Does capsule endoscopy impact clinical management in established Crohn's disease?

Monitoring of leucine-rich alpha-2-glycoprotein and assessment by small bowel capsule endoscopy are prognostic for Crohn's disease patients

Background and Aim

Endoscopy is important to determine the effectiveness of treatment for Crohn's disease (CD), but searching the entire small intestine is difficult. Thus, we investigated the usefulness of leucine-rich alpha-2 glycoprotein (LRG), a new biomarker for predicting mucosal activity, in evaluating the activity of CD small intestinal lesions. This will further determine whether the results of small bowel capsule endoscopy (SBCE) affect the prognosis of patients with CD.

Methods

A total of 114 patients with CD who underwent SBCE were included. We analyzed the correlation between LRG and Capsule Endoscopy Crohn's Disease Activity Index (CECDAI). The cutoff value of LRG to achieve mucosal healing was calculated using the receiver operating characteristic curve. Then, we compared the presence or absence of intervention and the relapse rate of patients who could not achieve mucosal healing.

Results

The CECDAI correlated with LRG. The calculated LRG value for achieving mucosal healing was ≤11.9. Ninety-one patients were in clinical remission at the time of SBCE. During the follow-up period, 17 patients relapsed. As a result of SBCE, when no treatment intervention was performed in the case of CECDAI ≥3.5, the relapse rate was significantly higher than when CECDAI <3.5 or intervention was performed in the case of CECDAI ≥3.5.

Conclusions

The results reveal that LRG correlates with the activity of the entire small intestine and that SBCE assessment and therapeutic intervention can influence patient prognosis.

Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022

MR1: ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2: ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3: ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4: ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5: ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6: ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7: ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn's disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8: ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9: ESGE recommends, in patients with established Crohn's disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10: ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11: ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for Billroth II patients).Strong recommendation, moderate quality evidence.

Monitoring endoscopic postoperative recurrence in Crohn’s disease after an ileocecal resection. Does capsule endoscopy have a role in the short and long term?

Background: Small bowel capsule endoscopy (SBCE) is a noninvasive method to detect endoscopic postoperative recurrence (POR) after an ileocolonic resection in Crohn’s Disease (CD). Few studies have evaluated the role of SBCE in the early POR (= 12 months). Data for detection of late POR (>12 months) and evaluation of treatment response in previous POR is scarce. We aimed to assess the SBCE performance in the three scenarios (early-POR, late-POR, and previous-POR) Methods: Retrospective 11-year cohort study of SBCE procedures performed on CD patients with ileocolonic resection. Disease activity by Rutgeerts score (RS), correlation with biomarkers, and therapeutic changes were recorded. Results: We included 113 SBCE procedures (34 early-POR, 44 late-POR, and 35 previous-POR). 105 procedures (92.9%) were complete and 97 SBCE (85.5%) were conclusive with no differences between groups. Relevant POR (RS ≥i2) was more frequent in the early-POR group compared to late-POR (58.8% vs 27.3%, p=0.02). In the previous-POR, RS improved in 43.5% of procedures, worsened in 26%, and remained unchanged in 30.5%. Fecal calprotectin (FCP) value of 100µg/g displayed the best accuracy: sensitivity 53.8%, specificity 78.8%, positive predictive value 66.7% and negative predictive value 68.4%. SBCE guided therapeutic changes in 43 patients (38%). No adverse events occurred in our cohort. Conclusion: SBCE is a safe and effective method to assess POR in the early and late setting in clinical practice, and for the evaluation of treatment response to previous POR. FCP is an accurate surrogate marker of POR and 100µg/g value had the best overall accuracy.

New Generation Express View: An Artificial Intelligence Software Effectively Reduces Capsule Endoscopy Reading Times

BACKGROUND: Reading capsule endoscopy (CE) is time-consuming. The Express View (EV) (IntroMedic, Seoul, Korea) software was designed to shorten CE video reading. Our primary aim was to evaluate the diagnostic accuracy of EV in detecting significant small-bowel (SB) lesions. We also compared the reading times with EV mode and standard reading (SR). METHODS: 126 patients with suspected SB bleeding and/or suspected neoplasia were prospectively enrolled and underwent SB CE (MiroCam®1200, IntroMedic, Seoul, Korea). CE evaluation was performed in standard and EV mode. In case of discrepancies between SR and EV readings, a consensus was reached after reviewing the video segments and the findings were re-classified. RESULTS: The completion rate of SB CE in our cohort was 86.5% and no retention occurred. The per-patient analysis of sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of EV compared to SR were 86%, 86%, 90%, 81%, and 86%, respectively, before consensus. After consensus, they increased to 97%, 100%, 100%, 96%, and 98%, respectively. The median reading time with SR and EV was 71 min (range 26−340) and 13 min (range 3−85), respectively (p < 0.001). CONCLUSIONS: The new-generation EV shows high diagnostic accuracy and significantly reduces CE reading times.