Small Intestinal Crohn's Disease Research Articles

Mucosal Healing and Clinical Efficacy of Adalimumab in Small Intestinal Crohn's Disease (SIMCHA Study): Final Results From a Prospective, Open-Label, Single-Arm Study.

Endoscopic healing is a key treatment target in inflammatory bowel disease; few data are available on the clinical and endoscopic efficacy of biological therapy in upper gastrointestinal Crohn's disease. This study aimed to investigate small bowel mucosal healing and clinical efficacy of adalimumab therapy by video capsule endoscopy in patients with endoscopically active upper gastrointestinal Crohn's disease. This prospective, open-label, single-arm study included Crohn's disease patients with moderate-severe endoscopic proximal small bowel involvement, defined by a Lewis score >790. Patients were treated with adalimumab monotherapy for 24 weeks. Co-primary outcomes were endoscopic healing, defined as Lewis score <350, and endoscopic response, defined as >50% decrease in Lewis score. Secondary outcomes included clinical (Harvey-Bradshaw index <4) and biomarker remission (fecal calprotectin <250 μg/g, and C-reactive protein <5 mg/L). A total of 59 Crohn's disease patients were screened; 17 patients have met eligibility criteria and were enrolled. Endoscopic healing was observed in 8 patients (47.1%) and endoscopic response in additional 5 patients (29.4%) at 24 weeks. Median Lewis score was significantly decreased compared to baseline (1912 vs. 337, P = .0005). Eleven of 13 patients (84.6%) with clinical activity achieved clinical remission (baseline: 13/17 vs. week 24: 2/17, P < .0001). Nine of 10 patients with elevated C-reactive protein achieved normal C-reactive protein after treatment and the median C-reactive protein significantly decreased from 7.4 to 1.6 mg/L, P = .032. In contrast, no change was observed in fecal calprotectin pre- and posttreatment. Adalimumab induced endoscopic healing and clinical remission in patients with active small bowel Crohn's disease, with approximately half of the patients achieving endoscopic healing.

Immediate Results of Small Bowel Crohn’s Disease Surgery

Introduction: Despite the progress made in the medical management of Crohn's disease (CD), a vast number of patients are operated on at least once in their lifetime. Although this is a mild disease that occurs mainly in young patients with little comorbidity, CD surgery is accompanied by significant postoperative morbidity (PO). This study aims to analyse the PO complications of the small intestine's CD and look for the risk factors for its occurrence. Patients and methods: this is a single-centre prospective study that collected 83 files of patients operated on for CD of the small intestine for 28 months (May 2017 - September 2019). All patients had histologic confirmation of CD. Isolated anoperineal and colorectal forms were excluded from this work. PO morbidity is defined by all complications occurring during the first 30 days of PO. A statistical analysis of PO morbidity was performed as a function of 12 parameters: age; sex; comorbidity; history of abdominal surgery; history of surgery for CD; haemoglobin level (Hb &lt;or&gt; at 10 mg/dl); albumin level (&lt;or&gt; at 34g / l); BMI (&lt;or&gt; at 19); ASA score; mode of surgery (cold vs emergency); intra-abdominal abscess; operative procedure (resection-anastomosis vs resection-stoma). Statistical analysis was performed first univariate and then multivariate (SPSS 16 software). Results: These were 56 women and 27 men, with a sex ratio of 2. The mean age of the patients was 35 years (13-65). The overall PO morbidity rate was 26%; this morbidity was surgical in 86%, septic in 89.5% and intra-abdominal septic in 50% of cases. Complications were major (CMPO) in 39.5% of cases. The mode of emergency surgery was an independent risk factor for the occurrence of complications (p = 0.005). Conclusion: Small intestine CD surgery is associated with very high PO morbidity. The mode of emergency surgery is an independent risk factor for the onset of PO complications. Patients who require surgery should be operated on as elective or scheduled surgery. The indications for emergency surgery for CD are sporadic.

Surgical strategies for intestinal Crohn's disease.

