Small Bowel Strictures Research Articles

The Utility of Patency Capsule in Patients With Crohn’s Disease

Background: Video capsule retention is a complication that can have serious consequences in patients with Crohn’s disease (CD). The patency capsule was developed to detect small bowel strictures. The usefulness of patency capsules in patients who do not have evidence of small bowel disease on imaging is uncertain. Study: This is a multicenter retrospective study of patients with suspected or confirmed CD who underwent a patency capsule study between January 2017 and February 2023. We excluded patients who were lost to follow-up or did not have computerized tomography or magnetic resonance imaging of the abdomen within 180 days before or after the patency capsule study. Results: A total of 105 patients met the inclusion criteria with 69% having a confirmed CD diagnosis. The majority of patients (95/105; 90.5%) passed their patency capsule. A total of 91 patients had their subsequent video capsule endoscopy (VCE), with 96.7% (88/91) successfully passing the capsule. Out of those who passed the VCE, 2 patients had patency capsule retention. Both had normal small bowel imaging. Meanwhile, the 3 patients who had VCE retention had evidence of small bowel disease in their imaging scans. The presence of abnormal small bowel wall thickening or stricture on imaging had a statistically significant association with VCE retention (P=0.02). Conclusion: Our study demonstrated a statistically significant association between small bowel disease on imaging and retention of both patency capsules and VCE. Small bowel imaging in patients with suspected or documented CD had a negative predictive value of 100% for VCE retention.

International expert guidance for defining and monitoring small bowel strictures in Crohn's disease on intestinal ultrasound: a consensus statement

Diagnostic imaging using CT enterography, magnetic resonance enterography, and intestinal ultrasound are important tools in evaluating stricturing Crohn's disease. Definitions of strictures have been developed for CT enterography and magnetic resonance enterography. However, expert recommendations for definitions and treatment response of strictures on intestinal ultrasound are not available. The aim of this study was to standardise definitions, diagnosis, and treatment response criteria in small bowel stricturing Crohn's disease on intestinal ultrasound. Using modified RAND-University of California Los Angeles Appropriateness Method, a diverse expert panel of 13 gastroenterologists, seven radiologists, and two patient representatives was assembled. A total of 466 statements on definitions and response to therapy of stricturing Crohn's disease on intestinal ultrasound were generated from a systematic review and from expert opinion, with subsequent rating for appropriateness. Two rounds of voting with an interposed survey result discussion were performed. Statements were classified as inappropriate, uncertain, or appropriate based on the median panel rating and degree of disagreement. Appropriateness was rated using a nine-point Likert scale (1 being inappropriate, 9 being highly appropriate). A naive or anastomotic small bowel Crohn's disease stricture on intestinal ultrasound is defined by the combination of bowel wall thickening, luminal narrowing, and pre-stenotic dilation. Bowel wall thickness is defined as being more than 3 mm. Luminal narrowing is defined as either a luminal diameter reduction of more than 50% in the narrowest area and relative to a normal adjacent bowel loop, or a luminal diameter of less than 1 cm. Pre-stenotic dilation is defined as more than 2·5 cm or an increase in bowel diameter relative to a normal adjacent bowel loop. Definitions for grading hyperaemia, inflammatory fat, wall stratification, intestinal ultrasound machine technical parameters, and image acquisition were also devised. Treatment response of strictures was defined as reduction in stricture length, bowel wall thickening, luminal narrowing, pre-stenotic dilation, and motility abnormalities. To our knowledge, this is the first intestinal ultrasound appropriateness rating exercise conducted for defining, diagnosing, and measuring response to therapy in small bowel stricturing Crohn's disease and informs future clinical use and intestinal ultrasound index development for clinical trials. Leona M and Harry B Helmsley Charitable Trust.

