Assessment of small bowel mucosal healing by video capsule endoscopy for the prediction of short-term and long-term risk of Crohn's disease flare: a prospective cohort study. Lancet Gastroenterol Hepatol. 2019;4:519-528. [PMID: 31080097 DOI: 10.1016/s2468-1253(19)30088-3]

Capsule Endoscopy in Inflammatory Bowel Disease: Evolving Role and Recent Advances

Capsule endoscopy has been proven as an efficient and accurate tool in the diagnosing and monitoring patients with inflammatory bowel disease, especially Crohn's disease (CD). The current European Crohn's and Colitis Organization guidelines recommend small bowel disease assessment in newly diagnosed CD, wherein small bowel capsule endoscopy (SBCE) is of prime importance. SBCE plays an essential role in assessing mucosal healing in patients with CD, serving as a monitoring tool in a treat to target strategy, and is capable of identifying high-risk patients for future flares.

Intestinal ultrasound accurately predicts future therapy failure in Crohn's disease patients in a biologics-induced remission

BACKGROUND

Intestinal ultrasound (IUS) is used to assess disease activity, complications, and treatment follow-up in Crohn's disease (CD). Less is known about the association of disease activity on IUS with the risk of future disease relapse during biologically sustained clinical remission in CD.

AIM

The study aimed to investigate the association between IUS activity parameters and subsequent therapy failure in asymptomatic biologically treated patients with CD.

METHODS

A retrospective cohort study examined the association between IUS parameters and forthcoming therapy failure (drug discontinuation, dose escalation, corticosteroid use, hospitalization, or surgery) in CD patients on biological therapy in remission.

RESULTS

A total of 57 patients with ileal (65%) or ileocolonic (35%) CD on biological therapy were included in the study. Therapy failure occurred in 50.8% [defined as need for dose escalation (31%), drug discontinuation (51.7%), steroid use (10.5%), and hospitalization (6.8%)] during a median follow-up of 5 (SD + 9.5) months after IUS. On univariate analysis, a bowel wall thickness (BWT) of 2.5 vs. 4 mm (P = 0.005), the existence of an enlarged lymph node (P = 0.02), and the loss of bowel wall stratification (P = 0.01) were correlated with therapy failure. On multivariable analysis, only BWT ≥ 4 mm was associated with the risk of future treatment failure (hazard ratio, 3.7; 95% confidence interval, 0.6-15; P = 0.02).

CONCLUSION

Our findings suggest that BWT ≥4 mm during clinical remission is associated with subsequent treatment failure in patients with CD treated with biologics. Our results support the use of IUS for monitoring CD during remission and may point to a novel threshold for predicting disease reactivation.

Pan-Enteric Crohn's Capsule [Eliakim] Score Reliability and Responsiveness to Change in Active Crohn's Disease

BACKGROUND AND AIMS

Pan-enteric capsule endoscopy (PillCam Crohn's capsule [PCC]) is a useful tool in diagnosing and monitoring Crohn's disease [CD]. Eliakim score [ES] reliability and its strong correlation to Lewis score [LS] and to inflammatory biomarkers have been previously demonstrated using PCC in quiescent CD. We aimed to examine ES performance in active CD and its responsiveness to clinical/biochemical change over time.

METHODS

Patients with CD who have started biologics were included, and were prospectively followed based on clinical visits, biomarkers, and PCC at baseline, after 14 and 52 weeks. Crohn's disease activity index [CDAI], C-reactive protein [CRP], and faecal calprotectin [FC] levels were determined, and LS and ES were calculated [independently reviewed by two experienced readers]. Inter-class classification [ICC], Spearman's baseline correlation, and repeated-measures correlation [RMC] analyses were performed.

RESULTS

Seventy-four patients were included (age: 30.5 [range 23.3-45.0] years old, male 50%). In total, 142 PCCs were read [baseline, 62; week 14, 58; week 52, 22]. Inter-rater agreement was high for both LS and ES (ICC: 0.872 [p < 0.001] and 0.925 [<0.001], respectively). Baseline correlations between FC&ES [r = 0.509 [p < 0.001]) and FC&LS (r = 0.467 [p < 0.001]) were comparable [p = 0.56]. RMCs between the inflammatory biomarkers and ES were higher than between the former and LS (Reader 1: CRP r = 0.306 vs r = 0.138 [p = 0.057], FC r = 0.479 vs r = 0.297 [p = 0.034]; Reader 2 CRP r = 0.376 vs r = 0.204 [p = 0.035], FC r = 0.549 vs r = 0.412 [p = 0.075]). Moreover, ES was better correlated to CDAI than LS [p = 0.036].

CONCLUSIONS

ES is a reliable scoring system in assessing pan-enteric mucosal inflammation in active CD, and might have a better responsiveness to clinical/biochemical change over time compared to LS.

Pro-motility Preparation Protocol May Reduce the Rates of Failed Patency Capsule Among Patients with Crohn's Disease in Clinical Remission

BACKGROUND

Patency capsule (PC) ingestion is commonly used to minimize capsule retention in high-risk patients with Crohn's disease (CD). However, false-positive rates remain high, precluding the use of video capsule endoscopy (VCE). We aimed to compare the efficacy of two preparation protocols in reducing failed PC rates in patients with CD.

METHODS

This bi-center retrospective case-control study included adult patients with small-bowel CD in clinical remission who underwent PC ingestion. The pro-motility group followed a low-residue diet, then a clear fluid diet, and took bisacodyl after ingestion, while the control group followed only a clear fluid diet. The primary outcome was failed PC, defined as the absence of PC excretion or presence on abdominal X-ray at 30 h post-ingestion. Multivariable logistic regression was used to identify predictors of failed PC.

RESULTS

Among 273 patients (83 in the pro-motility group, 190 controls), the pro-motility group was older (median 36 [27-48] vs. 31 [24-43], p = 0.012) and had a lower rate of B2/3 disease phenotype (32.5 vs. 53.1%, p = 0.002) compared to controls. The pro-motility group also had a lower failed PC rate (12.0 vs. 24.7%, p = 0.023). Longer disease duration (adjusted odds ratio (AOR) 1.053, 95% confidence interval (CI) 1.016-1.091, p = 0.005) increased the odds of failed PC, while the pro-motility protocol was protective (AOR 0.438, 95% CI 0.200-0.956, p = 0.038), outweighing the influence of B2/3 disease phenotype (AOR 1.743, 95% CI 0.912-3.332, p = 0.093).

CONCLUSIONS

The pro-motility preparation protocol could substantially improve the success rates of the small-bowel patency test in patients with CD undergoing PC ingestion, potentially reducing the risk of capsule retention and associated complications.

