Wireless capsule endoscopy versus ileocolonoscopy for the diagnosis of postoperative recurrence of Crohn's disease: a prospective study

Endoscopic Scores for Evaluation of Crohn's Disease Activity at Small Bowel Capsule Endoscopy: General Principles and Current Applications

The small bowel is affected in the vast majority of patients with Crohn's Disease (CD). Small bowel capsule endoscopy (SBCE) has a very high sensitivity for the detection of CD-related pathology, including early mucosal lesions and/or those located in the proximal segments of the small bowel, which is a major advantage when compared with other small bowel imaging modalities. The recent guidelines of European Society of Gastrointestinal Endoscopy (ESGE) and European Crohn's and Colitis Organisation (ECCO) advocate the use of validated endoscopic scoring indices for the classification of inflammatory activity in patients with CD undergoing SBCE, such as the Lewis Score or the Capsule Endoscopy Crohn's Disease Activity Index (CECDAI). These scores aim to standardize the description of lesions and capsule endoscopy reports, contributing to increase inter-observer agreement and enabling a stratification of the severity of the disease. On behalf of the Grupo de Estudos Português do Intestino Delgado (GEPID) - Portuguese Small Bowel Study Group, we aimed to summarize the general principles and clinical applications of current endoscopic scoring systems for SBCE in the setting of CD, covering the topic of suspected CD as well as the evaluation of disease extent (with potential prognostic and therapeutic impact), evaluation of mucosal healing in response to treatment and evaluation of post-surgical recurrence in patients with previously established diagnosis of CD.

Role of wireless capsule endoscopy in the follow-up of inflammatory bowel disease

The introduction of wireless capsule endoscopy in 2000 has revolutionized our ability to visualize parts of the small bowel mucosa classically unreached by the conventional endoscope, and since the recent introduction of colon capsule endoscopy, a promising alternative method has been available for the evaluation of large bowel mucosa. The advantages of wireless capsule endoscopy include its non-invasive character and its ability to visualize proximal and distal parts of the intestine, while important disadvantages include the procedure’s inability of tissue sampling and significant incompletion rate. Its greatest limitation is the prohibited use in cases of known or suspected stenosis of the intestinal lumen due to high risk of retention. Wireless capsule endoscopy plays an important role in the early recognition of recurrence, on Crohn’s disease patients who have undergone ileocolonic resection for the treatment of Crohn’s disease complications, and in patients’ management and therapeutic strategy planning, before obvious clinical and laboratory relapse. Although capsule endoscopy cannot replace traditional endoscopy, it offers valuable information on the evaluation of intestinal disease and has a significant impact on disease reclassification of patients with a previous diagnosis of ulcerative colitis or inflammatory bowel disease unclassified/indeterminate colitis. Moreover, it may serve as an effective alternative where colonoscopy is contraindicated and in cases with incomplete colonoscopy studies. The use of patency capsule maximizes safety and is advocated in cases of suspected small or large bowel stenosis.

Guidelines for video capsule endoscopy: emphasis on Crohn's disease

Video capsule endoscopy (VCE) is an ingestible video camera that transmits high-quality images of the small intestinal mucosa. This makes the small intestine more readily accessible to physicians investigating the presence of small bowel disorders, such as Crohn's disease (CD). Although VCE is frequently performed in Korea, there are no evidence-based guidelines on the appropriate use of VCE in the diagnosis of CD. To provide accurate information and suggest correct testing approaches for small bowel diseases, the Korean Gut Image Study Group, part of the Korean Society of Gastrointestinal Endoscopy, developed guidelines on VCE. Teams were set up to develop guidelines on VCE. Four areas were selected: diagnosis of obscure gastrointestinal bleeding, small bowel preparation for VCE, diagnosis of CD, and diagnosis of small bowel tumors. Three key questions were selected regarding the role of VCE in CD. In preparing these guidelines, a systematic literature search, evaluation, selection, and meta-analysis were performed. After writing a draft of the guidelines, the opinions of various experts were solicited before producing the final document. These guidelines are expected to play a role in the diagnosis of CD. They will need to be updated as new data and evidence become available.

Diagnosis and monitoring of postoperative recurrence in Crohn's disease

Despite advances in medical management, many patients with Crohn's disease (CD) require intestinal surgery throughout their lives. Surgery is not a cure, and postoperative recurrence is common in patients with CD. Ileocolonoscopy has been considered to be the gold standard in the diagnosis and monitoring of postoperative recurrence. However, the optimal monitoring strategy for postoperative recurrence has yet to be established. Capsule endoscopy and cross-sectional imaging techniques, including ultrasonography, computed tomography and MRI, have been used in the postoperative setting, and their usefulness in the monitoring of disease activity has been evaluated in recent clinical trials. The value of fecal markers, such as calprotectin and lactoferrin, has been also assessed in several studies. This review was to identify optimized methods for the diagnosis and monitoring of postoperative recurrence in CD.

Small bowel capsule endoscopy in the management of established Crohn's disease: clinical impact, safety, and correlation with inflammatory biomarkers

BACKGROUND

Multiple studies have established the superior diagnostic accuracy of video capsule endoscopy (VCE) for the diagnosis of small bowel (SB) Crohn's disease (CD). However, data on the clinical impact of VCE in patients with established CD are scarce. The aim of this study was to examine the impact and safety of VCE on the clinical management of patients with established CD.

METHODS

A retrospective, multicenter, cross-sectional study. The study cohort included consecutive patients with established SB CD who underwent VCE in 4 tertiary referral centers (1 Canada, 1 Sweden, and 2 United Kingdom) from January 2008 to October 2013. Patients were excluded if VCE was performed as a part of the initial diagnostic workup. The presence of SB mucosal inflammation was quantified using the Lewis score. Inflammatory biomarkers (C-reactive protein and fecal calprotectin) were measured and correlated with the Lewis score.

RESULTS

The study included 187 patients. No SB inflammation was observed in 28.4%, mild-to-moderate inflammation in 26.6%, and moderate-to-severe inflammation in 45% of the patients (median Lewis score, 662; range, 0-6400). A change in management was recommended in 52.3% of the patients based on VCE findings. Elevated C-reactive protein, fecal calprotectin, or the combination of both were poorly correlated with significant SB inflammation. SB capsule retention occurred in 4 patients (2.1%).