S3937 Location, Location, Location: A Case of Small Bowel Stricturing in a Crohn's Disease Patient Unrelated to Crohn's Disease

S3937 Location, Location, Location: A Case of Small Bowel Stricturing in a Crohn's Disease Patient Unrelated to Crohn's Disease

Endoscopic Diagnosis and Treatment of Benign Small Bowel Stricture

Benign small bowel strictures can occur in association with various conditions, including small bowel Crohn’s disease, nonsteroidal anti-inflammatory drug-induced enteritis, ischemic enteritis, intestinal tuberculosis, radiation enteritis, postoperative adhesions, and anastomotic strictures. Benign small bowel strictures are classified into two categories, low-grade and high-grade. Low-grade small bowel strictures involve a partial reduction of the internal diameter of the small intestine, causing slight obstruction of the passage of food and digestive fluids without significant bowel obstruction symptoms. By contrast, high-grade small bowel strictures involve a severe narrowing of the intestinal lumen, leading to marked obstruction of the passage of food and digestive fluids and pronounced bowel obstruction symptoms. Small bowel strictures can be diagnosed using various methods, including abdominal plain radiography, abdominal computed tomography, computed tomography enterography, magnetic resonance enterography, balloon-assisted enteroscopy, and abdominal ultrasound. Each diagnostic method has unique advantages and disadvantages as well as differences in diagnostic specificity and sensitivity. Therefore, even if small bowel strictures are not observed using a single imaging technique, their presence cannot be completely excluded. A comprehensive diagnosis that combines clinical information from multiple diagnostic modalities is necessary. Therapeutic approaches for managing small bowel strictures include medical therapy, endoscopic balloon dilation using balloon-assisted enteroscopy, and surgical methods such as strictureplasty and segmental resection. Endoscopic balloon dilation, in particular, can help reduce complications associated with repeated surgeries for strictures.

Prospective multicenter study to identify optimal target population for motorized spiral enteroscopy

Motorized spiral enteroscopy (MSE) enhances small bowel exploration, but the optimal target population for this technique is unknown. We aimed to identify the target population for MSE by evaluating its efficacy and safety, as well as detecting predictors of efficacy. A prospective multicenter observational study was conducted at 9 tertiary hospitals in Spain, enrolling patients between June 2020–2022. Analyzed data included demographics, indications for the procedure, exploration time, depth of maximum insertion (DMI), technical success, diagnostic yield, interventional yield, and adverse events (AE) up to 14 days from enteroscopy. Patients with prior gastrointestinal surgery, unsuccessful balloon enteroscopy and small bowel strictures were analyzed. A total of 326 enteroscopies (66.6% oral route) were performed in 294 patients (55.1% males, 65 years ± 21). Prior abdominal surgery was present in 50% of procedures (13.5% gastrointestinal surgery). Lower DMI (162 vs 275 cm, p = 0.037) and diagnostic yield (47.7 vs 67.5%, p = 0.016) were observed in patients with prior gastrointestinal surgery. MSE showed 92.2% technical success and 56.9% diagnostic yield after unsuccessful balloon enteroscopy (n = 51). In suspected small bowel strictures (n = 49), the finding was confirmed in 23 procedures (46.9%). The total AE rate was 10.7% (1.8% classified as major events) with no differences related to prior gastrointestinal/abdominal surgery, unsuccessful enteroscopy, or suspected small bowel strictures. The study demonstrates that MSE has a lower diagnostic yield and DMI in patients with prior gastrointestinal surgery but is feasible after unsuccessful balloon-enteroscopy and in suspected small bowel strictures without safety concerns.

Discrimination of pediatric cryptogenic multifocal ulcerous stenosing enteritis from small bowel Crohn's disease and gastrointestinal tuberculosis: A retrospective study (with videos).

