The role of capsule endoscopy in evaluating inflammatory bowel disease

Management of Crohn's disease in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease updated in 2023

Crohn's disease (CD) is a chronic, fluctuating inflammatory condition that primarily affects the gastrointestinal tract. Although the incidence of CD in Taiwan is lower than that in Western countries, the severity of CD presentation appears to be similar between Asia and the West. This observation indicates the urgency for devising revised guidelines tailored to the unique reimbursement system, and patient requirements in Taiwan. The core objectives of these updated guidelines include the updated treatment choices and the integration of the treat-to-target strategy into CD management, promoting the achievement of deep remission to mitigate complications and enhance the overall quality of life. Given the diversity in disease prevalence, severity, insurance policies, and access to medical treatments in Taiwan, a customized approach is imperative for formulating these guidelines. Such tailored strategies ensure that international standards are not only adapted but also optimized to local contexts. Since the inception of its initial guidelines in 2017, the Taiwan Society of Inflammatory Bowel Disease (TSIBD) has acknowledged the importance of continuous revisions for incorporating new therapeutic options and evolving disease management practices. The latest update leverages international standards and recent research findings focused on practical implementation within the Taiwanese healthcare system.

Performance of Capsule Endoscopy and Cross-Sectional Techniques in Detecting Small Bowel Lesions in Patients with Crohn's Disease

BACKGROUND

Crohn's disease (CD) can be classified according to endoscopic and cross-sectional imaging characteristics. Information regarding disease extent and phenotype may be provided by advanced endoscopic and imaging techniques. In this study, we compare the ability of capsule endoscopy (CE) and cross-sectional imaging techniques (CST) (MRE/Computer Tomography Enteroscopy [CTE]) in detecting small bowel (SB) lesions.

METHODS

We retrospectively analyzed 102 patients with a diagnosis of CD who underwent both CE and CST. Only patients with at least a 12-month follow-up after CE were included.

RESULTS

Sensitivity and specificity for the detection of SB lesions were, respectively, 100% and 83.3% for CE, 55.1% and 80% for CTE, and 60% and 82.3% for MRE. CE detected proximal CD lesions in 73% of patients, whereas MRE and CTE detected proximal lesions in 41% and 16% of patients, respectively (P < 0.001). Positive findings on CE led to management changes in all patients, in a median follow-up period of 58.7 months. During the follow-up period, 26.5% of patients underwent surgery. Multivariate analysis revealed that moderate-to-severe disease at CE was independently correlated with surgery (P = 0.03).

CONCLUSIONS

CE has a superior sensitivity for detecting CD lesions in the proximal and medium SB compared with CST. In the terminal ileum, MRE and CTE displayed similar performance to CE.

Modern Endoscopic Imaging in Diagnosis and Surveillance of Inflammatory Bowel Disease Patients

Endoscopy remains the most important diagnostic and monitoring modality in the management of inflammatory bowel disease. Advances in imaging have progressively added new tools into the armamentarium of endoscopists with the goal of more accurate, sensitive, and accessible visual diagnoses for the benefit of patients with gastrointestinal diseases. Here, we review the relevant literature regarding commonly used endoscopic techniques (dye-based and digital chromoendoscopy, high-definition endoscopy, capsule endoscopy, and endosonography), as well as advanced and experimental technologies (full-spectrum endoscopy, endocytoscopy, autofluorescence, laser endoscopy, and endomicroscopy, including molecular imaging), applicable to inflammatory bowel diseases and emerging for implementation into everyday practice. Additionally, we discuss future directions and techniques as candidates for a superior inflammation imaging in the diagnosis and prediction of therapeutic response.