CONCLUSIONS

VCE in patients with established CD is safe, and the results often have a significant clinical impact. VCE should not be limited to CD patients with positive inflammatory markers because their predictive value for significant SB inflammation is poor.

Small bowel Crohn's disease: an emerging disease phenotype?

An increasing understanding of the pathogenesis of Crohn's disease (CD), coupled with improvements in therapeutic options, has promoted the concept of stratifying patients with CD into distinct disease phenotypes according to risk. Small bowel CD, due to the numerous non-specific potential symptoms and the anatomical location of the disease, is a particularly difficult phenotype to identify. The fact that the majority of de novo strictures occur in the ileum/ileo-colonic region ensures that recognition of small bowel involvement is essential. Certainly, it is becoming increasingly recognised due to improvements in imaging and endoscopic techniques. Both CT and MR enterography appear capable of accurately diagnosing small bowel CD. Furthermore, the development of capsule endoscopy and balloon-assisted enteroscopy allow direct visualisation of the small bowel. Limited data to date would suggest that small bowel CD is a difficult entity to treat even in the current era of the ever-expanding field of biological therapies. Further long-term follow-up studies are necessary using both small bowel capsule endoscopy and cross-sectional imaging to truly assess, firstly, whether small bowel CD is more resistant to treatment and, secondly, whether it has an effect over time in terms of complications. In the future, serological and genetic tests, coupled with the aforementioned investigations, will permit early diagnosis and early treatment of small bowel CD.

Imaging techniques in IBD and their role in follow-up and surveillance

The assessment of extent and severity of IBD is crucial for directing treatment decisions. Clinical symptoms alone are neither sensitive nor specific for the assessment of lesion severity in IBD. Cross-sectional imaging techniques, as well as small-bowel capsule endoscopy (SBCE) and device-assisted enteroscopy, have a high accuracy for assessing the extent of mucosal lesions, and are reliable alternatives to ileocolonoscopy. New endoscopic techniques and devices are emerging for improved follow-up and surveillance. In this Review, we discuss different imaging techniques that are used to assess IBD activity and to survey patients with IBD, and highlight the latest developments in each area. Moreover, technical improvements and new tools that aim to measure intestinal fibrosis, postoperative recurrence, activity indices and endoscopic features are analysed. All of these imaging techniques are aimed at changing the paradigm from symptom-driven to lesion-driven treatment of IBD.

Current applications and potential future role of wireless capsule technology in Crohn's disease

BACKGROUND

The development of capsule technology has modified our approach to the diagnosis of gastrointestinal disease. The relatively rapid uptake of capsule endoscopy as an important clinical tool can be largely ascribed to a number of key factors, including the fact that it is a relatively easy examination to perform in an outpatient setting. It has been established as an integral part of the investigation pathway for obscure gastrointestinal bleeding and suspected small bowel Crohn's disease (CD). CURRENT USE OF CAPSULE ENDOSCOPY: Small bowel CD can be a challenging entity to diagnose. Capsule endoscopy has been shown to be both useful and safe in patients with both suspected and established small bowel CD. In suspected disease, capsule endoscopy has both a high diagnostic yield and negative predictive value. Capsule findings lead to changes in management in up to 73% of patients with established CD. However, while the technology appears capable of detecting subtle mucosal changes not readily apparent on alternate imaging modalities, the question of what actually constitutes small bowel CD as described by capsule is an issue that remains unresolved to date. Thus, capsule endoscopy is best utilised in tandem with advanced imaging and endoscopic techniques such as balloon- assisted enteroscopy.

FUTURE DEVELOPMENTS

The development of a capsule capable of viewing the colon coupled with improvements in image quality and battery life are likely to lead to the increasing uptake of this technology. In the future, 'interactive' capsules with the ability to view the entire gastrointestinal tract may be a reality.

Capsule endoscopy in Crohn’s disease: Are we seeing any better?

Crohn’s disease (CD) is a complex, immune-mediated disorder that often requires a multi-modality approach for optimal diagnosis and management. While traditional methods include ileocolonoscopy and radiologic modalities, increasingly, capsule endoscopy (CE) has been incorporated into the algorithm for both the diagnosis and monitoring of CD. Multiple studies have examined the utility of this emerging technology in the management of CD, and have compared it to other available modalities. CE offers a noninvasive approach to evaluate areas of the small bowel that are difficult to reach with traditional endoscopy. Furthermore, CE maybe favored in specific sub segments of patients with inflammatory bowel disease (IBD), such as those with IBD unclassified (IBD-U), pediatric patients and patients with CD who have previously undergone surgery.

Management of postoperative Crohn's disease

Surgical treatment does not cure Crohn's disease, and postoperative recurrence is a feature of the clinical course of the disease. Ileocolonoscopy remains the gold standard for the surveillance of recurrent Crohn's disease and should be performed 6-12 months after an operation. Many other non-invasive techniques are also useful and complement endoscopy for the early diagnosis of postoperative recurrence. Anti-TNF agents show great efficacy for the prevention of postoperative recurrence, and long-term use can maintain remission. It remains undetermined whether early treatment after postoperative endoscopic recurrence is ultimately as efficacious as prophylactic therapy.

An overview of the natural history of inflammatory bowel diseases

Inflammatory bowel disease includes two main conditions: Crohn's disease (CD) and ulcerative colitis (UC). Natural history studies of these two entities have shown relevant differences in several clinical outcomes, mainly a more chronic and persistent (although often subclinical) inflammatory activity and the development of complications related to long-term tissue damage in CD. This led in recent years to different long-term therapeutic strategies in each disease. In this article, we review the main phenotypic features of UC and CD at the time of disease diagnosis and their changes along the course of the disease, as well as their consequences regarding drug therapy and surgical requirements.

Capsule endoscopy in the small bowel Crohn's disease

CD is a chronic inflammatory disorder associated to mucosal and transmural inflammation of the bowel wall. It is well known that CD can affect the entire gastrointestinal. Therefore, ileocolonoscopy and biopsies of the terminal ileum as well as of each colonic segment to look for microscopic evidence of CD are the first-line procedures to establish the diagnosis. However, it has been observed that up to 30% of the patients have only small bowel involvement. Evaluation of the small bowel has been made with radiological procedures, barium radiography, and abdominal computed tomography or by ileocolonoscopy or enteroscopy, but they have many recognized limitations. CE is undoubtedly a very useful diagnostic tool proposed to observe small-bowel lesions undetectable by conventional endoscopy or radiologic studies. We review different studies that have been published reporting the use of CE in suspected and evaluation of the extension or the recurrence in CD and also its use in pediatric population and its complications.