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is a rare entity that mimics various inflammatory strictures of the small intestine. Pediatric literature is scarce. We analyzed the clinical, radiological, endoscopic and histopathological features of children with CMUSE that differentiate it from small bowel Crohn's disease (SBCD) and gastrointestinal tuberculosis (GITB). CMUSE was diagnosed by the following criteria: (1) unexplained small bowel strictures with superficial ulcers, (2) chronic/relapsing ulcers of small bowel after resection, (3) no signs of systemic inflammation, (4) absence of other known etiologies of small bowel ulcers. SBCD and GITB were diagnosed based on standard criteria. The clinical features, laboratory parameters, radioimaging, endoscopy (including video capsule endoscopy [VCE], intra-operative endoscopy), histopathological features and treatment outcome were noted. Out of 48,CMUSE was diagnosed in 13 (27%) isolated small bowel and ileocecal strictures, while GITB and SBCD accounted for 41% and 21% cases, respectively. Common presentations were sub-acute obstruction (46%), obscure gastrointestinal bleeding (38%) and protein-losing enteropathy (38%). CMUSE patients had significantly longer disease duration compared to SBCD and GITB (p < 0.001). SBCD (90.0%) and GITB (85%) cases had elevated C-reactive protein (CRP), none with CMUSE had elevated CRP (p < 0.001). The disease was localized in jejunum (100%) and proximal ileum (56%) in CMUSE, ileocecal region (85%) in GITB, but evenly distributed in small intestine in SBCD. Endoscopy showed evenly placed, superficial, circumferential ulcers with strictures in CMUSE, deep linear ulcers in SBCD and circumferential ulcers in GITB. Upfront immunosuppression was given in four; three (75%) of them relapsed. Only surgery was done in three with one (25%) having relapse. Upfront surgery followed by immunosuppression was used in six, but all relapsed and two required repeat surgery. CMUSE is important but underdiagnosed in children. Lack of constitutional symptoms, normal inflammatory parameters and characteristic ulcers with strictures helped in differentiating CMUSE from GITB and SBCD.

Nonsteroidal anti-inflammatory drug-induced small bowel strictures (diaphragm disease) – an under-recognized cause of small bowel obstruction

BackgroundSmall bowel obstruction is a major source of morbidity and mortality that carries a significant economic burden. Recurrent small bowel obstruction may be secondary to circumferential strictures (small bowel diaphragm disease), an under-recognized entity secondary to long-term NSAID use. We aim to describe the sensitivity of preoperative CT enterography in patients with surgically treated small bowel diaphragm disease. MethodsWe retrospectively reviewed adult patients who underwent elective small bowel resection for small bowel obstruction performed by a single minimally-invasive surgeon between 2010-2023. Patient history, radiographic, endoscopic, operative, and pathology reports were reviewed for reference to NSAID use, small bowel strictures, diaphragms, and enteropathy. Exclusion criteria were prior radiation, inflammatory bowel disease, malignancy, adhesive disease, and anastomotic strictures. ResultsA total of 225 patients were identified; of those, 22 patients (10%) met inclusion criteria. The mean age was 60.7 years (range 29-78), with 15 women (68%). All patients underwent minimally invasive small bowel resection for obstruction with histopathologic evidence of stricture without evidence of transmural inflammation, granuloma, or dysplasia and confirmed NSAID use (n=22; 100%). Anemia was present in 36% (n=8). Preoperative CT or MR enterography was performed in 18 patients (82%) and stricturing was reported in 13 patients (72%). Intraoperatively, palpation identified strictures in all patients. ConclusionNSAID-induced small bowel injury is an under-recognized condition that, in severe cases, can present as small bowel obstruction. Surgeons should consider diaphragm disease in patients with obstruction and NSAID use, in which preoperative CT or MR enterography may be useful but cannot rule out disease.