As a type of inflammatory bowel disease, Crohn's disease (CD) is characterized by jumping lesions and transmural inflammation. The treatment goal is to control the development of inflammation with drugs such as 5-Amino Salicylic Acid, azathioprine and hormones, but most patients still need surgical treatment eventually. The surgical treatment of CD requires exquisite surgical design and solid surgical procedures to minimize the progression of intestinal lesions and preserve the normal bowel segment as much as possible. This study aims to summarize and discuss the surgical treatments for intestinal CD, and to provide references for the surgical treatment of intestinal CD. Clinical data of 122 patients with CD were analyzed retrospectively. They all received surgical treatments in the Second Xiangya Hospital of Central South University between Jan. 1, 2015 and Jan. 1, 2021. The data included general information, clinical manifestations, preoperative examination, preoperative preparation, surgical methods, pathological examination, complications, and follow-up data. Except 1 case of emergency surgery, all the other patients met the surgical indications of intestinal CD after multi-disciplinary discussion (MDT) and they were transferred to surgery for elective surgery, and received high-quality intestinal preparation before surgery. Among them, 99 cases underwent one-stage abdominal operation and 23 cases underwent the second abdominal operation. All patients underwent successful surgery with good surgical results, with significantly alleviated clinical symptoms and the BMI significantly increased compared with those before surgery. There were 14 cases (11.5%) of postoperative complications. One case of delayed anastomotic fistula and one case of small intestinal cutaneous fistula which were successfully treated by conservative treatment, the other 12 cases were successfully treated by reoperation, and there were no complications with follow-up operation. The postoperative pathological diagnosis for all patients was clear. All patients received regular follow-up with 5-70 (median 36) months and no clinical recurrence was found. As the surgical treatment of intestinal CD, surgeons should strictly grasp the surgical indications based on the MDT. During the operation of small intestinal CD, it is advisable to preserve bowel segment as much as possible. For patients with short remaining normal bowel segment, the intestinal canal should be preserved as far as possible, even for the mildly diseased bowel, so as to avoid the occurrence of short bowel syndrome and leave room for possible reoperation. In the treatment of secondary duodenal CD, it is necessary to carefully identify the nature of the local lesions. Different surgical treatments should be performed according to whether there is an internal fistula and the size of this fistula. Meanwhile, duodenectomy or pancreaticoduodenectomy should be considered as the final surgical method in the treatment of primary duodenal CD.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Abdomen and/or Retroperitoneum.

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Abdomen and/or Retroperitoneum.

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

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

Systematic review with meta-analysis: efficacy of balloon-assisted enteroscopy for dilation of small bowel Crohn's disease strictures.

Evidence for endoscopic balloon dilation of small intestinal strictures in Crohn's disease (CD) using balloon-assisted enteroscopy is scarce. To evaluate endoscopic balloon dilation for the treatment of small intestinal CD strictures using balloon-assisted enteroscopy. Citations in Embase, MEDLINE, and Cochrane were systematically reviewed. In a meta-analysis of 18 studies with 463 patients and 1189 endoscopic balloon dilations, technical success was defined as the ability to dilate a stricture. Individual data were also obtained on 218 patients to identify outcome-relevant risk factors. In the pooled per-study analysis, technical success rate of endoscopic balloon dilation was 94.9%, resulting in short-term clinical efficacy in 82.3% of patients. Major complications occurred in 5.3% of patients. During follow-up, 48.3% of patients reported symptom recurrence, 38.8% were re-dilated and 27.4% proceeded to surgery. On the per-patient-based multivariable analysis, that patients with disease activity in the small intestine had lower short-term clinical efficacy (odds ratio 0.32; 95% confidence interval 0.14-0.73, P=0.007). Patients with concomitant active disease in the small and/or large intestine had an increased risk to proceed toward surgery (hazard ratio 1.85; 95% confidence interval 1.09-3.13, P=0.02 and hazard ratio 1.77; 95% confidence interval 1.34-2.34, P<0.001). Balloon-assisted enteroscopy for dilatation of CD-associated small intestinal strictures has high short-term technical and clinical efficacy and low complication rates. However, up to two-thirds of patients need re-dilation or surgery.

Clinical value of capsule endoscopy in small intestinal diseases

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

A Treat to Target Strategy Using Panenteric Capsule Endoscopy in Pediatric Patients With Crohn’s Disease