Role of capsule endoscopy in inflammatory bowel disease

Videocapsule endoscopy (VCE) has revolutionized our ability to visualize the small bowel mucosa. This modality is a valuable tool for the diagnosis of obscure small bowel Crohn’s disease (CD), and can also be used for monitoring of disease activity in patients with established small-bowel CD, detection of complications such as obscure bleeding and neoplasms, evaluation of response to anti-inflammatory treatment and postoperative recurrence following small bowel resection. VCE could also be an important tool in the management of patients with unclassified inflammatory bowel disease, potentially resulting in reclassification of these patients as having CD. Reports on postoperative monitoring and evaluation of patients with ileal pouch-anal anastomosis who have developed pouchitis have recenty been published. Monitoring of colonic inflammatory activity in patients with ulcerative colitis using the recently developed colonic capsule has also been reported. Capsule endoscopy is associated with an excellent safety profile. Although retention risk is increased in patients with small bowel CD, this risk can be significanty decreased by a routine utilization of a dissolvable patency capsule preceding the ingestion of the diagnostic capsule. This paper contains an overview of the current and future clinical applications of capsule endoscopy in inflammatory bowel disease.

Optimizing post-operative Crohn's disease treatment

Despite the availability of biological drugs and the widespread and earlier use of immunosuppressants, intestinal resection remains necessary in almost half of the patients with Crohn's disease. The development of new mucosal lesions in previously unaffected intestinal segments (a phenomenon known as post-operative recurrence, POR) occur within the first year in up to 80% if no preventive measure is started soon after resectional surgery, leading to clinical manifestations (clinical recurrence) and even needing new intestinal resection (surgical recurrence) in some patients. That is the reason why endoscopic monitoring has been recommended within 6 to 12 months after surgery. Active smoking is the only indisputable risk factor for early POR development. Among several evaluated drugs, only thiopurine and anti-tumor necrosis factor therapy seem to be effective and feasible in the long-term both for preventing or even treating recurrent lesions, at least in a proportion of patients. However, to date, it is not clear which patients should start with one or another drug right after surgery. It is also not well established how and how often POR should be assessed in patients with a normal ileocolonoscopy within the first 12 months.

Optimising monitoring in the management of Crohn's disease: a physician's perspective

Management of Crohn's disease has traditionally placed high value on subjective symptom assessment; however, it is increasingly appreciated that patient symptoms and objective parameters of inflammation can be disconnected. Therefore, strategies that objectively monitor inflammatory activity should be utilised throughout the disease course to optimise patient management. Initially, a thorough assessment of the severity, location and extent of disease is needed to ensure a correct diagnosis, identify any complications, help assess prognosis and select appropriate therapy. During follow-up, clinical decision-making should be driven by disease activity monitoring, with the aim of optimising treatment for tight disease control. However, few data exist to guide the choice of monitoring tools and the frequency of their use. Furthermore, adaption of monitoring strategies for symptomatic, asymptomatic and post-operative patients has not been well defined. The Annual excHangE on the ADvances in Inflammatory Bowel Disease (IBD Ahead) 2011 educational programme, which included approximately 600 gastroenterologists from 36 countries, has developed practice recommendations for the optimal monitoring of Crohn's disease based on evidence and/or expert opinion. These recommendations address the need to incorporate different modalities of disease assessment (symptom and endoscopic assessment, measurement of biomarkers of inflammatory activity and cross-sectional imaging) into robust monitoring. Furthermore, the importance of measuring and recording parameters in a standardised fashion to enable longitudinal evaluation of disease activity is highlighted.

A survey of current practices used to maintain surgically induced remission following intestinal resection for Crohn's disease

BACKGROUND AND AIMS

Post-operative Crohn's disease (CD) recurrence is common after intestinal resection. The European Crohn's and Colitis Organization has issued guidelines regarding the optimal post-operative management of patients who have undergone intestinal resection for CD. The current study aims to assess the current adjuvant therapy practices of colorectal surgeons and gastroenterologists.

METHODS

An electronic-based survey was sent to members of the Association of Coloproctology of Great Britain and Ireland and the Irish Society of Gastroenterology.

RESULTS

One hundred twenty-five surgeons and gastroenterologists responded. Gastroenterologists more frequently assessed for pre-clinical recurrence with serum inflammatory markers (97 vs. 51%, P < 0.001), faecal calprotectin (30 vs. 10%, P = 0.008) and ileocolonoscopy (67 vs. 23%, P < 0.001), while surgeons more frequently performed a CT scan (23 vs. 6%, P = 0.037). The majority of respondents estimated the 1-year endoscopic recurrence to be 10-25%, and 36% of respondents offered prophylaxis to all post-operative patients. Budesonide (8 vs. 4%, P = 0.006) and azathioprine/mercaptopurine (60 vs. 33%, P < 0.001) were more often prescribed for high-risk patients, while imidazole antibiotics (11 vs. 5%, P < 0.001) and 5-ASA derivatives were more often prescribed for low-risk patients (51 vs. 14%, P < 0.001).

CONCLUSION

Currently, surgeons and gastroenterologists involved in the peri-operative care of patients with CD underestimate the risk of recurrence following intestinal resection and under-utilize ileocolonoscopy to tailor adjuvant therapy.

State-of-the-art medical prevention of postoperative recurrence of Crohn's disease

Postoperative recurrence of Crohn's disease is a frequent and often severe sequela of the disease. Until a few years ago it was deemed inescapable, as all the conventional medications used to treat the disease have been proven of little benefit in preventing recurrence after surgical treatment. In the past few years, anti-TNF agents given immediately after surgery have shown a remarkable efficacy in the prevention of disease recurrence. Large, randomized, controlled trials are currently underway to confirm these findings. Anti-TNF treatment of endoscopic lesions that occur after surgery seems to be less effective than using TNF antagonists to prevent recurrence. However, although the data are limited, this treatment strategy seems to be still superior to all the other prevention strategies that are not based on anti-TNF agents. Limited data are available on long-term outcomes of patients treated with anti-TNF agents after surgery. They suggest that these medications are safe and effective after many years of treatment. In addition, these agents might prevent recurrence even at doses lower than those used in patients with Crohn's disease who have not had surgery.