Clinical Application and Feasibility of Capsule Endoscopy in Children at a Medical Center in Central Taiwan

Background/PurposeCapsule endoscopy (CE) is a noninvasive examination for excellent visualization of small bowel mucosal lesions. We aimed to evaluate the clinical efficacy and safety of CE in pediatric patients. MethodsFrom April 2014 to December 2022, CE procedures performed in children younger than 18 years of age at Taichung Veteran General Hospital were analyzed retrospectively. ResultsAmong 136 procedures, the completion rate was 95.6% (n=130), with a median age of 14 years old. Suspicion or evaluation of inflammatory bowel diseases (IBD) (41%) was the most common indication for CE. Other common indications of CE were chronic unexplained abdominal pain (35%) and obscure gastrointestinal bleeding or iron deficiency anemia (21%). No procedure-related complications occurred. The diagnosis of those patients with incomplete study were CD with small bowel stricture, graft-versus-host disease and duodenal ulcers. A total of 86 CE procedures showed positive findings, and the overall diagnostic yield rate was 63.2%. Small bowel ulcers (65.12%) were the most common findings. Overall, 26.5% of CE examinations resulted in a new diagnosis and 44.9% of CE exams led to a change in therapy. For patients with IBD, CE findings resulted in an even higher therapeutic change rate of 48.1%. ConclusionsCE is a safe and feasible diagnostic method to study the small intestine in children, especially for IBD. Incomplete study could be an indicator of positive finding and can potentially be a guide to identify the site of possible strictures.

The Utility of Magnetic Resonance Enterography and Double Balloon Enteroscopy-Assisted Endoscopic Balloon Dilatation for Small Bowel Strictures in Crohn’s Disease: A Retrospective Observational Study

Introduction: Crohn’s disease (CD) of the small bowel is associated with a severe course and increased risk of complications. Strictures at this location are challenging to diagnose and out-of-reach of colonoscopy. We aimed to evaluate the detection rate of small bowel strictures with magnetic resonance enterography (MRE) and assess the efficacy of double balloon enteroscopy-assisted endoscopic balloon dilatation (DBE-assisted EBD) in managing these strictures. Methods: A retrospective study included all patients with DBE-assisted EBD of small bowel strictures in CD in our facility. All patients had MRE to detect strictures prior to the dilatation. Sequential dilatation protocol was performed using through-the-scope (TTS) working channel balloons. The outcomes included technical success defined by the passage of the enteroscope post-dilatation, resolution of symptoms, and the requirement of repeated procedures or surgery during 12 months of follow-up. Results: Twenty DBE-assisted EBDs of small bowel strictures were attempted during 13 DBE procedures in 10 patients (6 males, median age 42). MRE identified 75% of the strictures with 100% accuracy in localisation. Retrograde DBE was the approach in 16/20 (80%) strictures. Anaesthetic intubation was used in 8/20 (40%). DBE reached 19/20 strictures. All the reached strictures were dilated successfully; the technical success following dilatation was 72.2%. The median DBE insertion time with TTS balloon dilatation was 66 min. Three patients required follow-up dilatations within 2–3 months. Surgery was not needed during the follow-up period. Conclusions: MRE is essential in diagnosing and localising small bowel strictures in CD. DBE reached 95% of strictures with successful dilatation. Immediate technical success was high, and safety was demonstrated. Planned repeat procedures for sequential dilatation were performed in a few patients. Surgical resection was avoided in all patients.

Differential expression of small bowel TGFβ1 and TGFβ3 characterizes intestinal strictures in patients with fibrostenotic Crohn's disease.

Small bowel strictures remain a debilitating consequence of Crohn's disease and contribute to poor outcomes for patients. Recently, TGFβ has been identified as an important driver of intestinal fibrosis. We studied the localization of TGFβ isoforms in ileal strictures of patients with Crohn's disease using in situ hybridization to understand TGFβ's role in stricture formation. The mucosa of strictures was characterized by higher TGFβ1 while the stricture submucosa showed higher TGFβ3 compared to normal ileum from patients without Crohn's disease (p = 0.02 and p = 0.044, respectively). We correlated these findings with single-cell transcriptomics which demonstrated that TGFβ3 transcripts overall are very rare, which may partially explain why its role in intestinal fibrosis has remained unclear to date. There were no significant differences in fibroblast or B cell TGFβ1 and/or TGFβ3 expression in inflamed vs. noninflamed ileum. We discuss the implications of these findings for therapeutic development strategies to treat patients with fibrostenotic Crohn's disease.