Management of Crohn's disease in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease

Crohn's disease (CD) is a chronic relapsing and remitting inflammatory disease of the gastrointestinal tract. CD is rare in Taiwan and other Asian countries, but its prevalence and incidence have been steadily increasing. A steering committee was established by the Taiwan Society of Inflammatory Bowel Disease to formulate statements on the diagnosis and management of CD taking into account currently available evidence and the expert opinion of the committee. Thorough clinical, endoscopic, and histological assessments are required for accurate diagnosis of CD. Computed tomography and magnetic resonance imaging are complementary to endoscopic evaluation for disease staging and detecting complications. The goals of CD management are to induce and maintain remission, reduce the risk of complications, and improve quality of life. Corticosteroids are the mainstay for inducing re-mission. Immunomodulating and biologic therapies should be used to maintain remission. Patients should be evaluated for hepatitis B virus and tuberculosis infection prior to treatment and receive regular surveillance for cancer. These consensus statements are based on current local evidence with consideration of factors, and could be serve as concise and practical guidelines for supporting clinicians in the management of patients with CD in Taiwan.

Testing for Chronic Diarrhea

Chronic diarrhea is a frequently encountered symptom in clinical practice. The etiologies for chronic diarrhea are diverse and broad with varying clinical implications. A useful method of categorizing chronic diarrhea to guide a diagnostic work-up is a pathophysiology-based framework. Chronic diarrhea may be categorized as malabsorptive, secretory, osmotic, and inflammatory or motility related. Frequently, overlap between categories may exist for any given diarrhea etiology and diagnostic testing must occur with an understanding of the differential diagnosis. Investigations to achieve a diagnosis for chronic diarrhea range from screening blood and stool tests to more directed testing such as diagnostic imaging, and endoscopic and histological evaluation. The pathophysiology-based framework proposed in this chapter will allow the clinician to select screening tests followed by targeted tests to minimize cost and complications to the patient, while providing a highly effective method to achieve an accurate diagnosis.

Capsule retention related to small bowel capsule endoscopy: a large European single-center 10-year clinical experience

BACKGROUND

The most concerning complication of video capsule endoscopy (VCE) is capsule retention (CR) in the gastrointestinal (GI) tract although clinical outcome and management of patients with CR are still uncertain in a large single center material.

OBJECTIVES

The aim of this retrospective study was to investigate incidence, causes, risk factors, management and clinical outcomes of CR in a large single center between 2001 and 2011.

RESULTS

2401 consecutive small-bowel (SB) VCEs were performed. CR was detected in 25 cases (1%). CR in patients with suspected and known Crohn's disease (CD) undergoing VCE occurred in 14/1370 (1%) including known CD 9/390 (2.3%) and suspected CD 5/980 (0.5%). CR in patients with obscure GI bleeding was observed in 11/816 (1.3%) cases. The SB was the most common site of CR with 17 cases followed by the esophagus (4 cases), colon (2 cases), and stomach (2 cases). Emergency endoscopic intervention (3 cases) and surgery (2 cases) was needed in 5 cases of CR. Elective capsule removal was performed by surgery in 6 cases and endoscopically in 8 cases. Three retained capsules dislodged after steroid treatment and another 3 cases of CR resolved without any intervention.

CONCLUSION

This large clinical material demonstrates that CR is a rare complication with a favorable clinical outcome. Most patients with CR can be electively managed with non-surgical intervention.

Capsule Endoscopy and Deep Enteroscopy in Irritable Bowel Disease

In approximately one-third of Crohn's disease patients, the disease is confined to the small bowel, inaccessible to the reach of standard endoscopy. Thorough and complete evaluation of the small bowel is crucial in such patients for the initial diagnosis, prognostication, and disease monitoring. Video capsule endoscopy and device-assisted enteroscopy have revolutionized the ability to visualize the small-bowel mucosa. This article reviews the literature pertaining to the use of capsule endoscopy and deep enteroscopy in established Crohn's disease, including the major indications, applications, and safety issues.

