface was covered with whitish exudates and slight ozing (Fig. 2A). The lesion was removed by endoscopic mucosal esection. Histological examination showed that the tumour was omposed of proliferation of capillary-sized vessels with mucosal

Peutz–Jeghers Syndrome in Capsule Endoscopy and Balloon Enteroscopy

Peutz–Jeghers syndrome (PJS) is a rare autosomal-dominant inherited disorder characterized by gastrointestinal hamartomas, mucocutaneous pigmentation, and an elevated cancer risk. Moreover, intussusception risk may be as high as 50% at the age of 20 years and is caused by large polyps. There is some evidence that endoscopic surveillance of PJS patients with removal of small intestinal polyps with a diameter of more than 15 mm efficiently prevents intussusceptions. In recent years, capsule endoscopy (CE) has largely replaced small-bowel radiography techniques to screen for small-bowel polyps. Magnetic resonance imaging may be equally efficient as CE for screening of large polyps. Balloon enteroscopy may be used for endoscopic snare resection of polyps. This article is part of an expert video encyclopedia.

Use and Misuse of Small Bowel Video Capsule Endoscopy in Clinical Practice

Video capsule endoscopy (VCE) was introduced into the United States in 2000 and has significantly advanced the ability to visualize the small intestinal mucosa by using noninvasive technology. Compared with traditional imaging with small bowel barium imaging, the use of VCE has demonstrated the ability to enhance diagnostic yield in patients with suspected small bowel pathology by approximately 25%‐50% in patients with suspected small bowel disorders. 1‐3 Although the use of VCE has been recommended as the next step in patients with obscure gastrointestinal hemorrhage after a negative upper and/or lower endoscopic examination, 4 its use in other clinical scenarios such as small bowel inflammatory disorders may not be associated with similar diagnostic yields. The major complication associated with the use of VCE remains small bowel retention. Although the risk of this event is virtually nil in patients with obscure bleeding, it can approach 10% in patients with known inflammatory bowel disease (IBD). 5 A critical appraisement of appropriate use of this technology may help physicians and third-party payers to determine which subset of patients with suspected or known small bowel disorders would benefit the most from undergoing a VCE procedure. To critically examine the use of VCE in clinical practice, an evidence-based approach was performed by using the GRADE system, 6,7 and a critical review of the literature on capsule endoscopy was performed by using PubMed, SCOPUS, and the Cochrane Database from 2000‐2012. The quality of evidence could range from high (implying that further research was unlikely to change the authors’ confidence in the estimate of the effect) to moderate (further research would be likely to have an impact on the confidence in the estimate of effect) or low (further research would be expected to have an important impact on the confidence in the estimate of the effect and would be likely to change the estimate). The strength of a recommendation was graded as strong when the desirable effects of an intervention clearly outweigh the undesirable effects and as conditional when there was uncertainty about the tradeoffs. The evidence-based statements generated from this review are shown in Table 1. Studies including more than 20 patients were included for each topic to increase data quality when metaanalyses or randomized controlled trials were not available.

Surgical management of small bowel metastases from primary carcinoma of the lung

To investigate the treatment and outcomes in a series of seven cases of small bowel metastases from lung cancer. A total of 4114 patients with lung cancer were referred to this institution from 1995 to 2005. Seven (0.17%) developed symptomatic small bowel metastasis and were treated surgically. The clinical, radiological, and pathological records were reviewed. Small bowel metastases were diagnosed from 0 to 31months (mean 11.5months) after the diagnosis of lung cancer. The clinical symptoms at presentation were acute peritonitis in two patients and abdominal pain in five. Small bowel metastasis was suspected on abdominal X-ray in three cases, computed tomography in two, small bowel radiography in one, and endogastroduodenoscopy in one. All patients underwent surgery and there were no perioperative deaths. Intestinal resection was performed in five cases and a bypass in two. A small bowel metastasis was found in the ileum in four patients. The mean survival period was 7.7months after surgery. One patient lived for 22months after bowel resection. Oral intake was possible 1month after surgery in six cases. Surgical management should be considered as palliative treatment in patients with a bowel obstruction or peritonitis caused by primary lung cancer.