Risk factors for surgery in stricturing small bowel Crohn's disease: A retrospective cohort study from the GETAID pédiatrique.

Previous studies have shown rates of surgical resection of up to 41% in stricturing pediatric Crohn's disease (CD). In this retrospective multicenter study, our aims were to identify clinical risk factors and magnetic resonance enterography (MRE) features of small bowel strictures associated with surgery. Pediatric patients with symptomatic stricturing small bowel CD (defined as obstructive symptoms or proximal dilatation on MRE) confirmed by MRE between 2010 and 2020 were recruited from 12 French tertiary hospitals. Patient characteristics were compared by surgical outcome multivariable Cox regression. Fifty-six patients (61% boys) aged 12.2 ± 2.7 years at diagnosis of CD were included. Median duration of CD before diagnosis of stricture was11.7 months (interquartile range [IQR]: 25-75: 1.2-29.9). Nineteen (34%) patients had stricturing phenotype (B2) at baseline. Treatments received before stricture diagnosis includedMODULEN-IBD (n = 31), corticosteroids (n = 35), antibiotics (n = 10), anti-TNF (n = 27), immunosuppressants (n = 28). Thirty-six patients (64%) required surgery, within 4.8 months (IQR: 25-75: 1.8-17.3) after stricture diagnosis. Parameters associated with surgical resection wereantibiotic exposure before stricture diagnosis (adjusted odds ratio [aOR]: 15.62 [3.35-72.73], p = 0.0005), Crohn's disease obstructive symptoms score (CDOS) > 4 (aOR: 3.04 [1.15-8.03], p = 0.02) and dilation proximal to stricture >28 mm (aOR: 3.62 [1.17-11.20], p = 0.03). In this study, antibiotic treatment before stricture diagnosis, intensity of obstructive symptoms, and diameter of dilation proximal to small bowel stricture on MRE were associated with risk for surgical resection.

Multimodality imaging features of small bowel cancers complicating Crohn's disease: a pictorial review.

Patients with Crohn's disease (CD) are at increased risk of developing small bowel cancer, since chronic inflammation may trigger the histopathological sequence that begins from low-grade dysplasia of the intestinal epithelium and may eventually lead to malignant transformation. Owing to their location in a portion of the gastrointestinal tract which is not easily accessible to conventional endoscopic techniques, the detection of CD-related small bowel cancers is still a clinical challenge. The radiological features of CD-related small bowel adenocarcinoma (SBA) in patients with CD have been described in some previous studies, including its appearance in both CT and MRI examinations. Radiological signs of active or fibrostenotic CD may be intermixed with those suggesting the presence of CD-related SBA. In CT studies, the most relevant findings consistent with malignant transformation are the presence of a stricture with irregular asymmetric thickening of small bowel walls, loss of mural stratification, and moderate enhancement after intravenous administration of iodinated contrast media, in association with enlarged adjacent mesenteric lymph nodes. Many of the CD-related SBA features that can be observed on CT imaging are similar to those detectable by MRI. This latter modality provides the additional value of the functional characterization of small bowel strictures, thereby helping to distinguish between inflammatory, fibrotic, and malignant stenosis in the setting of active CD. Positron Emission Tomography (PET)/CT enables the metabolic assessment of enlarged mesenteric lymph nodes, and PET/MRI fusion imaging can incorporate morphological, functional and metabolic information into a single set of imaging data, thus overcoming the limitations of the separate assessment of each individual modality. Owing to the low incidence and prevalence of this long-term complication of CD, we believe that a detailed multimodality pictorial essay on this topic, also including the PET-CT and fusion imaging documentation of some cases, would be useful to the medical literature.