State-of-the-art medical prevention of postoperative recurrence of Crohn's disease

Postoperative recurrence of Crohn's disease is a frequent and often severe sequela of the disease. Until a few years ago it was deemed inescapable, as all the conventional medications used to treat the disease have been proven of little benefit in preventing recurrence after surgical treatment. In the past few years, anti-TNF agents given immediately after surgery have shown a remarkable efficacy in the prevention of disease recurrence. Large, randomized, controlled trials are currently underway to confirm these findings. Anti-TNF treatment of endoscopic lesions that occur after surgery seems to be less effective than using TNF antagonists to prevent recurrence. However, although the data are limited, this treatment strategy seems to be still superior to all the other prevention strategies that are not based on anti-TNF agents. Limited data are available on long-term outcomes of patients treated with anti-TNF agents after surgery. They suggest that these medications are safe and effective after many years of treatment. In addition, these agents might prevent recurrence even at doses lower than those used in patients with Crohn's disease who have not had surgery.

The prevalence and outcome of jejunal lesions visualized by small bowel capsule endoscopy in Crohn's disease

BACKGROUND

Small bowel capsule endoscopy is the most sensitive technique for the detection of lesions in the small intestine. The aims of the study were to assess the prevalence and clinical significance of jejunal lesions detected by small bowel capsule endoscopy in patients with an established Crohn's disease.

RESULTS

One hundred and eight patients, including 32 patients with ileal disease, 25 patients with colonic disease, and 51 patients with ileocolonic disease, underwent small bowel capsule endoscopy, and findings were analyzed retrospectively. Jejunal lesions were detected in 56% of these patients, of whom 18 (17%) had lesions only in the jejunum. Jejunal lesions were less frequently detected (12% versus 38%, P = 0.001) when location of the disease was limited to the colon at ileocolonoscopy. Conversely, when Crohn's disease affected the ileum, jejunal lesions were more frequently detected (40% versus 17%, P = 0.007). During a median follow-up time of 24.0 months (interquartile, 8.0-46.2), 50 clinical relapses occurred. The presence of jejunal lesions was the only independent factor associated with an increased risk of relapse (P = 0.02). In nonsmokers and in patients treated by immunosuppressors, the presence of jejunal lesions tended to increase the risk of relapse (P = 0.06 and 0.05, respectively).

CONCLUSIONS

Jejunal lesions are detected in more than half of the patients with Crohn's disease. The prevalence of jejunal lesions is higher when the terminal ileum is involved and associated with an increased risk of further clinical relapse. It may be regarded as a factor of severity.

Clinical utility of capsule endoscopy in patients with Crohn's disease and inflammatory bowel disease unclassified

BACKGROUND

Although small bowel capsule endoscopy (SBCE) has developed an established role in Crohn's disease (CD), there is paucity of data on impact of SBCE on subsequent management. We investigated the clinical utility of SBCE in patients with suspected and established CD and inflammatory bowel disease unclassified (IBDU).

MATERIALS AND METHODS

Patients referred routinely from 2003 to 2009 with a diagnosis of IBDU, suspected or established CD were identified retrospectively. Data were collected for indications and findings at SBCE with subsequent follow-up.

RESULTS

A total of 315 patients were identified. There were n=265 referred for suspected CD (of which n=37 had a prior diagnosis of IBDU) and n=50 with established CD. SBCE was suggestive of CD in 17% of the suspected CD group, 43% in the IBDU group and 66% in the established CD patients. In the suspected CD cohort, an eventual diagnosis of CD was made in 12% (n=31) after a mean follow-up of 15 months (range 1-84), resulting in a change of management in 90% (n=28/31). In patients with IBDU, the diagnosis of CD was made in 38% (n=14) after an average follow-up of 19 months (±2). In patients with established CD, management was altered in 73% of patients after SBCE.

CONCLUSION

There was a low diagnostic yield in patients referred with suspected CD although a diagnosis at SBCE was predictive of a clinical diagnosis in the majority after a mean follow-up of 15 months. A diagnosis of CD was more likely in the IBDU and established CD cohort. SBCE diagnoses changed management in the majority of patients.

Endoscopic techniques for small bowel imaging

Advances in small bowel enteroscopy have led to an increase in the endoscopic evaluation and management of small bowel disorders. The entire small bowel can now be visualized in a noninvasive manner by capsule endoscopy, while therapeutic management can be performed with deep enteroscopy techniques, including balloon-assisted and spiral enteroscopy. Each of these enteroscopy tools has its unique advantages and disadvantages, which need to be taken into consideration during selection of the appropriate tool. Capsule endoscopy and deep enteroscopy are often used as complementary tests in the evaluation of small bowel disorders.

The evolving management of postoperative Crohn's disease

Two-thirds to three-quarters of Crohn's disease patients require intestinal surgery for medically refractory disease or complications. Surgery is not a cure and most patients develop recurrent Crohn's disease and require additional intestinal resections. There are a number of medications that have been investigated for preventing and treating recurrence. Risk factors for postoperative disease recurrence help guide the physician in determining the appropriate treatment strategy after Crohn's disease surgery. The approach to Crohn's disease treatment has evolved over the years. No longer should surgery be considered a failure of treatment, rather an important intervention to correct irreversible disease. In combination with a better understanding of postoperative medication strategies, patients with Crohn's disease may achieve longer term remission than previously realized. This review elucidates current understanding of the natural course of postoperative Crohn's disease, monitoring for recurrence, the risk factors for recurrence, and provides insight into an evolving new paradigm for postoperative Crohn's disease treatment.

Recent advances in small bowel diseases: Part II

As is the case in all areas of gastroenterology and hepatology, in 2009 and 2010 there were many advances in our knowledge and understanding of small intestinal diseases. Over 1000 publications were reviewed, and the important advances in basic science as well as clinical applications were considered. In Part II we review six topics: absorption, short bowel syndrome, smooth muscle function and intestinal motility, tumors, diagnostic imaging, and cystic fibrosis.