Current role of capsule endoscopy in Crohn’s disease

Capsule endoscopy (CE) currently plays an important role in Crohn’s disease (CD). It is a noninvasive technique that has led to a breakthrough in the endoscopic diagnosis of diseases of the small intestine. Its superior diagnostic performance and excellent safety profile lead to its considerable acceptance on the part of the patient. This paper reviews current indications of CE in three stages of clinical practice: Suspected CD, unclassified colitis and its extensive role in diagnosed CD. The diagnostic and therapeutic impact of the results of CE on the monitoring of this disease is also reviewed. Knowledge of its applications, the interpretation of its results in an appropriate context and the existence of a validated endoscopic activity index could change the way in which these patients are managed. The definition of mucosal healing and postoperative recurrence by means of endoscopic scoring systems will endow CE with new applications in the management of CD in the near future.

Video Capsule Endoscopy of the Small Bowel for Monitoring of Crohn's Disease

Video capsule endoscopy has revolutionized our ability to visualize the small bowel mucosa. This modality is a valuable tool for the diagnosis of suspected small bowel Crohn's disease, and it is increasingly used for the monitoring of disease activity in patients with established small bowel Crohn's. The purpose of the current article was to review the literature pertaining to the utilization of capsule endoscopy in established Crohn's disease, for monitoring of mucosal healing, postoperative recurrence, disease classification, and other indications.

Recent trends in diagnostic techniques for inflammatory bowel disease

Although ileocolonoscopy is the gold standard for diagnosis of inflammatory bowel disease and is useful for assessing the disease severity in the colon and terminal ileum, several alternative diagnostic techniques have been developed recently. For ulcerative colitis (UC), magnification colonoscopy, endocytoscopy, and confocal laser endomicroscopy enable assessment of histological inflammation without the need for biopsy. Capsule endoscopy is useful for detection of small intestinal and colonic lesions in both female and male patients. For UC, capsule endoscopy may be useful for evaluating colonic inflammation in patients with a previous poor colonoscopy experience, while it should be used only in Crohn's disease (CD) patients with unexplained symptoms when other examinations are negative. Magnetic resonance enterography (MRE) is particularly useful for detecting transmural inflammation, stenosis, and extraintestinal lesions, including abscesses and fistulas. MRE is also useful when evaluating small and large intestinal lesions, even in cases with severe strictures in which full evaluation of the small bowel would be virtually impossible using other devices. Therefore, the appropriate diagnostic devices for detecting CD lesions in the small and large intestine should be used.

Diagnostic modalities for the evaluation of small bowel disorders

PURPOSE OF REVIEW

This review summarizes the recent developments in the evaluation of small bowel disorders using videocapsule endoscopy (VCE) and serological and breath-test biomarkers.

RECENT FINDINGS

The ability to visualize the small bowel was revolutionized with the introduction of VCE technology. VCE allows for accurate, noninvasive visualization of the small bowel mucosa. This device is invaluable in the investigation of obscure gastrointestinal bleeding (OGIB), occult bleeding with iron deficiency anaemia, small bowel Crohn's disease (CD), small bowel neoplasms and other mucosal disorders. Recent studies underscored the utility of VCE for documenting the extent and severity of small bowel CD as well as monitoring activity after therapy. The accuracy of the discrimination between small bowel tumours and benign bulges has been improved by a novel endoscopic algorithm. The accuracy of VCE was also evaluated as a potential noninvasive alternative to small bowel biopsies in suspected celiac disease. New findings have been made using breath tests and other biomarkers for the diagnosis of celiac disease, irritable bowel syndrome and bacterial overgrowth.

SUMMARY

VCE as well as breath-test biomarkers play a major and expanding role in the diagnosis and monitoring of various small bowel disorders.

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.

Report of video-capsule endoscopy disruption producing episodic small bowel obstruction after prolonged retention

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We report a case of a patient who developed intermittent small bowel obstruction secondary to a retained video-capsule endoscopy with capsule disruption.

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Wireless video-capsule endoscopy is associated with elevated risk for capsule retention and intestinal obstruction in the setting of Crohn's disease.

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Prolonged video-capsule endoscopy retention may predispose to capsule fragmentation and intestinal perforation.

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Early intervention is indicated for retained video-capsule endoscopy without excellent patient compliance and follow-up.