Pan-enteric capsule endoscopy (PCE) is effective for assessment of small intestinal and colonic Crohn's disease (CD) in pediatric patients. We aimed to determine whether PCE can be used to monitor mucosal healing and deep remission, in a treat to target strategy for pediatric patients with CD. We performed a prospective study of 48 children with a diagnosis of CD at a tertiary care pediatric gastroenterology unit; 46 patients were included in the final analysis. Biomarker, imaging, and PCE analyses were performed at baseline and after 24 and 52 weeks. Small bowel and colonic mucosal healing were defined by Lewis scores <135 and simple endoscopic score for CD ≤1, respectively. Clinical remission was defined as defined as a pediatric CD activity index score <10 and biomarker-based remission based on normal levels of biomarkers; deep remission was defined as a combination of clinical remission, biomarker-based remission, and mucosal healing. Treatments were adjusted based on findings from PCE (imaging was considered only for patients with negative findings from PCE). Therapies were introduced, optimized, switched, or combined at the discretion of treating clinicians. The primary outcome was the ability of PCE to assess mucosal healing and deep remission at 3 timepoints and to guide a treat to target strategy. PCE detected inflammation in 34 patients (71%) at baseline, 22 patients (46%) at week 24, and 18 patients (39%) at week 52 (P for comparison among timepoints <.05). Findings from PCE led to a change in therapy for 34 patients (71%) at baseline and 11 patients (23%) at 24 weeks, whereas only 2 patients with negative results from PCE (4%) changed therapies based on findings from imaging. When the treat to target strategy was applied, proportions of patients with mucosal healing and deep remission increased from 21% at baseline, to 54% at week 24, to 58% at week 52 (P for comparison among timepoints <.05); 2 patients (4%) did not respond to treatment. In a prospective study of 48 children with CD, we found a treat to target strategy, based on findings from PCE, to significantly increase the proportions of patients with mucosal healing and deep remission. gov no: NCT03161886.

Fecal calprotectin correlates with active colonic inflammatory bowel disease but not with small intestinal Crohn's disease activity.

BackgroundThe utility of fecal calprotectin (FC) in small intestinal Crohn's disease (CD) is unclear. We examined how reliably FC reflects clinical and mucosal disease activity in small intestinal CD, colonic CD, and ulcerative colitis (UC).MethodsA total of 72 Inflammatory Bowel Disease (IBD) patients (23 colonic CD, 14 isolated small intestinal CD, and 35 UC) were included. Clinical activity was assessed using the Harvey–Bradshaw Index (HBI) (CD) and Mayo score (UC). Inflammatory activity was assessed through ileocolonoscopy, cross‐sectional imaging, C‐reactive protein (CRP), and FC. Clinical activity was defined as HBI > 4 or Mayo clinical score ≥ 3. Endoscopy activity was defined as Mayo endoscopic subscore ≥ 1, SES‐CD score ≥ 3, and Rutgeerts > i1.ResultsIn UC, FC was correlated with the Mayo clinical score (P < 0.0001) and was highly correlated with the total Mayo score (P < 0.0001). A cut‐off value of FC 100 μg/g provided sensitivity of 88% and specificity 100% for endoscopic activity. FC was lower for patients with endoscopic and clinical remission compared to active endoscopic disease (median 100 vs 1180 μg/g, P < 0.0001). In colonic CD, there was a significant correlation between FC and endoscopic activity (P < 0.001). For an FC cut‐off value of 100 μg/g, sensitivity was 100%, and specificity was 67%. In contrast, for isolated small intestinal CD, there was no significant correlation between FC and objective disease activity measured by either endoscopy or imaging (AUC 0.52, P = 0.58).ConclusionFC is reliable for the detection of colonic mucosal inflammation in both UC and CD but is less sensitive and reliable in the detection of small intestinal CD.

Osteoporosis as an initial manifestation in a patient with Crohn's disease: A case report.

The present case report details a rare case of osteoporosis as the initial manifestation of Crohn's disease (CD). A 43-year-old male was referred to the Second Xiangya Hospital of Central South University (Changsha, China) for further examination of low back pain (LBP) without digestive symptoms. Bone mineral density (BMD) analysis indicated osteoporosis, particularly in the lumbar spine. Endoscopy revealed an inflamed and strictured ileocecal valve with less inflammation in the ascending, transverse colon, sigmoid colon and rectum, compatible with CD, which was in accordance with the appearance of an abdominal computed tomography scan. Duodenal-balloon enteroscopy indicated segmental ulceration and stricture in the jejunum, in accordance with CD. The patient was diagnosed with CD following examination. It was suspected that osteoporosis may be an extra-intestinal manifestation of CD. Steroids and biological agents were prescribed in sequence. LBP and BMD rapidly improved following treatment, and inflammatory markers returned to normal after 1.5 years of treatment. According to this case, osteoporosis with unknown causes should be considered as a possible sign of small intestinal CD.