Diagnosis, prevention and treatment of postoperative Crohn's disease recurrence

Ileocolonoscopy remains the gold standard in diagnosing postoperative recurrence. After excluding stricture, wireless capsule endoscopy seemed accurate in small series, but no validated score is available. Ultrasonography is a non-invasive diagnostic method reducing radiation exposure and emerging as an alternative tool for identifying post-operative recurrence. Computed tomography enteroclysis yields objective morphologic criteria that help differentiate between recurrent disease and fibrostenosis at the anastomotic site, but ionising radiation exposure limits its use. Magnetic resonance imaging may be as powerful as ileocolonoscopy in diagnosing postoperative recurrence and in predicting the clinical outcome using specific MR-scores. Biomarkers such as faecal calprotectin and faecal lactoferrin showed promising results, but their specificity in the postoperative period will require further investigation. Numerous medications have been tested to prevent and/or to treat postoperative recurrence. Efficacy of mesalamine is very low and comparable to placebo in most series. Thiopurines have modest efficacy in the postoperative setting and are associated with a high rate of adverse events leading to drug withdrawal. Antibiotics such as metronidazole or ornidazole may be effective, but toxicity and drug resistance prevent their long-term use. Anti-Tumour Necrosis Factor therapy is the most potent drug class to prevent and to treat postoperative recurrence in Crohn's disease.

Evaluation for postoperative recurrence of Crohn disease

Disease recurrence following resective surgery for Crohn disease remains a challenging clinical problem, and more studies are needed to better define risk stratification and treatment recommendations in the postoperative setting. Endoscopy remains the gold standard for the assessment of postoperative disease recurrence, and all Crohn disease patients who undergo surgery should undergo ileocolonoscopy within 6 to 12 months of surgery. The degree of endoscopic recurrence in the neoterminal ileum during this procedure provides prognostic information regarding the severity of the future disease course. WCE, MRE, and SICUS are all promising noninvasive modalities to assess for postoperative Crohn disease activity. However, further studies are needed to better define scoring systems, operating characteristics and variability, and prognostic data for each of these modalities. In patients at risk for early disease recurrence, more aggressive prophylactic therapy should be considered, in hopes of delivering true “top-down” therapy that may offer maximum impact in altering the natural history of Crohn disease.

Small bowel endoscopy in inflammatory bowel disease

The last decade has witnessed a revolution in small bowel (SB) endoscopy technologies. Endoscopists are no longer confined to the use of push enteroscopy or the significantly more invasive intra-operative enteroscopy: SB capsule endoscopy (SBCE) and device assisted enteroscopy (DAE) have rapidly enabled endoscopic visualisation of the entire SB without the need for surgery. DAE goes a step further by allowing tissue sampling and the application of endotherapy. These developments have also been parallelled by rapid advances in dedicated radiological SB imaging technologies. Although it is clear that SBCE and DAE may have a significant role in the diagnosis and management of IBD patients, their respective place in relation to other technologies within the clinical paradigm of IBD is as yet unclear. This review outlines the current evidence base relating to these endoscopic technologies and their impact in the diagnosis and management of IBD and highlights current international recommendations.

Ultra-high-field magnetic resonance enterography in the diagnosis of ileitis (Neo-)terminalis: a prospective study

BACKGROUND AND GOALS

Magnetic resonance (MR) enterography provides the advantages of conventional enteroclysis and those of cross-sectional imaging. Adequate luminal distension, combined with ultrafast sequences, results in excellent delineation of mural and extramural manifestations of Crohn's disease. Recent technical advances, including ultra-high-field strength MR with its capability to provide fast multiplanar images with excellent soft tissue contrast, are only rarely included in abdominal studies.

STUDY

One hundred four consecutive patients with a proved or suspected diagnosis of ileitis terminalis were prospectively selected for MR imaging studies and ileocolonoscopy. The final diagnosis was based on histopathological findings or based on a combined endpoint of clinical, laboratory, endoscopic, and imaging findings.

RESULTS

According to the endoscopic examination, stenosis was present in 26 patients (25%) and could be ruled out in 78 patients (75%). Total agreement between MR and endoscopy could be reached in 74 patients (71%). Histology indicated absence of inflammation in 50 patients (48%). MR and endoscopic findings were concordant in 38 patients (76%) and 37 patients (74%), respectively. Corresponding results by ileocolonoscopy were 37 true negative, 29 true positive, 4 false positive, and 12 false negative (sensitivity, 70.7%; specificity, 74%).

CONCLUSIONS

MR enterography with a 3.0-T scanner is a powerful tool in the evaluation of ileal diseases, and has therefore made MR enterography the first-line modality at our institution in patients with suspected inflammatory bowel disease.

Postoperative recurrent luminal Crohn's disease: a systematic review

Despite improved immunosuppressive therapy, surgical resection is still often required for uncontrolled inflammatory disease and the stenosing and perforating complications of Crohn's disease. However, surgery is not curative. A majority of patients develop disease recurrence at or above the anastomosis. Subclinical endoscopically identifiable recurrence precedes the development of clinical symptoms; identification and treatment of early mucosal recurrence may therefore prevent clinical recurrence. Therapy to achieve mucosal healing should now be the focus of postoperative therapy. A number of clinical risk factors for the development of earlier postoperative recurrence have been identified, and reasonable evidence is now available regarding the efficacy of drug therapies in preventing recurrence. This evidence now needs to be incorporated into prospective treatment strategies.

Small bowel imaging in managing Crohn's disease patients

The small bowel is essential to sustain alimentation and small bowel Crohn's disease (CD) may severely limit its function. Small bowel imaging is a crucial element in diagnosing small bowel CD, and treatment control with imaging is increasingly used to optimize the patients outcome. Thereby, capsule endoscopy, Balloon-assisted enteroscopy, and Magnetic resonance imaging have become key players to manage CD patients. In this review, role of small bowel imaging is detailed discussed for use in diagnosing and managing Crohn's disease patients.

The impact of intestinal resection on serum levels of anti-Saccharomyces cerevisiae antibodies (ASCA) in patients with Crohn's disease

BACKGROUND

Antibodies to Saccharomyces cerevisiae (ASCA) are highly prevalent in sera of patients with Crohn's disease and have been proposed to identify subgroups of patients with a disabling disease course.

AIM

To investigate the impact of intestinal resection on serum levels of ASCA in patients with Crohn's disease and the predictive value of ASCA levels on surgical recurrence.

METHODS

Sera from 60 patients who underwent 'curative' intestinal resection due to stricturing and/or penetrating complications were collected preoperatively and during post-operative follow-up (week 2, months 4, 8 and 11 ± 1). Measurement of ASCA IgG and IgA isotypes were performed using ELISA. Re-operation rate was associated with ASCA status and serum levels.