INTRODUCTION

Wireless video-capsule endoscopy is a procedure which provides direct visualization of the gastrointestinal tract, particularly the jejunum and ileum. Capsule retention is the main risk associated with capsule endoscopy, occurring at a significantly elevated incidence in patients with known or suspected Crohn's disease.

PRESENTATION OF CASE

A case of a prolonged retained capsule with subsequent fragmentation producing a multicentric complete small bowel obstruction in a 39 year old male patient who had undergone wireless video capsule-endoscopy approximately three years prior. Management required surgical resection of the strictured jejunum and removal of retained capsule fragments under fluoroscopic guidance.

DISCUSSION

Although capsule endoscopy is capable of diagnosis, evaluation, and monitoring inflammatory bowel disease, understanding the elevated risk for capsule retention is important in this population. Specifically, prolonged capsule retention appears to increase the risk of capsule disruption, and likely the potential for intestinal perforation.

CONCLUSION

Patients should therefore be carefully selected for monitoring based upon treatment compliance and offered early endoscopic or surgical intervention in the setting of questionable compliance due to the risk for capsule disruption and subsequent intestinal perforation.

Is there a role for colon capsule endoscopy beyond colorectal cancer screening? A literature review

Colon capsule endoscopy is recommended in Europe alternatively to colonoscopy for colorectal cancer screening in average risk individuals. The procedure has also been proposed to complete colon examination in cases of incomplete colonoscopy or when colonoscopy is contraindicated or refused by the patient. As tissue samples cannot be obtained with the current capsule device, colon capsule endoscopy has no place in diagnosing ulcerative colitis or in dysplasia surveillance. Nevertheless, data are accumulating regarding its feasibility to examine ulcerative colitis disease extent and to monitor disease activity and mucosal healing, even though reported results on the capsule's performance in this field vary greatly. In this review we present the currently available evidence for the use of colon capsule endoscopy to complement colonoscopy failure to reach the cecum and its use to evaluate ulcerative colitis disease activity and extent. Moreover, we provide an outlook on issues requiring further investigation before the capsule becomes a mainstream alternative to colonoscopy in such cases.

Capsule endoscopy: High negative predictive value in the long term despite a low diagnostic yield in patients with suspected Crohn's disease

INTRODUCTION

The role of small bowel capsule endoscopy (SBCE) in Crohn's disease (CD) has expanded with greater understanding of the technology. The ability of SBCE to differentiate CD from other causes of inflammation has been questioned. Longitudinal studies are required to assess the long-term impact and significance of SBCE findings in suspected CD. This study aimed to determine the long-term clinical accuracy of SBCE in patients referred with suspected CD.

METHODS

A retrospective review was carried out on SBCE procedures performed for suspected CD since 2010. Only patients with at least 6 months of documented follow up were included. A chart review was undertaken to record SBCE findings/correlate with subsequent diagnosis and outcome.

RESULTS

In all, 95 patients with sufficient follow up were identified. The mean follow up was 13 months (range 8-24). In total, 72 (76%) SBCEs were negative and 23 (24%) positive for CD. Of the 72 negative tests, two patients (3%) were later diagnosed with CD. The negative predictive value is 96%. There was a strong positive correlation between results of WCE and subsequent clinical diagnosis.

CONCLUSIONS

SBCE appears capable of safely out-ruling CD, with only 3% of negative SBCE investigations being diagnosed with CD after 15 months.

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.

Inflammatory bowel disease and novel endoscopic technologies

Conventional ileocolonoscopy and barium small bowel follow-through are useful techniques for assessing the extension and severity of disease in patients with inflammatory bowel disease (IBD). More recently, novel techniques to enable IBD diagnosis have been developed, such as capsule endoscopy (CE), balloon enteroscopy (BE), computed tomography enterography (CTE) and magnetic resonance enterography (MRE). The advantages of CE and BE are that they enable mucosal assessment directly whereas the usefulness of CTE/MRE is in its ability to enable detection of transmural inflammation, stenosis, and extraintestinal lesions including abscesses and fistulas. In ulcerative colitis (UC), colitis-associated dysplasia/cancer is one of the critical complications in patients with chronic disease. Detection of colitis-associated cancer is difficult in cases with inflammation. Magnification colonoscopy has been used to detect dysplasia in patients with chronic UC. Furthermore, colon CE and endocytoscopy have also developed and these might be used for selected patients in the near future.