Multi-modal conservative management of intra-abdominal collections in fistulising Crohn’s disease

Background and Objectives: The management of intra-abdominal collections in fistulising Crohn’s disease (CD) has traditionally involved surgery. However, conservative management is a potential alternative. In this study, we report our experience with multi-modal conservative management of intra-abdominal collections secondary to perforating CD. Methods: Medical records of CD patients with a history of intra-abdominal collections or fistulas over the past five years were reviewed retrospectively. Patients were included if they were initially managed conservatively using any combination of antibiotics, exclusive enteral nutrition (EEN), percutaneous drainage of collections, endoscopic dilatation of associated strictures and medical therapy for IBD with steroids, immunomodulators and/or biologics. Results: Eleven participants were included. All participants had penetrating CD affecting the terminal ileum. Nine participants had intra-abdominal collection on cross-sectional imaging whilst the remaining two participants had fistulising disease and sepsis without a discrete collection. Eight participants completed a 6–8 weeks course of EEN. All participants were treated with antibiotics and a thiopurine. Steroids were used in eight participants and biological agents in six. Six participants underwent endoscopic dilatation of small bowel strictures. After a median follow up of 20 months [range: 3–210] nine participants had evidence of adequate clinical, biochemical, radiological and endoscopic improvement. Complete resolution of abscess was seen in 4/7 participants and a significant reduction in abscess size was seen in 2/7. Two participants had complete endoscopic and histological remission and complete resolution of abscess. Both participants with fistulising disease (without a collection) had evidence of healed fistula tract on progress imaging and endoscopy. Two participants underwent surgery after failure of initial conservative management. Conclusion: Intra-abdominal collections in fistulising CD can be managed successfully in appropriately selected patients using a multi-modal approach incorporating antibiotics, EEN, endoscopic dilatations of culprit strictures and optimised medical management using steroids (for induction of remission), immunomodulators and biologics.

DIETARY INTERVENTION AS A NOVEL TOOL TO IMPROVE DIAGNOSTIC ACCURACY OF PATENCY CAPSULE IN CROHN'S DISEASE PATIENTS

Abstract INTRODUCTION AND AIM Patency capsule (PC) is a recommended procedure to confirm that the gastrointestinal tract is patent before ingestion of video capsule endoscopy (VCE). However, in some patients non-expelled PC may be due to slow transit time and not due to small bowel stricture. We examined if a nutritional intervention during the PC test which we introduced into routine clinical practice could improve passed PC rate and reduce false positive results. METHODS A retrospective study of patients who were subjected to standard protocol of PC procedure or to a nutrition-modified protocol of PC. Nutritional-modification comprised individualized dietary advice on the consumption of personally-convicted laxative foods after PC ingestion. Imaging study at 30 hours post-ingestion was performed to ascertain passage of PC in patients who did not visually see a passed PC in stool. RESULTS A total of 49 Crohn's patients who ingested PC were included (median age 33.7, 28.6% with previous intestinal resection). 26 patients followed the nutrition-modified personalized protocol and 23 did not (15 for technical reasons, eight for non-compliance). In total, 38 PC passed and 11 failed. Patients on dietary modification had significantly reduced rate of a failed PC compared to patients receiving standard protocol (7.7% versus 39.13%, respectively, odds ratio 0.13, 95% [CI] 0.0244-0.687, P value = 0.016). All patients with a passed PC subsequently ingested a VCE without complications. CONCLUSION Personalized nutritional intervention to promote colonic transit time may serve as a novel practical easy-to-follow dietary tool, in order to improve the diagnostic accuracy of patency capsule. Prospective controlled trials are warranted to corroborate these findings. Study flowchart. CD, Crohn’s disease; CT: Computed tomography; PC: Patency capsule. Percentage (%) of patients with failed PC with nutrition protocol or with standard protocol.

