Capsule Endoscopy in Crohn’s Disease—From a Relative Contraindication to Habitual Monitoring Tool

Crohn’s disease (CD) is a chronic inflammatory disorder that may involve the gastrointestinal tract from the mouth to the anus. Habitual disease monitoring is highly important during disease management, aiming to identify and treat disease exacerbations, in order to avoid immediate and future complications. Currently, ilio-clonoscopy is the gold standard for mucosal assessment. However, the procedure is invasive, involves sedation and allows for visualization of the colon and only a small part of the terminal ileum, while most of the small bowel is not visualized. Since CD may involve the whole length of the small bowel, the disease extent might be underestimated. Capsule endoscopy (CE) provides a technology that can screen the entire bowel in a non-invasive procedure, with minimal side effects. In recent years, this technique has gained in popularity for CD evaluation and monitoring. When CE was first introduced, two decades ago, the fear of possible capsule retention in the narrowed inflamed bowel lumen limited its use in CD patients, and a known CD located at the small bowel was even regarded as a relative contraindication for capsule examination. However, at present, as experience using CE in CD patients has accumulated, this procedure has become one of the accepted tools for disease diagnosis and monitoring. In our current review, we summarize the historic change in the indications and contraindications for the usage of capsule endoscopy for the evaluation of CD, and discuss international recommendations regarding CE’s role in CD diagnosis and monitoring.

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

BMJ Open Gastroenterology ◽

10.1136/bmjgast-2019-000365 ◽

2020 ◽

Vol 7 (1) ◽

pp. e000365 ◽

Cited By ~ 1

Author(s):

David Henry Bruining ◽

Salvatore Oliva ◽

Mark R Fleisher ◽

Monika Fischer ◽

Joel G Fletcher

Keyword(s):

Crohn’S Disease ◽

Magnetic Resonance ◽

Small Bowel ◽

Crohn's Disease ◽

Capsule Endoscopy ◽

Terminal Ileum ◽

Imaging Modality ◽

Disease Diagnosis ◽

Magnetic Resonance Enterography ◽

Proximal Small Bowel

IntroductionCrohn’s disease diagnosis and monitoring remains a great clinical challenge and often requires multiple testing modalities. Assessing Crohn’s disease activity in the entire gastrointestinal (GI) tract using a panenteric capsule endoscopy (CE) system could be used as an alternative to colonoscopy and cross-sectional imaging. This study assessed the accuracy and safety of panenteric CE in Crohn’s disease as compared with ileocolonoscopy (IC) and/or magnetic resonance enterography (MRE).MethodsA prospective, multicentre study was performed in subjects with established Crohn’s disease. Individuals with proven small bowel patency underwent a standardised bowel preparation, followed by CE ingestion and IC either the same or following day. MRE, IC, and CE interpretations were performed by blinded central readers using validated scoring systems. The primary endpoint was the overall sensitivity of CE vs MRE and/or IC in Crohn’s disease subjects.ResultsStudy enrolment included 158 subjects from 21 sites in the USA, Austria, and Israel. Of those, 99 were included in the analysis. Imaging modality scores indicated none to mild inflammation in the proximal small bowel and colon, but discrepant levels of inflammation in the terminal ileum. Overall sensitivity for active enteric inflammation (CE vs MRE and/or IC) was 94% vs 100% (p=0.125) and specificity was 74% vs 22% (p=0.001). Sensitivity of CE was superior to MRE for enteric inflammation in the proximal small bowel (97% vs 71%, p=0.021), and similar to MRE and/or IC in the terminal ileum and colon (p=0.500–0.625). There were seven serious adverse advents of which three were related to the CE device.ConclusionPanenteric CE is a reliable tool for assessing Crohn’s disease mucosal activity and extent compared with more invasive methods. This study demonstrates high performance of the panenteric CE as compared to MRE and/or IC without the need for multiple tests in non-stricturing Crohn’s disease.Trial registration numberClinicalTrials.gov NCT03241368

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P168 Isolated terminal ileitis: when capsule endoscopy is key for Crohn’s disease diagnosis

Journal of Crohn s and Colitis ◽

10.1093/ecco-jcc/jjz203.297 ◽

2020 ◽

Vol 14 (Supplement_1) ◽

pp. S222-S222

Author(s):

M FREITAS ◽

T Cúrdia Gonçalves ◽

P Boal Carvalho ◽

F Dias de Castro ◽

B Rosa ◽

...