The Role of Small-Bowel Capsule Endoscopy in the Diagnostic Algorithm of Complicated Perianal Disease

INTRODUCTION

Complicated perianal disease (cPD) may be the sole presentation of Crohn's disease (CD). The role of small-bowel capsule endoscopy (SBCE) in the diagnostic algorithm of cPD is unclear. We aimed to evaluate the role of SBCE as a diagnostic tool, in patients with cPD, after a negative standard workup for CD.

METHODS

A multicenter, retrospective, cross-sectional study, in patients with cPD, and negative standard workup for CD (ileocolonoscopy and cross-sectional imaging), who underwent SBCE for suspected CD. Demographics, biomarkers, and the Lewis Score (LS) were recorded and analyzed. An LS ≥ 135 was considered a positive SBCE for diagnosing CD.

RESULTS

Ninety-one patients were included: 65 (71.4%) males; median age: 37 (29-51) years; cPD duration: 25.1 (12.5-66.1) months. Positive SBCE: 24/91 (26.4%) patients. Fecal calprotectin (FC) positively correlated with LS (r = 0.81; p < 0.001). FC levels of 100 µg/g and 50 µg/g had a sensitivity of only 40% and 55% to rule out small-bowel CD, with a negative predictive value (NPV) of only 76% and 80%, respectively.

CONCLUSIONS

SBCE contributed to CD diagnosis in a quarter of patients with cPD after a negative standard workup. FC levels correlated with the degree of inflammation defined by the LS. However, the NPV of FC was low, suggesting that SBCE should be considered for patients with cPD even after a negative standard workup.

Long-Term Monitoring and Clinical Implications of Small Bowel Capsule Endoscopy in Patients with Crohn's Disease with Small Bowel Lesions: A Retrospective Analysis

INTRODUCTION

Crohn's disease (CD) induces persistent inflammation throughout the gastrointestinal (GI) tract, potentially resulting in complications such as intestinal stenosis and fistulas, particularly in the small bowel. Small bowel capsule endoscopy (SBCE) is recommended for monitoring CD, especially when GI tract patency is maintained. This study aimed to retrospectively assess patients with CD who underwent SBCE to determine the timing of clinical changes and address the current lack of evidence regarding GI tract patency loss during CD treatment.

METHODS

Of the 166 consecutive patients who underwent SBCE at our institution, 120 were followed up and included in this study. Forty-six patients were excluded due to colitis type or immediate treatment changes post-SBCE. This study focused on the primary and secondary endpoints, including the cumulative stricture-free rate of the GI tract, emergency hospitalization post-SBCE, and post-SBCE treatment strategies, at the discretion of the attending physicians.

RESULTS

Demographic data revealed that the mean age of the study population was 43 years and that there was a male predominance (75%). The median disease duration was 12 years and the mean Crohn's Disease Activity Index was 98. During a 1,486-day observation period, 37% of patients experienced treatment changes. A Lewis score of >264 and perianal lesions were identified as independent risk factors for additional treatment needs. Emergency hospitalization occurred in 6% of patients and GI patency failure in 11%. Female sex and Lewis score>264 were associated with higher risks. GI patency rate declined 2 years after SBCE.

CONCLUSIONS

For patients who experienced no treatment changes based on SBCE results, it is recommended to undergo SBCE monitoring at intervals of no longer than 2 years.

Evaluation of Mucosal Healing in Crohn's Disease: Radiomics Models of Intestinal Wall and Mesenteric Fat Based on Dual-Energy CT

This study aims to assess the effectiveness of radiomics signatures obtained from dual-energy computed tomography enterography (DECTE) in the evaluation of mucosal healing (MH) in patients diagnosed with Crohn's disease (CD). In this study, 106 CD patients with a total of 221 diseased intestinal segments (79 with MH and 142 non-MH) from two medical centers were included and randomly divided into training and testing cohorts at a ratio of 7:3. Radiomics features were extracted from the enteric phase iodine maps and 40-kev and 70-kev virtual monoenergetic images (VMIs) of the diseased intestinal segments, as well as from mesenteric fat. Feature selection was performed using the least absolute shrinkage and selection operator (LASSO) logistic regression. Radiomics models were subsequently established, and the accuracy of these models in identifying MH in CD was assessed by calculating the area under the receiver operating characteristic curve (AUC). The combined-iodine model formulated by integrating the intestinal and mesenteric fat radiomics features of iodine maps exhibited the most favorable performance in evaluating MH, with AUCs of 0.989 (95% confidence interval (CI) 0.977-1.000) in the training cohort and 0.947 (95% CI 0.884-1.000) in the testing cohort. Patients categorized as high risk by the combined-iodine model displayed a greater probability of experiencing disease progression when contrasted with low-risk patients. The combined-iodine radiomics model, which is built upon iodine maps of diseased intestinal segments and mesenteric fat, has demonstrated promising performance in evaluating MH in CD patients.

Pan-enteric Capsule Endoscopy to Characterize Crohn's Disease Phenotypes and Predict Clinical Outcomes in Children and Adults: The Bomiro Study

BACKGROUND

Pan-enteric capsule endoscopy (PCE) provides useful information for the management of Crohn's disease (CD), especially in children. No study has evaluated the ability of PCE to characterize CD phenotypes and outcomes in children and adults.

METHODS

In a prospective multicenter observational study, we recruited patients with CD >6 years from 4 centers in Italy. Patients underwent clinical, biomarker assessment and PCE. Lesions were graded using the PCE system. For each segment, the most common lesion (MCL), the most severe lesion (MSL), and the extent of involvement were defined. Disease severity, extent, and clinical outcomes were compared between children and adults. A logistic regression analysis was used to identify predictive factors for negative outcomes in both age groups.

RESULTS

One hundred ninety-four consecutive patients (adults/children: 144/50) were evaluated for a total of 249 procedures. Children were more likely to have extensive disease, particularly in the colon. Higher MCL scores were independently associated with treatment escalation (odds ratio [OR], 4.09; 95% CI, 1.80-9.25; P = .001), while >30% disease extent was more indicative of clinical and endoscopic relapse (OR, 2.98; 1.26-7.08; P = .013). Disease extent was the only factor associated with endoscopic recurrence in children (OR, 4.50; 95% CI, 1.47-13.77; P = .008), while severe lesions in adults provided a better predictor of treatment escalation (OR, 4.31; 95% CI, 1.52-12.1; P = .006). Postexamination, PCE contributed to a change of therapy in 196/249 (79%) of the procedures.

CONCLUSIONS

PCE allowed the characterization of CD phenotypes in children and adults by assessing disease severity and extent, which are of different importance in predicting clinical outcomes in these age groups.