A Case of Small Intestinal Type Crohn's Disease with Diversion Colitis

A Case of Small Intestinal Type Crohn's Disease with Diversion Colitis

Diagnostic value analysis of capsule endoscopy in obscure gastrointestinal bleeding patients of different ages

Objective: To evaluate the diagnostic value of capsular endoscopy in patients with obscure gastrointestinal bleeding (OGIB) in different age groups, and assess its effectiveness and safety. Methods: A total of 216 patients who were diagnosed with OGIB between March 2005 and March 2016 at Department of Gastroenterology of Peking Union Medical College Hospital were retrospectively reviewed. They were assigned into three groups: young adults, middle-aged and elderly. The demographic characteristics, clinical manifestations, working performance as well as endoscopic features in each group were collected and analyzed. Results: The detection rate and diagnosis rate of the young adults and middle-aged group were 98.53% vs 98.51% (P=0.992), 92.65% vs 91.04% (P=0.734), while those between the young adults and the elderly group were 98.53% vs 91.14% (P=0.109), 92.65% vs 87.34% (P=0.289), and 98.51% vs 91.14% (P=0.113) and 91.04% vs 87.34 (P=0.475) between the middle-aged and elderly group. No significant difference existed in either detection rates nor diagnostic rates between the different age groups. The distribution of the small intestinal lesions varied between the different age groups. The top three common lesions in young adults were vascular malformation, small intestine ulcer and Crohn's disease, while in the middle-aged group vascular malformation, non-specific enteritis and small intestine ulcer were the most common. Patients in elderly group were most likely to have vascular malformation, small intestine ulcer and erosion. Conclusions: For patients of any age with OGIB, capsule endoscopy is a safe, effective and comfortable examination which can be widely used in clinical practice.

The relationship between jejunal-ileum lesions and terminal ileum lesions of isolated small intestinal Crohn disease under small bowel capsule endoscopy

Objective To study the relationship between jejunal-ileum lesions and terminal ileum lesions of patients with isolated small intestinal Crohn disease, and to compare the clinical and endoscopic features of patients having normal terminal ileum with those having abnormal terminal ileum in isolated small intestinal Crohn disease. Methods The data of patients diagnosed as having isolated small intestinal Crohn disease and successively receiving colonoscopy and small bowel capsule endoscopy in Nanfang Hospital of Southern Medical University from January 2008 to October 2015 were retrospectively analyzed. The patients were divided into normal terminal ileum group and abnormal terminal ileum group according to the result of colonoscopy. The clinical and endoscopic features of the two groups were compared. Results The data of 62 patients were collected, and jejunal-ileum lesions were found in all of the patients under small bowel capsule endoscopy. According to the result of colonoscopy, 40 patients (64.5%) were grouped to the abnormal terminal ileum group and 22 patients (35.5%) to the normal group. The patients in the normal terminal ileum group had a shorter disease duration than those of the abnormal group [68.2%(15/22) VS 12.5%(15/40), P=0.021]. The sex and age distribution, smoking history, clinical feature, upper gastrointestinal involvement, perianal lesion, disease behavior, Crohn disease activity index, inflammation markers and nutriture between the two groups had no statistical difference (P>0.05). Conclusion The terminal ileum lesions found by colonoscopy cannot predict small bowel lesions for Crohn disease. Small bowel capsule endoscopy is helpful for the detection of small intestinal lesions in Crohn disease. We should pay more attention to evaluating the small bowel lesions when the patients with Crohn disease have a short duration and normal terminal ileum. Key words: Crohn disease; Colonoscopy; Capsule endoscopes; Intestine, small; Terminal ileum

Small intestinal Crohn’s disease with hepatic portal venous gas: a case report

An 80-year-old man presented in another hospital with acute abdominal pain; computed tomography indicated hepatic portal venous gas (HPVG) and small intestinal thickening. He was then transferred to our hospital, where we diagnosed idiopathic inflammation and stenosis of the ileum. Because the patient’s abdominal symptoms were mild and his general condition was good, we chose to administer conservative therapy. His condition improved and we discharged him from our hospital. However, he was hospitalized again 9 days later because his abdominal pain had recurred and was worse. We performed a laparoscopic partial resection of the ileum 3 weeks after the patients’ initial presentation. Macroscopically, longitudinal ulcers were observed near the stenosis of the ileum; the segment of the small intestine that contained the ulcers was removed, and subsequent pathological findings indicated Crohn’s disease of the small intestine. The post-operative course was favorable, and the patient was discharged on post-operative day 9. Such serendipitous diagnosis of small intestinal Crohn’s disease in an elderly patient with hepatic portal venous gas is rare; to our knowledge, this is the first of such case in which laparoscopic surgery was performed.