Keyword(s):

Weight Loss ◽

Crohn’S Disease ◽

Small Bowel ◽

Crohn's Disease ◽

Capsule Endoscopy ◽

Disease Diagnosis ◽

Inflammatory Activity ◽

Extraintestinal Manifestations ◽

Terminal Ileitis ◽

Proximal Small Bowel

Abstract Background Terminal ileitis (TI) is a common condition in clinical practice and may be associated with a wide variety of diseases, mostly Crohn’s disease (CD). Data regarding predictors of CD diagnosis in isolated TI are lacking, particularly concerning small bowel capsule endoscopy (SBCE) findings. Aim To evaluate predictive factors for CD diagnosis in patients with isolated TI detected during ileocolonoscopy, submitted to SBCE. Methods Retrospective study including consecutive patients undergoing SBCE after diagnosis of TI without colonic mucosal abnormalities on ileocolonoscopy between January 2016 and September 2019. Demographic, clinical, biochemical, endoscopic and imaging data were collected. The diagnosis of CD was based on clinical evaluation, endoscopic, histological, radiological, and/or biochemical investigations. Results One hundred and two patients with isolated ileitis on ileocolonoscopy were included. After performing SBCE, 34.3% of the patients had a diagnosis of CD. All CD diagnosed patients had positive SBCE findings. Extraintestinal manifestations (p = 0.003), weight loss (p = 0.01), abnormal imaging (p = 0.04) and positive SBCE findings (p = 0.005) were independently associated with CD diagnosis. Regarding SBCE, presence of proximal small-bowel disease (p = 0.02), diffuse findings (p = 0.002) and presence of moderate to severe inflammatory activity (Lewis Score≥790) (p < 0.001) were independently associated with CD diagnosis. Conclusion SBCE is a valuable tool that should be systematically used in patients presenting with isolated TI, since it enabled CD diagnosis in approximately one-third of patients. A diagnosis of CD should be considered when a patient with TI shows extraintestinal manifestations, weight loss, abnormal imaging and positive SBCE findings, especially proximal involvement, diffuse findings and the presence of moderate to severe inflammatory activity.

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P576 The value of small bowel capsule endoscopy in the change of therapeutic management in patients with established Crohn’s disease

Journal of Crohn s and Colitis ◽

10.1093/ecco-jcc/jjz203.704 ◽

2020 ◽

Vol 14 (Supplement_1) ◽

pp. S484-S485

Author(s):

N Viazis ◽

E Tsoukali ◽

C Pontas ◽

G Karampekos ◽

F Gkeros ◽

...

Keyword(s):

Crohn’S Disease ◽

Small Bowel ◽

Crohn's Disease ◽

Capsule Endoscopy ◽

Terminal Ileum ◽

Therapeutic Management ◽

Clinical Relapse ◽

Terminal Ileitis ◽

Disease Extent ◽

Disease Location

Abstract Background Small bowel capsule endoscopy (SBCE) is widely used for various indications in patients with established Crohn’s disease (CD). Our aim was to investigate whether SBCE can lead to changes in the therapeutic management of CD patients. Methods Retrospective analysis of prospectively collected data [September 2003 - September 2019] from patients with established CD subjected to SBCE in two tertiary referral centres for inflammatory bowel diseases. All patients were tested with the Pillcam SB. Findings consistent with small bowel CD involvement were the presence of aphthoid or larger ulcers with or without inflammation of the adjacent mucosa. Results In total, 839 patients [median age (range) 36 (17–78) years, 471 (56.41%) men, median disease duration 6 years] diagnosed with CD according to established criteria underwent SBCE in the participating centres for the evaluation of disease extent and mucosal healing or the investigation of clinical relapse or iron deficiency anaemia. Based on ileo-colonoscopy findings disease location was documented in 618 patients (73.65%) as follows: colitis in 219 (26.10%), ileo-colitis in 253 (30.15%), and terminal ileitis in 146 (17.40%) patients; in contrast, full disease location was not documented in 221/839 (26.34%) patients who had colonic involvement but the ileocaecal valve could not be intubated. In the latter group, SBCE revealed small bowel involvement in 96 (43.43%) patients. In addition, SBCE revealed more proximal lesions in 105/618 (16.99%) patients with ileo-colonoscopy documented colitis, ileo-colitis or terminal ileitis. These findings led to a change in therapeutic management in 98 patients (11.68%): 36 patients (4.29%) received biologics, 21 patients (2.50%) received intensified doses of or changed the administered biologic, 39 patients (4.64%) received corticosteroids and/or conventional immunosuppressants and 2 patients (0.23%) underwent surgery. Therapeutic management changes were commoner in patients in whom small bowel lesions were found during SBCE and in whom the terminal ileum had not been examined during colonoscopy (57/96 patients vs. 41/105, p = 0.003]. Capsule retention occurred in 9 patients (1.07%) and passed after administration of corticosteroids (n = 6), or the capsule was retrieved with push enteroscopy (n = 1) or surgery (n = 1). Conclusion SBCE is a valuable tool in the management of patients with established CD, especially in those whom the terminal ileum has not been examined during the preceding colonoscopy.