Long-term effectiveness and acceptability of switching from intravenous to subcutaneous infliximab in patients with inflammatory bowel disease treated with intensified doses: The REMSWITCH-LT study

BACKGROUND

The long-term risk of relapse after switching from intravenous (IV) to subcutaneous (SC) infliximab remains unknown in inflammatory bowel disease (IBD).

AIMS

To assess the long-term effectiveness and acceptability of switching from IV to SC infliximab in patients with IBD treated with or without an intensified IV regimen.

METHODS

We extended the follow-up of the REMSWITCH study including patients with IBD in clinical remission who were switched from IV to SC infliximab (120 mg/2 weeks). Relapse was defined as clinical relapse or faecal calprotectin increase ≥150 μg/g compared to baseline.

RESULTS

After median follow-up of 18 [15-20] months, among 128 patients, rates of relapse were 13.8% (8/58), 18.4% (7/38), 35.3% (6/17) and 86.7% (13/15) at last follow-up (p < 0.001), in those receiving 5 mg/kg/8 weeks, 10 mg/kg/8 weeks, 10 mg/kg/6 weeks and 10 mg/kg/4 weeks at baseline, respectively. Among relapsing patients, dose escalation led to clinical remission in 82.1% (23/28). In multivariable analyses, factors associated with higher risk of relapse were IV infliximab 10 mg/kg/4 weeks (OR = 61.0 [6.1-607.0], p < 0.001) or 10 mg/kg/6 weeks (OR = 4.7 [1.1-20.2], p = 0.017), and decreased (OR = 5.6 [1.5-20.3], p = 0.004) or stable (OR = 5.0 [1.6-15.0], p = 0.009) serum levels of infliximab between baseline and first post-switch visit. Acceptability was improved at 6 months and did not decrease over time (6.9 ± 1.6 before the switch vs. 8.8 ± 1.3 at 6 months and 8.8 ± 1.3 at last follow-up; p < 0.001). No severe adverse events were reported.

CONCLUSIONS

Switching from IV to SC infliximab 120 mg every other week is safe and well accepted leading to low long-term risk of relapse. Tight monitoring and dose escalation should be recommended for patients receiving 10 mg/kg/6 weeks and 4 weeks, respectively.

Serum food specific IgG antibodies are associated with small bowel inflammation in patients with Crohn's disease

BACKGROUND/AIMS

Food antigens are thought to play a vital role in the initiation and perpetuation of Crohn's disease (CD). The main purpose of this study was to evaluate the potential association of serum food specific IgG antibodies and small bowel (SB) inflammation in CD patients.

METHODS

We conducted a prospective observational study with 96 CD patients. Demographic, disease-related data and inflammatory parameters were collected. Serum food IgG antibodies were measured using enzyme-linked immunosorbent assay (ELISA). Capsule endoscopy was performed to detect SB inflammation quantified by the Lewis Score.

RESULTS

Seventy-eight of (81.3%) CD patients were detected positive for at least one food-specific antibody. The five most prevalent food antibodies in CD patients were tomato, egg, corn, rice, and soybean. Patients with SB inflammation had a higher positive rate of food IgG antibodies (P = 0.010) and more IgG-positive food items (P = 0.010) than those without. Specifically, patients with SB inflammation were more likely to have positive food-specific IgG against egg (P = 0.014), corn (P = 0.014), and wheat (P = 0.048). Additionally, the number of positive food IgGs ≥ 3 and elevated ESR were independently associated with concurrent SB inflammation (P = 0.015 and P = 0.013, respectively).

CONCLUSION

Our study confirmed that CD patients with SB inflammation had a higher positive rate of food IgG antibodies and more IgG-positive food items. The number of food positive IgGs ≥ 3 and elevated ESR were independently associated with concurrent SB inflammation.

Predicting Therapeutic Intervention for Patients with Quiescent Crohn's Disease Using the Small Bowel Capsule Endoscopy Score

Introduction

Small bowel (SB) capsule endoscopy (SBCE) is a sensitive modality for screening the entire SB of patients with Crohn's disease (CD); however, the prognostic impact of the results is unclear. We evaluated the ability of the SBCE score to predict therapeutic intervention for patients with CD and SB lesions without clinical symptoms as well as negative C-reactive protein (CRP) levels.

Methods

Fifty-six patients who underwent a patency evaluation and had a CD activity index (CDAI) score <150 mg/dL and CRP level <0.5 mg/dL were included. Twenty-one and 35 patients had CD classified as Montreal classifications L1 and L3, respectively. The initial SBCE scores were subsequently grouped according to the presence or absence of intervention based on cutoff values. We examined whether the scores could predict the need for therapeutic intervention at 1 year, 2 years, and 5 years. The CD activity in capsule endoscopy (CDACE) score was used as the SBCE score.

Results

The median observation period was 1,326 days. Twenty-one patients received therapeutic intervention. There were significant differences between patients with and without treatment intervention according to the CDACE cutoff value of 420 at 1 year, 2 years, and 5 years. Significant differences between patients with Montreal classification L1 with and without intervention were observed at 1 year and 2 years. The CDACE score was moderately and strongly correlated with the Lewis score and capsule endoscopy CDAI score, respectively (Spearman rank correlation coefficient: ρ = 0.6462 and ρ = 0.9199, respectively; p < 0.0001).

Conclusion

A CDACE score ≥420 is predictive of intervention after 1 year for patients with CD, a CDAI score <150, and a CRP level <0.5 mg/dL. A larger study with a prospective design is necessary to validate our findings.

Reclassification of Inflammatory Bowel Disease Type Unclassified by Small Bowel Capsule Endoscopy

Background and Objectives: Ulcerative colitis (UC) and Crohn's disease (CD) are idiopathic inflammatory bowel diseases (IBDs) without a unique, gold standard diagnostic test. UC and Crohn's colitis are impossible to distinguish in approximately 10% of cases. The term IBD type unclassified (IBD-U) is recommended for cases of chronic colitis showing overlapping endoscopic, radiological, and biopsy histological features between UC and CD, while indetermined colitis is reserved for colectomy specimens. Our aim was to assess the role of small-bowel capsule endoscopy (SBCE) in the diagnostic work-up of IBD-U. Materials and Methods: We retrospectively studied the cases of IBD-U explored by SBCE in a tertiary referral gastroenterology center. Patients were investigated using SBCE after contraindications were excluded. Diagnostic criteria for small bowel CD consisted in more than three ulcerations, irregular ulcers, or stenosis, and the Lewis score was used for the quantification of inflammation. The immediate impact of reclassification and outcome data was recorded over a follow-up period of more than one year. Results: Twenty-eight patients with IBD-U were examined using SBCE. Nine patients had small bowel lesions that met the diagnostic criteria for CD, resulting in a reclassification rate of 32.1%. In five of these cases, the treatment was subsequently changed. In the remaining nineteen examinations, no significant findings were observed. There were no complications associated with SBCE. Median follow-up time was 32.5 months (range 12-60). During follow-up, twelve patients were classified as having UC, and seven remained as having an unclassified type; one case of colectomy, for medically refractory UC, was recorded. Conclusions: SBCE is a useful safe tool in the work-up of IBD-U, allowing reclassification in about one third of cases, with subsequent treatment modifications. SBCE may provide a definite diagnosis, enhance the comprehension of the disease's progression, and optimize the short- and long-term management strategy.