Double-Contrast Barium Enteroclysis as a Patency Tool for Nonsteroidal Anti-Inflammatory Drug-Induced Enteropathy

Evaluating small bowel patency is recommended for capsule endoscopy in patients suspected of nonsteroidal anti-inflammatory drug-induced (NSAID) enteropathy. The aim of this investigation was to examine whether radiography is a candidate of patency tool in NSAID enteropathy. We reviewed double-contrast barium enteroclysis in 21 patients with NSAID enteropathy diagnosed either by capsule endoscopy or balloon-assisted endoscopy. The endoscopic findings were classified into circular ulcers, linear ulcers and small mucosal defects. The radiographic signs of the corresponding endoscopic findings were retrieved and the depiction rate was calculated. Of the 21 patients, endoscopy detected circular ulcers, linear ulcers, and small ulcers in 12, 3 and 12 patients, respectively. Small bowel radiography depicted circular narrowing as pseudo-folds in 10 patients (83%) and linear ulcers as eccentric rigidity in 2 patients (67%). However, radiography was able to depict small mucosal defects in only 3 patients (17%). Two of 5 patients with pseudo-folds experienced retention of the capsule. "Pseudo-folds" is a sign corresponding to circular ulcer in NSAID enteropathy, which may be predictive of capsule retention.

1. Small Bowel Radiography

1. Small Bowel Radiography

Response to Doherty, Moss, and Cheifetz

To the Editor: We thank Doherty et al. (1) for their interest in our article as well as for their valuable comments. The data in our meta-analysis (2) and our conclusions were based on prior studies included in the analysis. We realize that many of the studies had limitations that would influence the interpretation of our data. For example, it is clear that false-positive capsule endoscopy (CE) findings as well as selection bias in the published studies we analyzed are among the limitations. In the only prospective, blinded study comparing CE, computed tomography (CT) enterography, small bowel radiography and colonoscopy, the sensitivity of CE and CT enterography was identical. However, the specificity of CE was significantly lower than other tests (3) possibly indicating higher false-positive rate. We thoroughly agree with Dougherty et al. (1) that a standardized grading scale for CE findings is indeed important and should be applied to future studies to improve specificity and overall diagnostic accuracy of CE in the diagnosis of small bowel inflammation and suspected Crohn's disease.

Does Capsule Endoscopy Improve Outcomes in Obscure Gastrointestinal Bleeding? Randomized Trial Versus Dedicated Small Bowel Radiography

Capsule endoscopy improves the diagnostic yield in patients with obscure gastrointestinal (GI) bleeding, but whether it improves outcomes is uncertain. Patients with obscure GI bleeding and negative upper endoscopy, colonoscopy, and push enteroscopy were randomly assigned to capsule endoscopy or dedicated small bowel contrast radiography. Patients returned at 1, 2, 3, 6, 9, and 12 months for follow-up visits and to check hemoglobin level. The primary endpoint was further bleeding. The predefined sample size of 136 patients (54 overt bleeding, 82 occult bleeding) was enrolled. Diagnostic yield was 20 (30%) with capsule vs 5 (7%) with radiography (difference = 23%; 95% CI: 11%-36%). Further bleeding with capsule versus radiography occurred in 20 (30%) versus 17 (24%) (difference, 6%; 95% confidence interval [CI], -9% to 21%), subsequent diagnostic or therapeutic interventions for bleeding were performed in 17 (26%) versus 15 (21%) (difference, 4%; 95% CI, -10% to 19%), subsequent hospitalizations for bleeding were required in 8 (12%) versus 4 (6%) (difference, 6%; 95% CI, -3% to 16%), and subsequent blood transfusions were given in 5 (8%) versus 4 (6%) (difference, 2%; 95% CI, -7% to 10%). Further bleeding was more common in patients presenting with overt bleeding than in those with occult bleeding (21/54 [39%] vs 16/82 [20%]; difference, 19%; 95% CI, 4% to 35%). The significant improvement in diagnostic yield with capsule endoscopy may not translate into improved outcomes in a population with obscure GI bleeding. Most patients do well whether or not abnormalities are identified, and additional diagnostic or therapeutic interventions may be required whether or not capsule endoscopy identifies a source of bleeding.