P613 Dietary intervention as a novel tool to improve diagnostic accuracy of patency capsule in Crohn’s Disease patients

Abstract Background Patency capsule (PC) is recommended to confirm the patency of the small bowel before ingestion of video capsule endoscopy (VCE). However, in some patients non-expelled PC could be due to slow transit time and not due to small bowel stricture. We examined if dietary intervention during the PC could improve passed PC rate and reduce false positive results. Methods A retrospective study of patients who received diet-modified protocol of PC test, introduced into routine clinical practice on February 2023, compared with standard protocol. Dietary-modification comprised individualized dietary advice on the consumption of personally-conceived laxative foods after PC ingestion. Abdominal X-ray at 30 hours post-ingestion was performed to ascertain passage of PC in patients who did not see an intact PC in stool, followed by low-dose limited computed tomography (CT) in patients with evident PC on X-ray to assure passage to colon. Results A total of 52 Crohn's patients who ingested PC were included (median age 32.4, 28.8% with previous intestinal resection). 26 of the patients followed the dietary-modified personalized protocol and 26 followed the standard protocol. In total, 38/52 PC passed and 14/52 (26.9%) failed. Patients on dietary modification had significantly reduced rate of a failed PC compared to patients receiving standard protocol (7.7% versus 46.1%, respectively, odds ratio 0.1, 95% confidence interval 0.02-0.49, P=0.005). 12/14 patients with a failed PC underwent low-dose CT, which showed PC was in the colon (false positive PC) in 11/12 patients (92%, 9/11 in standard group, 2/11 in dietary group). All 11 patients with a passed PC in colon subsequently ingested a VCE without complications. Conclusion Majority of failed PC are falsely positive, stemming from slow-transit of PC in the colon. Personalized dietary intervention to promote colonic transit may serve as a novel practical tool to reduce false positive tests and improve the diagnostic accuracy of patency capsule.

P643 Magnifying Endoscopy with Narrow Band Imaging for Graft Failure and Disease Recurrence in Patients with Crohn’s Disease after Intestinal Transplantation

Abstract Background Crohn’s disease (CD) is one of the common causes of short bowel syndrome (SBS) and intestinal failure (IF). Intestinal transplantation (IT) is sometimes needed for patients with CD who develop IF after multiple intestinal resections due to CD-related complications, such as uncontrollable bleeding and penetrating diseases. However, there have been limited case reports concerning the endoscopic surveillance of CD patients after IT. Methods We retrospectively investigated two patients with CD who underwent IT because of SBS-IF after multiple intestinal resection. We administered post-transplantation immunosuppressants and conducted regular magnifying endoscopy with narrow-band imaging (ME-NBI) via ileostomy chimney for surveillance of grafte rejection. Endoscopic prediction of rejection were based on our previously published "VENCH" score which is composed of five parameters: "V" (villi appearance), "E" (erythema), "N" (capillary network), "C" (crypt widening), and "H" (heterogeneity). Endoscopic biopsy were taken for histologic confirmation of graft rejection severity. Results Case 1 was a 60-year-old male patient with CD who received three times of intestinal resection for small bowel stricture and perforation, followed by IT due to SBS-IF. He lived uneventful until seven years thereafter with bloody diarrhea presented. Endoscopic surveillance revealed normal VENCH score of background mucosa but deep longitudinal ulcers which was indicative of recurrence of CD rather than graft rejection. Anti-tumor necrosis factor alpha with adalimumab was prescribed and his diarrhea and graft ulcers improved. Case 2 was a 39-year-old male patient with CD who received extensive intestinal resection due to multiple perforations, followed by IT because of SBS-IF. Endoscopic surveillance revealed normal VENCH score without histologic graft rejection two years thereafter. Both enrolled cases demonstrated favorable outcomes after endoscopic surveillance of intestinal graft with ME-NBI and management accordingly. Conclusion The post IT follow-up of CD patients remains challenging. We highlight the usefulness of the ME-NBI using VENCH score for early detection of graft rejection and its value in monitoring CD patients after IT. Additionally, ulcerations without changes in morphology of surrounding villi should take into consideration the disease recurrence of underlying CD. Further research is needed in endoscopic follow-up and molecular genetics to better understand CD after IT.