Middle small-bowel segment Lewis score may predict long-term outcomes among patients with quiescent Crohn's disease

Background

Video capsule endoscopy (VCE) has been proven to accurately diagnose small-bowel inflammation and predict flares among patients with quiescent Crohn's disease (CD). However, data regarding its predictive role in this population over an extended follow-up are scarce.

Objectives

To predict clinical exacerbation and to assess the yield of Lewis score in identifying CD patients with future clinical exacerbation during an extended follow-up (>24 months).

Design

A post hoc analysis study.

Methods

Adult patients with quiescent small-bowel CD who were followed with VCE, inflammatory biomarkers and magnetic resonance enterography in a prospective study (between 2013 and 2018). We extracted extended clinical data (up to April 2022). The primary composite outcome (i.e. clinical exacerbation) was defined as intestinal surgery, endoscopic dilation, CD-related admission, corticosteroid administration, or biological/immunomodulator treatment change during follow-up.

Results

Of the 61 patients in the study [median age 29 (24-37) years, male 57.4%, biologic treatment 46.7%], 18 patients met the primary outcome during an extended follow-up [median 58.0 (34.5-93.0) months]. On univariable analysis, complicated [hazard ratio (HR) 7.348, p = 0.002] and stricturing disease phenotype (HR 5.305, p = 0.001) were associated with higher risk for clinical exacerbation during follow-up. A baseline VCE middle small-bowel segment Lewis score (midLS) ⩾ 135 identified patients with future exacerbation [AUC (area under the curve) 0.767, 95% confidence interval (CI) 0.633-0.902, p = 0.001, HR 6.317, 93% negative predictive value], whereas the AUC of the conventional Lewis score was 0.734 (95% CI: 0.589-0.879, p = 0.004). Sensitivity analysis restricted to patients with either complicated (n = 34) or stricturing (n = 26) disease phenotype revealed that midLS still predicted clinical exacerbation during follow-up (AUC 0.747/0.753, respectively), in these patients.

Conclusion

MidLS predicts treatment failure in quiescent CD patients (median follow-up of 5 years) independently of disease phenotype.

Capsule Endoscopy in Inflammatory Bowel Disease: Panenteric Capsule Endoscopy and Application of Artificial Intelligence

Video capsule endoscopy (VCE) of the small-bowel has been proven to accurately diagnose small-bowel inflammation and to predict future clinical flares among patients with Crohn's disease (CD). In 2017, the panenteric capsule (PillCam Crohn's system) was introduced for the first time, enabling a reliable evaluation of the whole small and large intestines. The great advantage of visualization of both parts of the gastrointestinal tract in a feasible and single procedure, holds a significant promise for patients with CD, enabling determination of the disease extent and severity, and potentially optimize disease management. In recent years, applications of machine learning, for VCE have been well studied, demonstrating impressive performance and high accuracy for the detection of various gastrointestinal pathologies, among them inflammatory bowel disease lesions. The use of artificial neural network models has been proven to accurately detect/classify and grade CD lesions, and shorten the VCE reading time, resulting in a less tedious process with a potential to minimize missed diagnosis and better predict clinical outcomes. Nevertheless, prospective, and real-world studies are essential to precisely examine artificial intelligence applications in real-life inflammatory bowel disease practice.

Spatiotemporal analysis of small bowel capsule endoscopy videos for outcomes prediction in Crohn's disease

Background

Deep learning techniques can accurately detect and grade inflammatory findings on images from capsule endoscopy (CE) in Crohn's disease (CD). However, the predictive utility of deep learning of CE in CD for disease outcomes has not been examined.

Objectives

We aimed to develop a deep learning model that can predict the need for biological therapy based on complete CE videos of newly-diagnosed CD patients.

Design

This was a retrospective cohort study. The study cohort included treatment-naïve CD patients that have performed CE (SB3, Medtronic) within 6 months of diagnosis. Complete small bowel videos were extracted using the RAPID Reader software.

Methods

CE videos were scored using the Lewis score (LS). Clinical, endoscopic, and laboratory data were extracted from electronic medical records. Machine learning analysis was performed using the TimeSformer computer vision algorithm developed to capture spatiotemporal characteristics for video analysis.

Results

The patient cohort included 101 patients. The median duration of follow-up was 902 (354-1626) days. Biological therapy was initiated by 37 (36.6%) out of 101 patients. TimeSformer algorithm achieved training and testing accuracy of 82% and 81%, respectively, with an Area under the ROC Curve (AUC) of 0.86 to predict the need for biological therapy. In comparison, the AUC for LS was 0.70 and for fecal calprotectin 0.74.

Conclusion

Spatiotemporal analysis of complete CE videos of newly-diagnosed CD patients achieved accurate prediction of the need for biological therapy. The accuracy was superior to that of the human reader index or fecal calprotectin. Following future validation studies, this approach will allow for fast and accurate personalization of treatment decisions in CD.

Prospective Validation of the Lémann Index in Children: A Report From the Multicentre Image Kids Study

BACKGROUND

The Lémann Index [LI] and the recently updated LI are tools for measuring structural bowel damage in adults with Crohn's disease [CD] but have not been evaluated in children. We aimed to validate the updated LI in the prospective multicentre ImageKids study of paediatric CD.

METHODS

We included children with CD undergoing magnetic resonance enterography [MRE], pelvic magnetic resonance imaging [MRI] and ileocolonoscopy. Half were followed for 18 months, when MRE was repeated. Serum was collected for fibrosis-related proteomic markers. The LI was calculated by central readers from the MRE, ileocolonoscopy, physical examination and surgical data. Reliability and construct validity were assessed at baseline, while responsiveness and test-retest reliability were explored longitudinally.