Capsule Endoscopy Has a Significantly Higher Diagnostic Yield in Patients With Suspected and Established Small-Bowel Crohn's Disease: A Meta-Analysis

Capsule endoscopy (CE) has demonstrated superior performance compared with other modalities in its ability to detect early small-bowel (SB) Crohn's disease (CD), especially when ileoscopy is negative or unsuccessful. The aim of this study was to evaluate the diagnostic yield of CE compared with other modalities in patients with suspected and established CD using a meta-analysis. A thorough literature search for prospective studies comparing the diagnostic yield of CE with other modalities in patients with CD was undertaken. Other modalities included push enteroscopy (PE), colonoscopy with ileoscopy (C+IL), SB radiography (SBR), computed tomography enterography (CTE), and magnetic resonance enterography (MRE). Data on diagnostic yield among various modalities were extracted, pooled, and analyzed. Data on patients with suspected and established CD were analyzed separately. Weighted incremental yield (IYW) (diagnostic yield of CE-diagnostic yield of comparative modality) and 95% confidence intervals (CIs) of CE over comparative modalities were calculated. A total of 12 trials (n=428) compared the yield of CE with SBR in patients with CD. Eight trials (n=236) compared CE with C+IL, four trials (n=119) compared CE with CTE, two trials (n=102) compared CE with PE, and four trials (n=123) compared CE with MRE. For the suspected CD subgroup, several comparisons met statistical significance. Yields in this subgroup were CE vs. SBR: 52 vs. 16% (IYw=32%, P<0.0001, 95% CI=16-48%), CE vs. CTE: 68 vs. 21% (IYw=47%, P<0.00001, 95% CI=31-63%), and CE vs. C+IL: 47 vs. 25% (IYw=22%, P=0.009, 95% CI=5-39%). Statistically significant yields for CE vs. an alternate diagnostic modality in established CD patients were seen in CE vs. PE: 66 vs. 9% (IYw=57%, P<0.00001, 95% CI=43-71%), CE vs. SBR: 71 vs. 36% (IYw=38%, P<0.00001, 95% CI=22-54%), and in CE vs. CTE: 71 vs. 39% (IYw=32%, P=or<0.0001, 95% CI=16-47%). Our meta-analysis demonstrates that CE is superior to SBR, CTE, and C+IL in the evaluation of suspected CD patients. CE is also a more effective diagnostic tool in established CD patients compared with SBR, CTE, and PE.

Enteroscopy in the Diagnosis and Management of Crohn Disease

Crohn disease is a chronic disorder that can affect any part of the gastrointestinal tract, and is characterized by mucosal and transmural inflammation of the bowel wall. The disease most commonly involves the small bowel. Evaluation of patients with suspected Crohn disease has traditionally involved the use of ileocolonoscopy, push enteroscopy, and barium small bowel radiography. A large proportion of patients with mild small bowel disease or involvement of the mid small bowel can potentially be missed if only these tests are utilized. Enteroscopy is defined as direct visualization of the small bowel using a fiber optic or wireless endoscope. Following recent advances in technology, enteroscopy currently plays a pivotal role not only in the diagnosis of small bowel Crohn disease but also in the management of its complications, such as bleeding and strictures. Enteroscopy may have additional roles in the future, including the objective assessment of mucosal response to therapy, and surveillance for small bowel malignancy. This article focuses on the utility of enteroscopy, and its advantages and limitations in the evaluation and longterm management of Crohn disease.

Does Capsule Endoscopy Improve Outcomes in Obscure GI Bleeding: Randomized Controlled Trial of Capsule Endoscopy vs. Dedicated Small Bowel Radiography

Capsule endoscopy (CE) increases diagnostic yield in patients with obscure GI bleeding, but whether CE also improves outcomes is uncertain. We performed a randomized trial of CE vs. dedicated small bowel contrast radiography (SB) to assess outcomes in patients with obscure GI bleeding. Our primary hypothesis was that the improved diagnostic yield of CE would lead to a decrease in further bleeding. Methods: Patients with obscure GI bleeding and negative EGD, colonoscopy, and push enteroscopy were randomly assigned to CE or SB.

Combining two imaging techniques is best to diagnose small-bowel Crohn's disease

In most patients with Crohn's disease, diagnostic gastrointestinal lesions are located in the small bowel, which is not easily accessible to direct investigation. This commentary focuses on an article by Solem et al., which compared the utility of four primary small-bowel imaging modalities (CT enterography, ileocolonoscopy, capsule endoscopy, and small-bowel follow-through) in diagnosis of active small-bowel Crohn's disease. Capsule endoscopy had lower diagnostic specificity than the other techniques. This result, in conjunction with the need to perform preliminary small-bowel radiography to detect asymptomatic, partial, small-bowel obstructions, makes capsule endoscopy a poor choice as a first-line test for Crohn's disease. We concur with Solem et al.'s opinion that a combination of two of the other available imaging methods is the best diagnostic option for small-bowel Crohn's disease, although the choice of which two to use should be based on the facilities and expertise that are available locally.