Use of capsule endoscopy in patients with Crohn's disease in Japan: a multicenter survey

BACKGROUND AND AIM

Until the approval of patency capsule, capsule endoscopy (CE) has not been routinely applied for the diagnosis of Crohn's disease (CD) in Japan. We aimed to survey current situation of CE use for patients with CD in Japan.

METHODS

The nationwide survey of 40 Japanese institutions identified 94 patients with established CD (eCD) and 80 patients with suspected CD (sCD), who were examined by CE. Types and positive rates of mucosal injury under CE and capsule retention rate were investigated. In sCD, final diagnosis after CE was also analyzed.

RESULTS

Patients with eCD comprised 82 patients of ileitis or ileocolitis type, while 12 patients had CD of colitis type. CE identified mucosal injuries in 83 of 94 patients. Eight of 12 patients with eCD of colitis type had ileal lesions under CE, thereby being reclassified as ileocolitis type. In patients with sCD, CE detected mucosal injuries in 58 patients. Linear ulceration and cobblestone appearance were depicted in 22 and 3 patients, respectively, thereby resulting in established diagnosis of CD in 23 patients. Mucosal lesion was not found in 22 patients with sCD, who were diagnosed as not having CD. Capsule retention rate was not statistically different between patients with eCD and those with sCD (7.4% vs 6.3%, P = 1.0).

CONCLUSIONS

CE is useful for the evaluation of small bowel mucosal injuries in Japanese patients with sCD and eCD. Possible intestinal stricture needs to be carefully evaluated before CE even in patients with sCD.

Role of capsule endoscopy Pillcam COLON 2 in patients with known or suspected Crohn's disease who refused colonoscopy or underwent incomplete colonoscopic exam: a case series

BACKGROUND

Almost 70-80 % of patients with Crohn's disease and virtually all patients with ulcerative colitis have colorectal mucosa involvement. Colon capsule endoscopy is an interesting option for patients unable or unwilling to undergo colonoscopy. We report our experience with the second-generation colon capsule PillCam(®) COLON 2 in the detection of significant lesions in patients with known or suspected Crohn's disease, who refused colonoscopy or underwent incomplete colonoscopic exam.

METHODS

We have retrospectively reviewed the results of capsule endoscopy in 6 patients who refused colonoscopy (n = 3) or underwent incomplete colonoscopic exam (n = 3) between March 2011 and October 2012. In all patients, a CT scan was obtained before capsule endoscopy to rule out significant stenosis.

RESULTS

In our series of 6 patients, 4 had both small bowel and colonic involvement. The use of the PillCam(®) COLON 2 capsule allowed a thorough examination and evaluation of the mucosal lesions with high acceptability, the method being perceived as noninvasive by the patients. No adverse events related to the capsule or bowel preparation were recorded.

CONCLUSION

In this patient population, PillCam(®) COLON 2 capsule endoscopy was safe. The capsule findings had an important impact on treatment decisions and patient management.

Clinical applications of small bowel capsule endoscopy

Video capsule endoscopy has revolutionized our ability to visualize the entire small bowel mucosa. This modality is established as a valuable tool for the diagnosis of obscure gastrointestinal bleeding, Crohn's disease, small bowel tumors, and other conditions involving the small bowel mucosa. This review includes an overview of the current and potential future clinical applications of small bowel video endoscopy.

Clinical applications of small bowel capsule endoscopy

Video capsule endoscopy has revolutionized our ability to visualize the entire small bowel mucosa. This modality is established as a valuable tool for the diagnosis of obscure gastrointestinal bleeding, Crohn’s disease, small bowel tumors, and other conditions involving the small bowel mucosa. This review includes an overview of the current and potential future clinical applications of small bowel video endoscopy.