RESULTS

In total, 240 children were included (mean age, 14.2 ± 2.5 years; median disease duration, 2.2 years [interquartile range, IQR 0.25-4.42]; median baseline LI, 4.23 [IQR 2.0-8.8]). The updated LI had excellent inter-observer reliability (interclass correlation coefficient [ICC] = 0.94, 95% confidence interval [CI] 0.92-0.95) but poor, although statistically significant, correlation with radiologist and gastroenterologist global assessments of damage and with serum proteomic levels of fibrotic markers [rho = 0.15-0.30, most p < 0.05]. The updated LI had low discriminative validity for detecting damage (area under the receiver operating characteristic curve [AUC-ROC] 0.69, 95% CI 0.62-0.75). In 116 repeated MREs, responsiveness was suboptimal for differentiating improved from unchanged disease [AUC-ROC 0.58, 95% CI 0.45-0.71]. Test-retest reliability was high among stable patients [ICC = 0.84, 95% CI 0.72-0.91].

CONCLUSION

Overall, the updated LI had insufficient psychometric performance for recommending its use in children. An age-specific index may be needed for children with shorter disease duration than typical adult cohorts.

Development and validation of a deep learning-based approach to predict the Mayo endoscopic score of ulcerative colitis

Background

The ulcerative colitis (UC) Mayo endoscopy score is a useful tool for evaluating the severity of UC in patients in clinical practice.

Objectives

We aimed to develop and validate a deep learning-based approach to automatically predict the Mayo endoscopic score using UC endoscopic images.

Design

A multicenter, diagnostic retrospective study.

Methods

We collected 15120 colonoscopy images of 768 UC patients from two hospitals in China and developed a deep model based on a vision transformer named the UC-former. The performance of the UC-former was compared with that of six endoscopists on the internal test set. Furthermore, multicenter validation from three hospitals was also carried out to evaluate UC-former's generalization performance.

Results

On the internal test set, the areas under the curve of Mayo 0, Mayo 1, Mayo 2, and Mayo 3 achieved by the UC-former were 0.998, 0.984, 0.973, and 0.990, respectively. The accuracy (ACC) achieved by the UC-former was 90.8%, which is higher than that achieved by the best senior endoscopist. For three multicenter external validations, the ACC was 82.4%, 85.0%, and 83.6%, respectively.

Conclusions

The developed UC-former could achieve high ACC, fidelity, and stability to evaluate the severity of UC, which may provide potential application in clinical practice.

Registration

This clinical trial was registered at the ClinicalTrials.gov (trial registration number: NCT05336773).

Video Capsule Endoscopy Plays an Important Role in the Management of Crohn's Disease

Crohn's disease (CD) is a chronic inflammatory disorder characterized by a transmural inflammation that may involve any part of the gastrointestinal tract. An evaluation of small bowel involvement, allowing recognition of disease extent and severity, is important for disease management. Current guidelines recommend the use of capsule endoscopy (CE) as a first-line diagnosis method for suspected small bowel CD. CE has an essential role in monitoring disease activity in established CD patients, as it can assess response to treatment and identify high-risk patients for disease exacerbation and post-operative relapse. Moreover, several studies have shown that CE is the best tool to assess mucosal healing as part of the treat-to-target strategy in CD patients. The PillCam Crohn's capsule is a novel pan-enteric capsule which enables visualization of the whole gastrointestinal tract. It is useful to monitor pan-enteric disease activity, mucosal healing and accordingly allows for the prediction of relapse and response using a single procedure. In addition, the integration of artificial intelligence algorithms has showed improved accuracy rates for automatic ulcer detection and the ability to shorten reading times. In this review, we summarize the main indications and virtue for using CE for the evaluation of CD, as well as its implementation in clinical practice.

Mucosal healing assessment in Crohn's disease with normalized iodine concentration from dual-energy CT enterography: comparison with endoscopy

OBJECTIVES

Mucosal healing (MH) is an important goal in the treatment of patients with Crohn's disease (CD). Noninvasive assessment of MH with normalized iodine concentration (NIC) is unknown.

METHODS

In this retrospective study, 94 patients with diagnosed CD underwent endoscopy and dual-energy CT enterography (DECTE) at the post-infliximab treatment review. Two radiologists reviewed DECTE images by consensus for assessing diseased bowel segments of the colon or terminal ileum, and the NIC was measured. Patients were divided into transmural healing (TH), MH and non-MH groups. The diagnostic performance of the MH and non-MH groups with clinical factors and NIC was assessed utilizing receiver operating characteristic (ROC) curve analysis.

RESULTS

Of the 94 patients included in our study, 8 patients achieved TH, 34 patients achieved MH, and 52 patients did not achieve MH at the post-IFX treatment review. The area under the ROC curve (AUC), sensitivity, specificity, and accuracy values were 0.929 (95% confidence interval [CI] 0.883-0.967), 0.853, 0.827, and 0.837, respectively, for differentiating MHs from non-MHs, and the optimal NIC threshold was 0.448. The AUC of the combined model for distinguishing MHs from non-MHs in CD patients, which was based on the NIC and calprotectin, was 0.964 (95% CI 0.935-0.987).

CONCLUSIONS

The normalized iodine concentration measurement in DECTE has good performance in assessment MH in patients with CD. Iodine concentration from DECTE can be used as a radiologic marker for MH.

Development and validation of a clinical radiomics nomogram to predict secondary loss of response to infliximab in Crohn's disease patients

Background

Infliximab (IFX) is the first-line treatment for Crohn's disease (CD). However, the secondary loss of response (LOR) is common in IFX therapy. Therefore, non-invasive assessment of LOR in CD patients is the goal pursued by clinicians.

Methods

A multicenter study involving 181 CD patients was conducted, with patients being split into a training cohort (n = 102), testing cohort (n = 45), and validation cohort (n = 34). The study evaluated various clinical factors to establish a clinical model, and a radiomics signature was constructed based on reproducible features from computed tomography enterography (CTE). Logistic regression modeling was used to create models based on the radiomics signature and significant clinical factors, with the receiver operating characteristic curve (ROC) used to compare their performance.

Results

The study found that 64 of the 181 CD patients included experienced secondary LOR. The radiomics signature performed well in predicting secondary LOR, showing good discrimination in the training cohort (AUC [area under the curve], 0.947; 95% confidence interval [CI], 0.910-0.976), the testing cohort (AUC, 0.860; 95% CI, 0.768-0.941), and the validation cohort (AUC, 0.921; 95% CI: 0.831-1.000). Decision curve analysis (DCA) demonstrated the clinical value of the radiomics nomogram.

Conclusions

The CTE-based radiomics model showed good performance in predicting secondary LOR in CD patients. The nomogram can help clinicians choose alternative biologics early for CD patients.