The Role of Capsule Endoscopy in the Evaluation of Crohn&amp;s Disease

Crohn&s disease (CD) is a systemic granulomatous disorder that may involve any part of the alimentary tract: the small bowel is the affected site in 30-40% of cases. CD remains a clinical diagnosis based on a typical clinical history, physical examination, small-bowel radiography, and ileocolonoscopy with biopsy. Conventional endoscopic techniques are limited by the length and multiple, complex looped configurations of the small bowel, and mild lesions confined to the mucosa may be missed by barium-contrast radiographs and computerized tomographic (CT) scans. The diagnosis becomes even more difficult if symptoms are atypical, and a missed diagnosis can profoundly affect clinical care and patient outcome. Capsule endoscopy allows direct visualization of the entire small-bowel mucosa. A number of recently published studies report diagnostic yields of >70% for CD from capsule endoscopy in patients with negative or inconclusive findings on prior small-bowel series and ileocolonoscopy. Capsular endoscopy examination has been shown to be a very effective diagnostic tool in patients with a high clinical probability of having the disease, but whose classic endoscopic and radiographic studies have been negative. This review offers a brief introduction to capsule endoscopy, a recap of clinical studies on capsular endoscopy in evaluating CD, and a description of expectations for this technology in future clinical practice.

Double contrast small-bowel radiography in the preoperative assessment of Crohn’s disease: Is it still useful?

To evaluate the usefulness of double contrast small-bowel radiography (SBR) in the preoperative assessment of patients with Crohn's disease (CD). Thirty-nine consecutive patients who underwent surgery for CD between 2000 and 2004, preceded by a preoperative small-bowel series evaluation, were enrolled in our study. The radiologic findings were compared with the intraoperative findings. Small-bowel radiography was associated with good specificity and sensitivity for the detection of stenosis. Although its main limitation was a remarkable overestimation of stenosis, the main indications for surgery were always confirmed. Sensitivity and specificity were lower for the detection of internal fistulas and the correlation was significant only for SBR performed within 3 months of the operation; however, the concordance between radiological and operative findings was greater. No correlation was observed for the detection of an abdominal mass. Small-bowel radiography is still reliable for evaluating stenoses and internal fistulas. However, magnetic resonance imaging or computed tomography is mandatory to evaluate an abdominal mass.

Is Small-Bowel Radiography Necessary Before Double-Balloon Endoscopy?

Small-bowel radiography may be replaced by enteroscopy in the diagnosis of small-intestine lesions. We retrospectively elucidated the diagnostic yield of small-bowel radiography performed before double-balloon endoscopy. One hundred twenty-four patients who underwent double-balloon endoscopy during the period 2004-2006 were classified into those with abnormal radiographic findings (n = 45), normal radiographic findings (n = 31), and no small-bowl radiographs (n = 48). The classification was based on the use of small-bowel radiography and the diagnosis before double-balloon endoscopy. The indications for, approaches to, and diagnostic yields of double-balloon endoscopy were compared for the three groups. The diagnostic yield of small-bowel radiography was considered positive when any sign of pathologic change in the small bowel was identified. The diagnostic yield of double-balloon endoscopy was considered positive when endoscopic or biopsy findings explained the clinical manifestations. The group with abnormal findings on small-bowel radiography was younger (15-86 years) and less frequently had obscure bleeding (8.9%) than the group with normal findings on small-bowel radiography (age, 17-84 years; frequency of obscure bleeding, 45.2%) (p = 0.01) or the group without small-bowel radiographs (age, 15-91 years; frequency of obscure bleeding, 64.6%) (p < 0.0001). The positive diagnostic yield of double-balloon endoscopy was highest in the group with abnormal findings on small-bowel radiography (71.1%), followed by the group with no small-bowel radiographs (45.8%) and the group with normal findings on small-bowel radiography (35.5%) (p = 0.0002). Among patients who did undergo small-bowl radiography, the accuracy of the technique was 68.4%, the positive predictive value was 71.1%, and the negative predictive value was 64.5%. The positive diagnostic yields of small-bowel radiography and double-balloon endoscopy were not statistically different (59.2% for small-bowel radiography, 56.6% for double-balloon endoscopy; p > 0.1). The diagnostic accuracy of double-balloon endoscopy seems to improve if the procedure is preceded by small-bowel radiography.