Mo2028 The Cast Hood Facilitates Double-Balloon Endoscopy in Patients With Small Intestinal Crohn's Disease

Mo2028 The Cast Hood Facilitates Double-Balloon Endoscopy in Patients With Small Intestinal Crohn's Disease

Tu1979 Capsule Endoscopy Reveals Small Intestinal Mucosal Crohn's Disease Healing After Treatment With Adalimumab: Preliminary Results of the SIMCHA Study

Tu1979 Capsule Endoscopy Reveals Small Intestinal Mucosal Crohn's Disease Healing After Treatment With Adalimumab: Preliminary Results of the SIMCHA Study

How Accurate Are Capsule Endoscopy and Small Bowel Imaging for Small Intestinal Crohnʼs Disease? Using Total Enteroscopy via Double-Balloon Enteroscopy as the Reference Standard

Introduction: The target for treatment in small intestinal Crohn's disease (CD) is mucosal healing. The diagnostic modalities used to not only assess healing, but also diagnose Crohn's disease are small bowel imaging and capsule endoscopy (CE). However, ileocolonoscopy has been the reference standard for their accuracies. The aim of this study was to measure the true accuracy of these modalities by using total enteroscopy (TE) via double balloon enteroscopy (DBE). Methods: Single center, retrospective chart review of patients with suspected and established CD status post TE via DBE and small bowel imaging. CD activity was defined as positive if >1: aphthous lesion, small ulcer, large ulcer, ulcerated mucosa, and/or stenoses. For imaging, CD was defined as positive if presence of wall thickening, increased contrast enhancement, or hyperemia, and/or the presence of stenoses. Results: 2216 DBEs were performed between 2004-2015 with 635 TEs in 361 patients. 75 TEs were achieved in one direction. 61 patients (M40: F21, 51yo) identified with CD (33 suspected and 28 established) underwent 120 DBEs for 64 TEs. 14 DBEs required balloon dilation. 6 DBEs were performed for capsule retrieval. 0 perforations, pancreatitis. 19 patients underwent CE with a median Niv score 6.0. The median CRP was 0.21 mg/dl (0.04-18.5) and median fecal calprotectin 160.6 mcg/g (46.8-1360.0). Because of TE, there was maintenance or escalation of therapy 9, resection/lysis of adhesions 4, IBS 8, de-escalation of therapy 2, symptom improvement post balloon dilation 3, diagnosis of CD 20, CD ruled out 5, and other diagnoses 7(celiac sprue, NSAID enteropathy, carcinoid, Meckel's). For all imaging modalities the sensitivity for CD was 80% vs 67% in CE, yet CE had a PPV of 83%. Specific small bowel imaging, such as CTE/MRE/SBFT, had a similar sensitivity at 79% but lower PPV at 52%. However, in terms of strictures, CTE/MRE/SBFT had a lower sensitivity of 56% vs 86% in CE. Additionally, CE had a 100% specificity for strictures. Conclusion: Although there were fewer CEs in this study, CE had a high PPV overall for CD activity and a high sensitivity for strictures, especially inflammatory strictures, when compared to small bowel imaging. Specifically, imaging was excellent for identifying the presence of inflammation but inaccurate when identifying the degree of inflammation, such as stenoses.Therefore, CE can be an adjunct study to imaging as a safe modality to assess not only accurate disease phenotype, but also healing post treatment.Table 1: Imaging vs. CE for Stricturing Small Bowel Crohn's DiseaseTable 2: Operating Characteristics of Imaging vs. CE: Total Enteroscopy as the Reference StandardFigure 1

Mo1584 Differentiating Small Intestinal Crohn's Disease From Intestinal Tuberculosis: Can Capsule Endoscopy Help?

Mo1584 Differentiating Small Intestinal Crohn's Disease From Intestinal Tuberculosis: Can Capsule Endoscopy Help?

Su1236 High Fecal Calprotectin Correlate With Active Colonic Disease but Not With Small Intestinal Crohn's Disease Activity

Su1236 High Fecal Calprotectin Correlate With Active Colonic Disease but Not With Small Intestinal Crohn's Disease Activity

Small intestinal crohn disease: a case report

Small intestinal crohn disease: a case report