Evaluation of Crohn's Disease Small-Bowel Mucosal Healing Using Capsule Endoscopy and Usefulness of Leucine-Rich α2-Glycoprotein

Recently, the importance of achieving clinical and deep remissions with mucosal healing (MH) has been demonstrated as a therapeutic goal to avoid Crohn's disease (CD) surgical operations. Although ileocolonoscopy (CS) is considered the gold standard, there are increasing reports on the benefits of capsule endoscopy (CE) and serum leucine-rich α2-glycoprotein (LRG) for evaluating small-bowel lesions in CD. We evaluated the data of 20 patients with CD who underwent CE in our department between July 2020 and June 2021 and whose serum LRG level was measured within 2 months. Concerning the mean LRG value, there was no significant difference between the CS-MH and CS-non-MH groups. Conversely, the mean LRG level was 10.0 μg/mL in seven patients in the CE-MH group and 15.2 μg/mL in 11 patients in the CE-non-MH group with a significant difference between the two groups (p = 0.0025). This study's findings show that CE can sufficiently determine total MH in most cases, and LRG is useful for evaluating CD small-bowel MH because of its correlation with CE-MH. Furthermore, satisfying CS-MH criteria and a cut-off value of 13.4 μg/mL for LRG suggests its usefulness as a CD small-bowel MH marker, which could be incorporated into the treat-to-target strategy.

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.

Patency capsule: A novel independent predictor for long-term outcomes among patients with quiescent Crohn's disease

INTRODUCTION

Patency capsule (PC) is a recommended procedure to rule-out small-bowel stenosis before video capsule endoscopy (VCE). We examined future clinical outcomes among patients with failed-PC versus patients in whom PC had passed (passed-PC).

METHODS

A Post-hoc analysis of two prospective cohort studies of adult patients with quiescent small-bowel CD that underwent PC between 2013-2020. The primary composite-outcome was the need for intestinal-surgery or endoscopic-dilation during follow-up in patients with or without failed-PC.

RESULTS

A total of 190 patients were included (47-failed PC, 143-passed PC, median follow-up 34.12 months). Patients with a failed-PC had higher rates of the primary composite-outcome (21.3% vs. 1.4%, Hazard ratio [HR] 20.3, 95% confidence interval [CI] 4.4-93.7, p<0.001) and also secondary outcomes including intestinal-surgery (14.9% vs. 0.70%, p<0.001), endoscopic-dilation (14.9% vs. 0.70%, p<0.001), admissions (23.3% vs. 5.7%, p<0.001) and clinical-flares (43.9% vs. 27.7%, p=0.005) during follow-up compared with controls. Failed-PC was the only statistically significant factor for surgery and/or endoscopic-dilation, regardless of a B2/B3 phenotype at baseline. In sensitivity-analyses restricted only to patients with stricturing phenotype (n=73), failed-PC still predicted worse long-term composite-outcome (HR 8.68 95% CI 1.72-43.68, p=0.002). Of the 190 patients ingesting a PC, only one patient with a failed-PC had 48 hours of self-limiting mild symptoms.

DISCUSSION

Clinically-stable CD patients with failed-PC have worse long-term clinical outcomes than those without, independently of CD phenotype. Standalone PC may serve as a novel, safe and affordable prognostic examination, to identify patients with quiescent CD who have a higher risk for future worse clinical outcomes.

Endoscopic Postoperative Recurrence in Crohn's Disease After Curative Ileocecal Resection with Early Prophylaxis by Anti-TNF, Vedolizumab or Ustekinumab: A Real-World Multicentre European Study

BACKGROUND

Endoscopic-post-operative-recurrence [ePOR] in Crohn's disease [CD] after ileocecal resection [ICR] is a major concern. We aimed to evaluate the effectiveness of early prophylaxis with biologics and to compare anti-tumour necrosis factor [anti-TNF] therapy to vedolizumab [VDZ] and ustekinumab [UST] in a real-world setting.

METHODS

A retrospective multicentre study of CD-adults after curative ICR on early prophylaxis was undertaken. ePOR was defined as a Rutgeerts score [RS] ≥ i2 or colonic-segmental-SES-CD ≥ 6. Multivariable logistic regression was used to evaluate risk factors, and inverse probability treatment weighting [IPTW] was applied to compare the effectiveness between agents.

RESULTS

The study included 297 patients (53.9% males, age at diagnosis 24 years [19-32], age at ICR 34 years [26-43], 18.5% smokers, 27.6% biologic-naïve, 65.7% anti-TNF experienced, 28.6% two or more biologics and 17.2% previous surgery). Overall, 224, 39 and 34 patients received anti-TNF, VDZ or UST, respectively. Patients treated with VDZ and UST were more biologic experienced with higher rates of previous surgery. ePOR rates within 1 year were 41.8%. ePOR rates by treatment groups were: anti-TNF 40.2%, VDZ 33% and UST 61.8%. Risk factors for ePOR at 1 year were: past-infliximab (adjusted odds ratio [adj.OR] = 1.73 [95% confidence interval, CI: 1.01-2.97]), past-adalimumab [adj.OR = 2.32 [95% CI: 1.35-4.01] and surgical aspects. After IPTW, the risk of ePOR within 1 year of VDZ vs anti-TNF or UST vs anti-TNF was comparable (OR = 0.55 [95% CI: 0.25-1.19], OR = 1.86 [95% CI: 0.79-4.38]), respectively.

CONCLUSION

Prevention of ePOR within 1 year after surgery was successful in ~60% of patients. Patients treated with VDZ or UST consisted of a more refractory group. After controlling for confounders, no differences in ePOR risk were seen between anti-TNF prophylaxis and other groups.

Development, Validation, and Evaluation of the Pediatric Inflammatory Crohn's Magnetic Resonance Enterography Index From the ImageKids Study

BACKGROUND & AIMS

Cross-sectional imaging is important in the assessment of transmural inflammation in Crohn's disease (CD). Small bowel involvement is often more extensive in pediatric CD, requiring a panentering measuring tool. We undertook to develop a magnetic resonance enterography (MRE)-based index that would measure inflammation in all segments of the intestine, without rectal contrast.

METHODS

Children with CD underwent ileocolonoscopy and MRE and half were prospectively followed for 18 months when MRE was repeated. Item generation and reduction were performed by a Delphi panel of pediatric radiologists, a systematic literature review, a cross-sectional study of 48 MREs, and a steering committee. Formatting and weighting were performed using multivariate modeling adjusted by a steering committee. MREs were read locally and centrally. Reliability, validity, and responsiveness were determined using several clinimetric and psychometric approaches.