Small-bowel imaging in Crohn's disease: a prospective, blinded, 4-way comparison trial

With the introduction of new techniques to image the small bowel, there remains uncertainty about their role for diagnosing Crohn's disease. To assess the sensitivity and specificity of capsule endoscopy (CE), CT enterography (CTE), ileocolonoscopy, and small-bowel follow-through (SBFT) in the diagnosis of small bowel Crohn's disease. Prospective, blinded trial. Inflammatory bowel disease clinic at an academic medical center. Known or suspected Crohn's disease. Exclusion criteria included known abdominal abscess and non-steroidal anti-inflammatory drug (NSAID) use. Partial small-bowel obstruction (PSBO) at CTE excluded patients from subsequent CE. Patients underwent all 4 tests over a 4-day period. Sensitivity, specificity, and accuracy of each test to detect active small-bowel Crohn's disease. The criterion standard was a consensus diagnosis based upon clinical presentation and all 4 studies. Forty-one CTE examinations were performed. Seven patients (17%) had an asymptomatic PSBO. Forty patients underwent colonoscopy, 38 had SBFT studies, and 28 had CE examinations. Small-bowel Crohn's disease was active in 51%, absent in 42%, inactive in 5%, and suspicious in 2% of patients. The sensitivity of CE for detecting active small-bowel Crohn's disease was 83%, not significantly higher than CTE (83%), ileocolonoscopy (74%), or SBFT (65%). However, the specificity of CE (53%) was significantly lower than the other tests (P < .05). One patient developed a transient PSBO due to CE, but no patients had retained capsules. Use of a consensus clinical diagnosis as the criterion standard-but this is how Crohn's disease is diagnosed in practice. The sensitivity of CE for active small-bowel Crohn's disease was not significantly different from CTE, ileocolonoscopy, or SBFT. However, lower specificity and the need for preceding small-bowel radiography (due to the high frequency of asymptomatic PSBO) may limit the utility of CE as a first-line test for Crohn's disease.

Performance Characteristics of the Suspected Blood Indicator Feature in Capsule Endoscopy According to Indication for Study

The suspected blood indicator (SBI) feature of wireless capsule endoscopy (WCE) was developed for rapid screening of intestinal lesions with bleeding potential. Our aim was to assess the accuracy and performance characteristics of the SBI according to the indications for study in a large cohort of patients. We reviewed collected data on all WCE studies performed at Johns Hopkins Hospital from January 2006 to June 2007. Study indications were as follows: anemia of unknown origin (n = 53), obscure gastrointestinal bleeding (n = 112), suspected Crohn's disease (n = 122), and other (n = 4). Concordant and discordant findings between gastroenterologists' readings and SBI were recorded for each patient. A total of 221 lesions with bleeding potential was detected. The overall sensitivity, specificity, positive predictive value, and negative predictive value for the SBI were 56.4%, 33.5%, 24.0%, and 67.3%, respectively. For actively bleeding lesions, the SBI sensitivity and positive predictive value were only 58.3% and 70%, respectively. The sensitivity was highest (64%) in patients undergoing WCE for suspected Crohn's disease, with a negative predictive value of 80.4%. The sensitivity was only 58.3% and 41.3%, respectively, in studies performed for obscure gastrointestinal bleeding and anemia. Performance characteristics of the currently available SBI feature in WCE are suboptimal and insufficient to screen for lesions with bleeding potential. Even in patients with active intestinal bleeding, the sensitivity of SBI was less than 60%, which is lower than previously reported. However, in patients with suspected Crohn's disease, the high sensitivity and negative predictive value of SBI may make it a useful tool for the detection of large areas of abnormal mucosa.

Recent advances of endoscopy in inflammatory bowel diseases.

Endoscopy plays a key role in the diagnosis and treatment in inflammatory bowel disease (IBD). The most valuable tool for distinguishing different types of IBD is a complete ileocolonoscopy with mucosal biopsy. Endoscopic localization of the disease not only aids in determining prognosis and appropriateness of medical therapies but also aids decision-making in those undergoing surgical therapy. With regard to therapeutic applications, obstructive symptoms caused by benign fibrotic strictures can be treated adequately by endoscopic balloon dilation. Epidemiological studies have demonstrated an increased risk of colorectal cancer in patients with both ulcerative colitis and colonic Crohn's disease (CD). Colonoscopy is currently considered to be the gold standard for cancer surveillance. Published guidelines recommend that two to four biopsy samples should be obtained every 10 cm in the colorectum, necessitating 20-50 samplings per examination. This may result in standard colonoscopy - which is also very time-consuming and laborious - missing significant numbers of small lesions. Various novel techniques have been applied to reduce the required number of biopsy samples and the duration of examinations, including chromoendoscopy with or without magnification, fluorescence endoscopy, narrow-band imaging, optical coherence tomography, and confocal laser endomicroscopy. Until recently the only way to evaluate the small-bowel mucosa in a patient with CD was by barium small-bowel radiographs and intubation of the distal terminal ileum. Both wireless-capsule endoscopy (WCE) and double-balloon enteroscopy (DBE) allow light to be used in the inspection of the small bowel and may replace radiological methods. WCE is more convenient than DBE for probing small-bowel mucosal changes, but only DBE allows a biopsy sample to be obtained from the deep small bowel, and these two examinations can be considered complementary. The wider application of new techniques in the near future might increase the role played by endoscopy in the management of IBD.