RESULTS

At baseline 44/60 (73%) of patients were rated as positive for ASCA IgG, 45/60 (75%) for ASCA IgA and 52/60 (87%) as positive for at least one of both. ASCA serum levels remained stable during first year from resection. After a median of 106 months 10 of 40 (25%) patients with long-term follow-up underwent one or more intestinal re-operations. Neither ASCA positivity nor absolute ASCA serum levels were predictive of surgical recurrence.

CONCLUSIONS

Serum ASCA levels remain stable after curative intestinal resection in Crohn's disease. This indicates the persistence of both stimulus and immunological mechanism operative in the production of ASCA even after complete surgical resection of macroscopically inflamed intestinal tissue. After intestinal resection, neither ASCA positivity nor ASCA serum levels predict the risk of surgical recurrence during long-term follow-up.

Capsule endoscopy and Crohn's disease

Capsule endoscopy has been shown to detect small bowel inflammatory changes better than any other imaging modality. Selection criteria have been optimized to increase the yield of capsule endoscopy in patients suspected of having Crohn's disease. Capsule endoscopy allows for earlier diagnosis of Crohn's disease of the small bowel and improved diagnosis of colitis in patients where it is unclear if they suffer from Crohn's or ulcerative colitis. A test capsule is available to assess for small bowel strictures and thus avoid capsule retention. It is envisioned that the manner in which we treat Crohn's disease in the future will change, based on earlier diagnosis and treatment aimed at mucosal healing rather than symptom improvement.

New concepts in intestinal imaging for inflammatory bowel diseases

In the last decade, multiple imaging technologies have been developed that improve visualization of the mucosal, mural, and perienteric inflammation associated with inflammatory bowel diseases. Whereas these technologies have traditionally been used to detect and stage suspected enteric inflammation, we review new, emerging roles in detecting clinically occult inflammation (in asymptomatic patients) and inflammatory complications, predicting response prior to therapy, assessing response after therapy, and enteric healing. We compare the relative performance of these technologies in detecting inflammation, focusing on their advantages and disadvantages and how they might complement each other. We also discuss their potential benefits for patients and clinical trials, reviewing technologic developments and areas of research that could provide important insights into the pathophysiology of inflammatory bowel diseases-related enteric inflammation.

Small bowel capsule endoscopy vs conventional techniques in patients with symptoms highly compatible with Crohn's disease

BACKGROUND & AIMS

The diagnostic role of Small Bowel Capsule Endoscopy (SBCE) in Crohn's Disease (CD) is under investigation. In a prospective study we investigated the diagnostic role of SBCE in patients with symptoms highly compatible with CD and undefined diagnosis after conventional techniques.

METHODS

From September 2005 to May 2009, all patients with clinically suspected CD and not conclusive diagnosis after Ileocolonoscopy (IC), Small Bowel Follow Through (SBFT) and Small Intestine Contrast Ultrasonography (SICUS) were enrolled. Findings compatible with CD included: bowel wall thickness (BWT) >3mm (for SICUS), ulcers, stenosis/strictures, fistulae (for SICUS, SBFT); >5 aphtoid ulcers, deep ulcers and/or strictures (for SBCE).

RESULTS

Conventional techniques did not lead to a conclusive diagnosis in 30 patients (19 F, median age 31 years, range 8-57), showing chronic diarrhoea (n=27), abdominal pain (n=23), weight loss (n=5), fever (n=5), Iron Deficiency Anaemia (IDA)(n=5) and/or perianal disease (n=4). Findings compatible but not diagnostic for small bowel CD were detected in 19 (63%) by IC in 12 (40%) by SICUS and in 15 (50%) by SBFT. SBCE showed ileal lesions in 15 (50%) patients, including findings compatible with CD in 12 (40%). SBCE retention requiring surgery was observed in 1 patient. A significant concordance was observed between SBCE and IC k=0.33 C(k)=[0.25;0.42], but not between SBCE and SICUS k=0.13 IC(k)=[0.045;0.22] and between SBCE and SBFT k=0 IC(k)=[-0.089;0.089].

CONCLUSIONS

SBCE may detect lesions compatible with small bowel CD in almost one third of patients with symptoms highly compatible with CD and not conclusive diagnosis by using conventional techniques.

Ileoscopy via stoma after diverting ileostomy: a safe and effective tool to evaluate for Crohn's recurrence of neoterminal ileum

BACKGROUND

Recurrence of Crohn's disease (CD) most commonly occurs in the neoterminal ileum near the stoma after fecal diverting ileostomy. Methods used to assess CD recurrence include small bowel series, ileostomy injection, computed tomography (CT) enterography, and capsule endoscopy. Retrograde ileoscopy via stoma is also a valuable tool for recognition of CD recurrence; however, this technique has not been formally studied.

OBJECTIVE

To evaluate the safety and utility of retrograde ileoscopy via stoma in patients with CD.

METHODS

Patients with CD who underwent ileoscopy via stoma between January 1, 2001, through December 31, 2008 were included. This was a retrospective study in a tertiary referral center. The main outcome measures were procedural complications and findings.

RESULTS

A total of 243 ileoscopies were performed on 99 patients. The most common indications for ileoscopy were CD activity assessment in 34.5% and abdominal pain in 33.3%. The procedure was outpatient in 75.8%. Meperidine and midazolam were most commonly used. Average depth of intubation was 28.4 cm. CD recurrence was detected in 70% of patients. Biopsies were obtained during ileoscopy in 117 studies, and biopsy and ileoscopy findings correlated in 111 studies (94.8%). One polypectomy, 24 balloon stricture dilations, and 8 intralesional steroid injections were performed. All patients tolerated the procedure well without procedure- or anesthesia-related complications. No hospital admissions or procedure-related deaths occurred.

CONCLUSIONS

Retrograde ileoscopy via stoma is a safe and effective procedure for evaluating recurrence of CD of the neoterminal ileum. It also allows for therapeutic interventions such as balloon dilatation of ileal strictures and steroid injections.

Interobserver agreement in describing video capsule endoscopy findings: a multicentre prospective study

BACKGROUND AND AIM

Few studies have specifically addressed interobserver agreement in describing lesions identified during capsule endoscopy. The aim of our study is to evaluate interobserver agreement in the description of capsule endoscopy findings.