RESULTS

Thirty items were initially generated and reduced to 5 using regression analysis on 159 MREs: wall thickness, wall diffusion weighted imaging, ulcerations, mesenteric edema, and comb sign. In the validation cohort of 81 MREs, the weighted global PICMI correlated well with the radiologist global assessment (r = 0.85; P < .001) and with the simple endoscopic score in a subsample with ileocolonic disease (r = 0.63; P < .001). Interobserver and test-retest reliability were high (interclass correlation coefficients, 0.84; 95% confidence interval [CI], 0.79-0.87; and 0.81, 95% CI, 0.65-0.90, respectively; both P < .001). Excellent responsiveness was found at repeated visits (n = 116 MREs; area under the receiver operating characteristic curve 0.96; 95% CI, 0.93-0.99). Transmural healing was defined as PICMI ≤10 and response as a change of >20 points with excellent discriminative validity (area under the receiver operating characteristic curve = 0.96; 95% CI, 0.93-0.99).

CONCLUSIONS

The PICMI is a valid, reliable, and responsive index for assessing transmural inflammation in pediatric CD. It scores the entire bowel length and does not require intravenous contrast or rectal enema and, therefore, is suitable for use in children. (ClinicalTrials.gov, Number: NCT01881490.).

Key research questions for implementation of artificial intelligence in capsule endoscopy

BACKGROUND

Artificial intelligence (AI) is rapidly infiltrating multiple areas in medicine, with gastrointestinal endoscopy paving the way in both research and clinical applications. Multiple challenges associated with the incorporation of AI in endoscopy are being addressed in recent consensus documents.

OBJECTIVES

In the current paper, we aimed to map future challenges and areas of research for the incorporation of AI in capsule endoscopy (CE) practice.

DESIGN

Modified three-round Delphi consensus online survey.

METHODS

The study design was based on a modified three-round Delphi consensus online survey distributed to a group of CE and AI experts. Round one aimed to map out key research statements and challenges for the implementation of AI in CE. All queries addressing the same questions were merged into a single issue. The second round aimed to rank all generated questions during round one and to identify the top-ranked statements with the highest total score. Finally, the third round aimed to redistribute and rescore the top-ranked statements.

RESULTS

Twenty-one (16 gastroenterologists and 5 data scientists) experts participated in the survey. In the first round, 48 statements divided into seven themes were generated. After scoring all statements and rescoring the top 12, the question of AI use for identification and grading of small bowel pathologies was scored the highest (mean score 9.15), correlation of AI and human expert reading-second (9.05), and real-life feasibility-third (9.0).

CONCLUSION

In summary, our current study points out a roadmap for future challenges and research areas on our way to fully incorporating AI in CE reading.

Deep Learning Multi-Domain Model Provides Accurate Detection and Grading of Mucosal Ulcers in Different Capsule Endoscopy Types

Background and Aims: The aim of our study was to create an accurate patient-level combined algorithm for the identification of ulcers on CE images from two different capsules. Methods: We retrospectively collected CE images from PillCam-SB3′s capsule and PillCam-Crohn’s capsule. ML algorithms were trained to classify small bowel CE images into either normal or ulcerated mucosa: a separate model for each capsule type, a cross-domain model (training the model on one capsule type and testing on the other), and a combined model. Results: The dataset included 33,100 CE images: 20,621 PillCam-SB3 images and 12,479 PillCam-Crohn’s images, of which 3582 were colonic images. There were 15,684 normal mucosa images and 17,416 ulcerated mucosa images. While the separate model for each capsule type achieved excellent accuracy (average AUC 0.95 and 0.98, respectively), the cross-domain model achieved a wide range of accuracies (0.569–0.88) with an AUC of 0.93. The combined model achieved the best results with an average AUC of 0.99 and average mean patient accuracy of 0.974. Conclusions: A combined model for two different capsules provided high and consistent diagnostic accuracy. Creating a holistic AI model for automated capsule reading is an essential part of the refinement required in ML models on the way to adapting them to clinical practice.

Predicting Mucosal Healing in Crohn's Disease: A Nomogram Model Developed from a Retrospective Cohort

Purpose

Mucosal healing (MH) has become a therapeutic end point for Crohn's disease (CD). The purpose of this study was to identify potential risk factors responsible for a lower probability of mucosal healing in CD. It also aimed to create and validate a noninvasive tool for predicting mucosal healing in CD to aid clinical decision-making.

Patients and Methods

We established a derivation cohort diagnosed with CD, in which endoscopic examination was performed before and after treatment at the First Affiliated Hospital of Nanjing Medical University between January 2010 and June 2021. Patient data including demographic and clinical characteristics and treatment details were collected. The achievement of mucosal healing (without ulceration on endoscopic examination) after treatment was the endpoint observed during follow-up. We performed logistic regression analysis to identify factors associated with mucosal healing. These factors were used to develop a model (CD mucosal healing prediction nomogram) to predict mucosal healing in CD. External validation was performed using a new cohort of 60 patients from the Second Affiliated Hospital of Soochow University between January 2012 and June 2021.

Results

A total of 331 patients were included in the derivation cohort. We found the following factors to be independently associated with mucosal healing after treatment: disease course <11 months, ulcer size <0.5 cm, Harvey-Bradshaw Index score <9, infliximab treatment, and non-exclusive use of 5-aminosalicylic acid. The model incorporating these factors achieved good discrimination, calibration, and clinical decision curve analysis results on internal validation (C-index: 0.788, 95% confidence interval [CI]: 0.74-0.84). The external validation cohort also demonstrated good discrimination (C-index: 0.785, 95% CI: 0.68-0.90) and calibration.

Conclusion

The CD mucosal healing prediction nomogram model demonstrated good reliability and validated. It can potentially be developed into a simple and clinically useful tool for predicting mucosal healing in CD.

Diagnostic significance of mesenteric lymph node involvement in proximal small bowel Crohn's disease

BACKGROUND

The diagnosis of proximal small bowel involvement in Crohn's disease (CD) can be challenging at magnetic resonance enterography (MRE). The inflammatory process in CD can be associated with peri-intestinal inflammatory reactions, including the presence of inflamed mesenteric lymph nodes.

OBJECTIVES

To evaluate the significance of inflamed mesenteric lymph nodes adjacent to the jejunum at MRE in CD and the association with proximal bowel disease as detected by video capsule endoscopy (VCE).

DESIGN

This retrospective study was performed in two tertiary medical centres, and included 64 patients with CD who underwent MRE as well as VCE within 1 year.

METHODS

Data were collected for examinations performed between August 2013 and February 2021. MRE images were independently reviewed by radiologists who were blinded to the clinical data. Association between the presence of mesenteric lymph nodes adjacent to jejunum at MRE and disease activity according to VCE Lewis scores of proximal small bowel was examined.