Mucosal Atrophy in Celiac Disease: Extent of Involvement, Correlation With Clinical Presentation, and Response to Treatment

Wireless capsule endoscopy provides an opportunity to study the macroscopic features in celiac disease by providing a magnified view of the intestinal mucosa. In this study, we evaluated the following: (1) the distribution of atrophy in untreated celiac disease, (2) the correlation between extent of changes and clinical manifestations, (3) the accuracy and interobserver agreement of wireless capsule endoscopy assessment, and (4) the effect of gluten withdrawal. Thirty-eight consecutive patients with untreated biopsy-proven celiac disease underwent wireless capsule endoscopy. Each subject was invited to undergo repeat testing after at least 6 months of gluten withdrawal. The video images of each patient were reviewed independently by 2 investigators. Thirty-five (92%) subjects had visible atrophy detected by capsule endoscopy. Twenty-two (59%) subjects showed an extensive enteropathy, 12 (32%) had enteropathy limited to the duodenum, and only 1 had a jejunal enteropathy. No association was shown between the extent of the lesion and clinical manifestations. Capsule endoscopy had a better overall sensitivity for the detection of atrophy as compared with upper endoscopy (92% vs 55%, P = .0005), with a specificity of 100%. The overall interobserver agreement for the 2 reviewers was relatively high (% total agreement, 86.5%). After gluten withdrawal, the extent and the pattern of atrophy improved both qualitatively and quantitatively. Celiac disease affects a highly variable portion of the small intestine starting at the duodenum. The extent of visible enteropathy does not explain differences in clinical presentation. Most subjects with visually detected villous atrophy showed a clinically significant improvement after gluten withdrawal.

Lactoferrin Assessment of Rectal Effluent as an Aid to Colonoscopy for Determining Intestinal Inflammation

Purpose: Accurate evaluation of intestinal inflammation is vital in the management of inflammatory bowel disease (IBD) patients. A limitation of conventional colonoscopy is the inability to visualize the entire intestinal tract. Fecal lactoferrin, a marker of intestinal inflammation, may function as an aid to colonoscopy for assessing IBD patients. Our aim was to evaluate lactoferrin levels in rectal effluent in conjunction with colonoscopy to assess the presence of inflammation in IBD patients undergoing screening or diagnostic colonoscopy. Methods: Fifty-nine adult IBD patients from a single tertiary care center were enrolled. Each subject provided a sample of the effluent passed towards the end of the bowel preparation procedure prior to colonoscopy. The specimens were screened for elevated lactoferrin using the IBD-CHEK®, a commercially available enzyme-linked immunosorbent assay (ELISA) (TechLab, Blacksburg). There were 27 active patients and 32 inactive patients based on colonoscopy and histology. Results: Forty-four Crohn's disease (CD) and 15 ulcerative colitis patients were included in the study. The median age was 44 (22–72) and there were 42 females and 17 males. The lactoferrin ELISA had 74.1% sensitivity, 84.4% specificity, and 79.7% correlation with colonoscopic findings. Five patients characterized as inactive by colonoscopy had moderately high lactoferrin levels. Four of these patients had Crohn's disease, and the elevated lactoferrin may represent inflammation unseen by conventional colonoscopy. This suggests a role for lactoferrin testing to help target CD patients requiring additional testing such as small bowel radiography. Seven samples with endoscopically defined inflammation were negative on the lactoferrin ELISA. Conclusion: Rectal effluent samples are easily obtained with a relatively high degree of patient compliance. Testing for lactoferrin provides an aid to colonoscopy for determining intestinal inflammation. A positive lactoferrin result in an endoscopically inactive patient may indicate unresolved inflammation but further investigation is needed. A negative result in an effluent sample is not clinically relevant due to the potential dilution of lactoferrin during the bowel preparation procedure and should not be used to rule out the presence of intestinal inflammation.