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Current Clinical Indications for Small Bowel Capsule Endoscopy

Acta Médica Portuguesa ◽

10.20344/amp.6128 ◽

2015 ◽

Vol 28 (5) ◽

pp. 632 ◽

Cited By ~ 6

Author(s):

Bruno Rosa ◽

José Cotter

Keyword(s):

Crohn’S Disease ◽

Small Bowel ◽

Crohn's Disease ◽

Gastrointestinal Bleeding ◽

Capsule Endoscopy ◽

Diagnostic Yield ◽

Diagnostic Instrument ◽

Obscure Gastrointestinal Bleeding ◽

Disease Extent ◽

Small Bowel Tumors

Introduction: Small bowel capsule endoscopy is currently the first line diagnostic examination for many diseases affecting the small bowel. This article aims to review and critically address the current indications of small bowel capsule endoscopy in clinical practice. Material and Methods: Bibliographic review of relevant and recent papers indexed in PubMed. Results and Discussion: Small bowel capsule endoscopy enables a non-invasive full-assessment of the small bowel mucosa, with high diagnostic yield even for subtle lesions. In patients with obscure gastrointestinal bleeding, diagnostic yield is higher when performed early after the onset of bleeding. Endoscopic treatment of angioectasias using balloon-assisted enteroscopy may contribute to reduce rebleeding, while the risk of rebleeding in patients with “negative“ small bowel capsule endoscopy is debatable. Cross-sectional imaging may be more accurate than small bowel capsule endoscopy for the diagnosis of large small bowel tumors. The Smooth Protruding Index on Capsule Endoscopy (SPICE score) may help to differentiate submucosal tumors from innocent bulges. Small bowel capsule endoscopy is also a key diagnostic instrument in patients with suspected Crohn’s disease and non-diagnostic ileocolonoscopy; it may also influence prognosis and therapeutic management, by determining disease extent and activity in patients with known Crohn’s disease. The role of small bowel capsule endoscopy to investigate possible complications in patients with non-responsive coeliac disease is evolving. Conclusions: Small bowel capsule endoscopy is a valuable diagnostic instrument for patients with obscure gastrointestinal bleeding and/or suspected small bowel tumors; it may also be a key examination in patients with suspected Crohn’s disease, or patients with known Crohn’s disease to fully assess disease extension and activity; finally, it may contribute for the diagnosis of complications of non-responsive coeliac disease.

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W1084 Capsule Endoscopy (CE) in ‘Suspected’ Small Bowel (SB) Crohn's Disease (CD): Economic Impact of Disease Diagnosis and Treatment

Gastroenterology ◽

10.1016/s0016-5085(09)62998-x ◽

2009 ◽

Vol 136 (5) ◽

pp. A-650

Author(s):

Jonathan A. Leighton ◽

Ian M. Gralnek ◽

Randel E. Richner ◽

Michael J. Lacey ◽

Frank J. Papatheofanis

Keyword(s):

Crohn’S Disease ◽

Small Bowel ◽

Crohn's Disease ◽

Economic Impact ◽

Capsule Endoscopy ◽

Disease Diagnosis ◽

Diagnosis And Treatment

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P202 Crohn’s disease extent and small bowel inflammatory activity: Results of a small bowel capsule endoscopy study

Journal of Crohn s and Colitis ◽

10.1093/ecco-jcc/jjz203.331 ◽

2020 ◽

Vol 14 (Supplement_1) ◽

pp. S239-S240

Author(s):

I Mitselos ◽

C Lamouri ◽

V Theopistos ◽

A Kavvadias ◽

M Moutzoukis ◽

...

Keyword(s):

Crohn’S Disease ◽

Small Bowel ◽

Crohn's Disease ◽

Disease Activity ◽

Capsule Endoscopy ◽

Terminal Ileum ◽

Inflammatory Activity ◽

Disease Extent ◽

Upper Gi ◽

Proximal Small Bowel

Abstract Background Small bowel capsule endoscopy (SBCE) enables the direct visualisation of the entire small bowel (SB) mucosa and the application of the Lewis score allows the reliable assessment of the SB mucosal inflammatory activity in Crohn’s disease (CD) patients. The study aim was to investigate the association of disease location, extent and inflammatory activity in CD patients with the use of SBCE Methods Retrospective study of 80 consecutive patients with an established CD that underwent SBCE in the Gastroenterology Department of the University Hospital of Ioannina between January 2007 and October 2019, for the evaluation of disease extent and disease activity. Results Fifty-one patients had evidence of endoscopic disease activity. In 30 of these patients (58.8%), the disease was located in the ileum and proximal SB, whereas in 20 patients (39.2%) the disease was located solely in the terminal ileum. In one patient (2%) treated with adalimumab, the disease was located solely in the jejunum. Eight patients (15.7%) had evidence of disease activity in the upper GI. All patients with upper GI disease activity demonstrated proximal SB disease involvement. The median Lewis score in patients with proximal CD was 1350 (mean 1666.3; Std 1343) median) against 458 (mean 1548,6; Std 1751) in patients with disease located in the ileum (p = 0.10). Conclusion In our study, proximal small bowel disease involvement was present in >50% of CD patients. Upper GI involvement was associated with extensive SB disease. Patients with proximal SB CD demonstrated a higher median Lewis score compared with those with CD located solely in the terminal ileum.

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