MATERIALS AND METHODS

Consecutive short segments of capsule endoscopy were prospectively observed by 8 investigators. Seventy-five videos were prepared by an external investigator (gold standard). The description of the findings was reported by the investigators using the same validated and standardized capsule endoscopy structured terminology. The agreement was assessed using Cohen's kappa statistic.

RESULTS

As concerns the ability to detect a lesion, the agreement with the gold standard was moderate (kappa 0.48), as well as the agreement relating to the final diagnosis (κ 0.45). The best agreement was observed in identifying the presence of active bleeding (κ 0.72), whereas the poorest agreement concerned the lesion size (κ 0.32). The agreement with the GS was significantly better in endoscopists with higher case/volume of capsule endoscopy per year. Diagnostic concordance was better in the presence of angiectasia than in the presence of polyps or ulcers/erosions.

CONCLUSIONS

Correct lesion identification and diagnosis seem more likely to occur in presence of angiectasia, and for readers with more experience in capsule endoscopy reading.

The role of endoscopic imaging of the small bowel in clinical practice

Enteroscopy, defined as direct visualization of the small bowel (SB) with the use of a fiberoptic or wireless endoscope, has progressed considerably over the past several years. Technological advancements in the field have facilitated endoscopic evaluation of the SB. This comprehensive clinical review summarizes the latest modalities available to aid gastroenterologists in exploring the SB for evaluation of obscure gastrointestinal bleeding, tumors, inflammatory bowel disease, and celiac disease. Previous physical limitations in equipment that made a complete evaluation of the SB difficult have all but disappeared with the advent of capsule endoscopy, balloon-assisted enteroscopy, and spiral enteroscopy.

Diagnosis and assessment of Crohn's disease: the present and the future

Diagnosis of Crohn's disease (CD) is often challenging and requires the utmost precision and perseverance in defining location, extent, severity and type of disease (inflammatory vs stricturing/penetrating), as well as in excluding septic complications and extraintestinal manifestations. Endoscopy and histology remain, as of today, the best tests for initial diagnosis of CD. Increasingly important roles are played by imaging techniques (small bowel MRI, computed tomographic enterography and intestinal ultrasound) and noninvasive markers of disease such as fecal calprotectin and specific autoantibodies. Here, we will review the main tools presently available to make the initial diagnosis of intestinal and perianal CD, to evaluate the response to treatment and to diagnose disease recurrence after surgery. Finally, we will discuss some of the future diagnostic challenges in CD.

Minimally invasive surgery for obscure idiopathic ileal varices diagnosed by capsule endoscopy and double balloon endoscopy: report of a case

Small intestinal bleeding is difficult to detect and can be life-threatening. Capsule endoscopy (CE) is a new, minimally invasive diagnostic procedure designed to detect gastrointestinal (GI) bleeding. We report the successful management of idiopathic ileal varices by capsule endoscopy and laparoscopic surgery. Massive bleeding occurred suddenly with intermittent melena, and the patient was finally admitted to a local hospital in hypovolemic shock. Her condition was stabilized with conservative therapy but the site of bleeding was not defined by endoscopy, computed tomography, scintigraphy, or angiography. Thus, she was transferred to our hospital. On admission, CE revealed idiopathic ileal varices, so we performed laparoscopic partial ileal resection immediately. Follow-up CE has shown no evidence of recurrence in the 2 years since surgery. Idiopathic ileal varices are rare, difficult to diagnose, and often fatal. Capsule endoscopy is a minimally invasive diagnostic procedure that detects this disorder in time for laparoscopic surgery to be performed effectively and safely.

Non-invasive diagnosis and grading of postsurgical endoscopic recurrence in Crohn's disease: usefulness of abdominal ultrasonography and (99m)Tc-hexamethylpropylene amineoxime-labelled leucocyte scintigraphy

Non-invasive techniques aim to be an alternative to endoscopy in the assessment of postsurgical recurrence of Crohn's disease (CD). The object of this study was to evaluate the accuracy of abdominal ultrasonography (AUS) and (99m)Tc-hexamethylpropylene amineoxime ((99m)Tc-HMPAO)-labelled leucocyte scintigraphy (LLS) compared with endoscopy in the diagnosis and grading of postsurgical recurrence of CD. Between January 2006 and May 2007, all patients with CD and resection with ileocolic anastomosis were included prospectively. Within three days they underwent an ileocolonoscopy, AUS with evaluation of bowel wall thickness and the presence of Doppler flow, and LLS. Forty patients who met the study conditions were included; 5 patients did not agree to have the ileocolonoscopy and it was not possible to assess the anastomosis in 2 patients. Endoscopic recurrence was detected in 26 patients (78.8%), in 15 of whom it was moderate-severe. For the diagnosis of recurrence, both AUS and LLS showed acceptable sensitivity and positive predictive value, with an accuracy of 72.7% and 78.1%, respectively. The results of the AUS and LLS for diagnosing moderate-severe recurrence were better, with an accuracy of 78.8% and 81.3%, respectively. The best assessment of the severity of the recurrence was obtained with the combination of both techniques (sensitivity, specificity, positive and negative predictive values, accuracy and kappa index were, respectively: 93.3%, 72.2%, 73.7%, 92.9%, 81.8% and 0.64). The variables evaluated, both sonographic and scintigraphic, had areas under the curve that were similar and significantly different from 0.5.

CONCLUSION

Abdominal ultrasonography and (99m)Tc-HMPAO-labelled leucocyte scintigraphy are two useful non-invasive techniques for the assessment of postsurgical recurrence of Crohn's disease.

Endoscopic vs ultrasonographic findings related to Crohn's disease recurrence: a prospective longitudinal study at 3 years

BACKGROUND AND AIMS

Ileocolonoscopy (IC) is the gold standard for assessing Crohn's Disease (CD) recurrence after ileo-colonic resection. In a prospective longitudinal study we compared findings related to CD recurrence when using techniques visualizing either the luminal or the extraluminal surface (IC and small bowel follow through, SBFT vs Small Intestine Contrast Ultrasonography, SICUS).