P458 Diagnostic accuracy of patency capsule and cross-sectional imaging for capsule endoscopy retention: A systematic review and meta-analysis

Abstract Background Although small bowel capsule endoscopy (SBCE) has been widely used to evaluate small bowel lesions including Crohn’s disease, there is a risk of capsule retention that can cause obstructive symptoms potentially necessitating surgical treatment. We conducted a systematic review and meta-analysis to evaluate the accuracy of patency capsule (PC) and cross-sectional imaging (CSI) for predicting capsule retention. Methods MEDLINE/PubMed, EMBASE, Web of science, and the Cochrane library databases were searched for articles that invested the diagnostic accuracy of PC or CSI for predicting capsule retention up to August 15, 2023. Pooled sensitivity and specificity were calculated using a bivariate random-effects model. Considering that SBCE was generally not performed when capsule retention was suspected on PC, the false-negative rates of PC and CSI were separately analyzed and compared using a single-proportion meta-analysis based on random-effects modeling. Quality assessment of the selected studies was performed using the revised Quality Assessment of Diagnostic Accuracy Studies-2 tool. Results A total of 22 peer-reviewed articles, including 17 articles for PC (covering 2,234 patients) and 7 articles for CSI (covering 302 patients) were included in this systematic review. The pooled sensitivity and specificity for predicting capsule retention with CSI were 64% [95% confidence interval (CI), 31%–87%] and 85% [95% CI, 62%–95%], respectively. The pooled sensitivity and specificity for predicting capsule retention with PC were 75% [95% CI, 43%–92%] and 94% [95% CI, 90%–96%], respectively (Figure 1, Table 1). Although there was no statistically significant difference in prediction accuracy between PC and CSI on the bivariate random-effects model (P=0.14), the pooled false-negative rate was significantly lower in the PC compared to CSI (2.5% [95% CI, 1.4%–4.7%] vs. 11.0% [95% CI, 5.2%–21.8%]; P=0.003) (Table 1). Conclusion Cross-sectional imaging showed good specificity, but showed moderate sensitivity in predicting capsule retention. In contrast, patency capsule showed good sensitivity and excellent specificity, with a significantly lower false-negative rate compared to cross-sectional imaging. Therefore, in patients with clinically suspicious small bowel stenosis, the patency capsule is a more reliable modality for predicting capsule retention.

Imaging of Strictures in Crohn's Disease.

Crohn's disease (CD) is a chronic inflammation of the digestive tract, and it frequently affects young patients. It can involve any intestinal segment, even though it frequently affects the distal ileum. Up to 80% of patients with CD present with inflammatory behavior, and 5% to 28% develop stricturing disease. Based on the predominant mechanism causing them, strictures can be categorized as inflammatory, fibrotic, or mixed. Determining the relative amounts of inflammation and fibrosis in a stricture can influence treatment decisions. Imaging is an extremely useful tool in patients with small bowel stricturing CD to confirm the diagnosis and to evaluate disease characteristics, usually using CT or MRI. The aim of this paper is to describe how imaging can evaluate a patient with small bowel CD stricture.

Small bowel stricture: Endoscopic balloon dilatation

Small bowel stricture: Endoscopic balloon dilatation

S3236 Spontaneous Elimination of a Video Endoscopy Capsule from a Small Bowel Stricture After 9 Months in a Patient With Crohn’s Disease

S3236 Spontaneous Elimination of a Video Endoscopy Capsule from a Small Bowel Stricture After 9 Months in a Patient With Crohn’s Disease