METHODS

From 2003 to 2008, 25 CD patients undergoing ileo-colonic resection were enrolled. Clinical assessment (CDAI) was performed at 1, 2 and 3 years. IC was performed at 1 (n=25) and 3 years (n=15), SBFT at 2 years (n=21) and SICUS at 1 (n=25), 2 (n=21) and 3 years (n=15). Recurrence was assessed by SBFT and SICUS (bowel wall thickness, BWT) when using IC as gold standard.

RESULTS

At 1 year, all patients were inactive and recurrence was detected by IC in 24/25 (96%) and by SICUS in 25/25 patients. At 2 years, 6/21 patients (29%) were active and recurrence was detected by SBFT in 12/21 (57%) and by SICUS in 21/21 patients. At 3 years, 5/15 patients (33%) were active, IC showed recurrence in 14/15 (93%), and SICUS in 15/15 patients. The endoscopic score at 1 year was higher in patients developing relapse at 2 years (n=5) than in patients maintaining remission (n=10) (median: 4, range 3-4 vs 2, range 0-3; p=0.003). The same finding was not observed by using SICUS (median BWT at 1 year: 5, range 4-7 vs 3.7, range 3.5-6; p=0.19).

CONCLUSIONS

Although IC and SICUS provide a different view of the bowel wall, in experienced hands SICUS provides findings compatible with endoscopic recurrence after ileo-colonic resection for CD. Discrepant findings may be observed in a low proportion of patients with minor lesions related to CD recurrence.

Inter-observer agreement for detection of small bowel Crohn's disease with capsule endoscopy

OBJECTIVE

Compared to other modalities, capsule endoscopy (CE) has a high diagnostic yield for diagnosing small bowel Crohn's disease (CD). The aim of this study was to determine the inter-observer agreement for detection of small bowel CD with predefined diagnostic criteria.

MATERIAL AND METHODS

Thirty patients with suspected or known CD were included in the study. Observers were blind to patient histories, the results of ileo-colonoscopies, and small bowel examinations. More than three ulcerations (aphthous lesions or ulcers) or the presence of stenosis caused by inflammation or fibrosis was diagnostic of small bowel CD. Three observers with experience in gastrointestinal endoscopy and CE participated in the study.

RESULTS

The presence or absence of small bowel CD was determined with complete agreement in 23 patients, nine patients with and 14 without small bowel CD. The inter-observer agreement was substantial for the diagnosis (kappa = 0.68) and moderate for the localization of CD (kappa = 0.44). Aphthous lesions were detected with only fair agreement (kappa = 0.38). The time intervals to passage of the pylorus and ileo-caecal valve were detected with excellent intra-class correlation.

CONCLUSIONS

CE is performed with substantial inter-observer agreement for detection of small bowel CD. In the majority of patients, the presence or absence of small bowel CD is unequivocal. However, in patients with few or minor lesions, the diagnosis is observer dependent.

Wireless capsule endoscopy and proximal small bowel lesions in Crohn’s disease

AIM: To investigate the prevalence of proximal small bowel (SB) lesions detected by wireless capsule endoscopy (WCE) in Crohn’s disease (CD).

METHODS: WCE was performed in 64 patients: 32 with CD of the distal ileum, and 32 controls with iron-deficiency anemia (IDA) or diarrhea. WCE was performed using the Given SB-WCE, followed by small intestine contrast ultrasonography (SICUS). Findings compatible with CD by using WCE included erosions, aphthoid or deep ulcers, and strictures/stenosis.

RESULTS: WCE detected proximal SB lesions in 16/32 (50%) patients (14 aphthoid ulcers, 2 deep ulcers, one stricture), which appeared not to be related to clinical parameters [epigastric pain, age, smoking, non-steroidal anti-inflammatory drugs (NSAIDs), IDA]. Among patients with proximal SB lesions, 6 (37%) were smokers, 3 (19%) NSAID users, 3 (19%) had epigastric pain and 4 (25%) had IDA. SICUS detected proximal SB lesions in 3/32 patients (19%) also showing lesions with WCE. No correlations were observed between proximal SB lesions assessed by WCE or by SICUS (χ² = 1.5, P = 0.2).

CONCLUSION: The use of WCE allows the detection of previously unknown upper SB lesions in a high proportion of patients with a previous diagnosis of CD involving the distal ileum.

Video capsule endoscopy in inflammatory bowel disease: past, present, and future redux

Over the last 8 years, capsule endoscopy (CE) has revolutionized the visualization of the small bowel. In 2004 this journal published "Capsule endoscopy in IBD: past, present and future" Kornbluth et al [2004] Inflamm Bowel Dis 10:278-285). In this article we review advances since that time and discuss whether CE has achieved its potential and what remaining goals it can and should hope to achieve. In the 2004 article we listed a series of clinical questions to be answered with regard to the use of capsule endoscopy We review those questions that have been addressed in the intervening 5 years, and also update those topics for which information was available at the time of the initial article.

Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohn's disease: a meta-analysis

OBJECTIVES

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.

METHODS

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.

RESULTS

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%).

CONCLUSIONS

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.

Role of wireless capsule endoscopy in inflammatory bowel disease

Capsule endoscopy (CE) offers state-of-the-art imaging of the small bowel. In Crohn’s disease its clinical role is still uncertain. This report analyses the usefulness of CE in patients with suspected Cronh’s disease, in patients with established Crohn’s disease (when assessing severity, occult gastrointestinal bleeding and/or as a guide to therapy), in patients with inflammatory bowel disease unclassified (IBDU), and in individuals with ulcerative colitis. The first item in this group is the most important although there is no strong evidence to establish the position of CE in the diagnostic workup. In patients with established Crohn’s disease, recently developed activity scores are promising tools for an accurate assessment of severity. As a guide to therapy, CE should be focused on patients with unexplained symptoms when other investigations are inconclusive. In postoperative Crohn’s Disease, international consensus recommended considering CE only if ileocolonoscopy is contraindicated or unsuccessful. In the case of IBDU, studies have shown a significant proportion of patients reclassified with Crohn’s disease. In this setting, CE could have a role determining small bowel involvement. The role of CE in ulcerative colitis is limited. Some authors advocate CE before colectomy for refractory cases in order to exclude Crohn’s disease. In summary, CE offers a new horizon in inflammatory bowel disease, and a better knowledge of mucosal abnormalities that could offer a paradigm shift: changing from symptom-based disease activity estimation to direct mucosal healing monitoring. Nevertheless, randomized controlled studies are still needed to provide stronger evidence in this setting.