RESULTS

VCE detected proximal disease in 24/64 patients (37.5%). Presence of regional lymph nodes in the jejunal mesentery was significantly associated with jejunal disease as seen on VCE (p < 0.001). Of the 20 patients who had proximal mesenteric lymph nodes at MRE, 15 (75%) had jejunal disease at VCE (sensitivity, 62.5%; specificity, 87.5%; and negative and positive predictive values, 79.5 and 75%, respectively). The number of regional lymph nodes was positively correlated with jejunal disease (mean: 2.63 ± 2.90 versus 0.78 ± 2.60, p = 0.01). Other MRE features of lymph nodes were not significantly predictive of jejunal CD.

CONCLUSION

In patients with CD, inflamed regional lymph nodes in the jejunal mesentery at MRE can be valuable to suggest proximal small bowel disease, even when bowel wall features at imaging do not suggest disease involvement.

PLAIN LANGUAGE SUMMARY

The diagnosis of proximal small bowel involvement in Crohn's disease (CD) can be challenging at magnetic resonance enterography (MRE). We analysed MRE examinations in patients with CD for the presence of lymph nodes adjacent to the proximal small bowel. We included 64 patients with CD who had MRE examinations and video capsule endoscopy (VCE) examinations within 1 year. Of 64 patients, 24 had proximal small bowel disease according to VCE. We found that of 20 patients who had regional mesenteric lymph nodes in the jejunal mesentery at MRE, 15 had proximal bowel disease involvement. We also found that patients with jejunal disease had a larger number of regional lymph nodes compared to patients without jejunal disease. All but one patient had normal appearing bowel at MRE. But, using regional mesenteric lymphadenopathy at MRE as an indicator for disease, 15/24 (62.5%) patients with proximal small bowel disease were detected. We therefore conclude that regional mesenteric lymph nodes assessment at MRE can aid diagnose proximal bowel disease, even when the proximal bowel looks normal at imaging. Presence of proximal mesenteric lymph nodes at MRE in patients with CD possibly warrant further investigation of the proximal small bowel by endoscopic measures.

Clinical implication of radiologic complete remission on Crohn's Disease: Compared with endoscopic remission

OBJECTIVES

To determine the clinical implications of radiologic complete remission (CR) in Crohn's disease (CD) evaluated by computed tomography (CT) or magnetic resonance enterography (MRE) in comparison with endoscopic CR.

METHODS

Twenty-five CD patients who achieved endoscopic CR after medical treatment were retrospectively enrolled in this study. All patients underwent ileocolonoscopy, CT, or MRE at baseline, at the time of endoscopic CR, and during follow-up. Two radiologists assessed the mural and perienteric abnormalities on pre- and post-treatment CT or MRE in consensus. Patients were divided into radiologic CR and non-CR groups at the time of endoscopic CR. CD recurrence during subsequent follow-up periods was evaluated using clinical, laboratory, and CT/MRI findings. Statistical analysis was performed to assess whether there were significant differences in patient outcomes between the groups.

RESULTS

At the time of endoscopic CR, nine patients (mean age, 36.6 years) showed normalization of all radiologic features and were designated as the radiologic CR group. However, 16 patients (mean age: 32.9 years) showed residual CT/MRE abnormalities, suggesting persistent active inflammation, and were designated as the radiologic non-CR group. During follow-up, there was a significant difference between the groups regarding clinical outcomes (deep CR, 8/9 vs 5/16, P = 0.011; CD recurrence, 1/9 vs 14/16, P < 0.001). The mean fecal calprotectin level was significantly lower in the radiologic CR group (287.5 ug/g) than in the non-CR group (652.4 ug/g) (P = 0.023).

CONCLUSIONS

Radiologic CR can represent a better therapeutic endpoint in CD, showing superiority over endoscopic CR in predicting both clinical and biochemical outcomes.

Mechanisms of mucosal healing: treating inflammatory bowel disease without immunosuppression?

Almost all currently available treatments for inflammatory bowel disease (IBD) act by inhibiting inflammation, often blocking specific inflammatory molecules. However, given the infectious and neoplastic disease burden associated with chronic immunosuppressive therapy, the goal of attaining mucosal healing without immunosuppression is attractive. The absence of treatments that directly promote mucosal healing and regeneration in IBD could be linked to the lack of understanding of the underlying pathways. The range of potential strategies to achieve mucosal healing is diverse. However, the targeting of regenerative mechanisms has not yet been achieved for IBD. Stem cells provide hope as a regenerative treatment and are used in limited clinical situations. Growth factors are available for the treatment of short bowel syndrome but have not yet been applied in IBD. The therapeutic application of organoid culture and stem cell therapy to generate new intestinal tissue could provide a novel mechanism to restore barrier function in IBD. Furthermore, blocking key effectors of barrier dysfunction (such as MLCK or damage-associated molecular pattern molecules) has shown promise in experimental IBD. Here, we review the diversity of molecular targets available to directly promote mucosal healing, experimental models to identify new potential pathways and some of the anticipated potential therapies for IBD.

Mechanisms of mucosal healing: treating inflammatory bowel disease without immunosuppression?

Almost all currently available treatments for inflammatory bowel disease (IBD) act by inhibiting inflammation, often blocking specific inflammatory molecules. However, given the infectious and neoplastic disease burden associated with chronic immunosuppressive therapy, the goal of attaining mucosal healing without immunosuppression is attractive. The absence of treatments that directly promote mucosal healing and regeneration in IBD could be linked to the lack of understanding of the underlying pathways. The range of potential strategies to achieve mucosal healing is diverse. However, the targeting of regenerative mechanisms has not yet been achieved for IBD. Stem cells provide hope as a regenerative treatment and are used in limited clinical situations. Growth factors are available for the treatment of short bowel syndrome but have not yet been applied in IBD. The therapeutic application of organoid culture and stem cell therapy to generate new intestinal tissue could provide a novel mechanism to restore barrier function in IBD. Furthermore, blocking key effectors of barrier dysfunction (such as MLCK or damage-associated molecular pattern molecules) has shown promise in experimental IBD. Here, we review the diversity of molecular targets available to directly promote mucosal healing, experimental models to identify new potential pathways and some of the anticipated potential therapies for IBD.

A novel clinical radiomics nomogram at baseline to predict mucosal healing in Crohn's disease patients treated with infliximab

OBJECTIVES

Mucosal healing (MH) is currently the gold standard in Crohn's disease (CD) management. Noninvasive assessment of MH in CD patients is increasingly a concern of clinicians.

METHODS

This retrospective study included 106 patients with confirmed CD who were divided into a training cohort (n = 73) and a testing cohort (n = 33). Patient demographics were evaluated to establish a clinical model. Radiomics features were extracted from computed tomography enterography (CTE) images. A radiomics signature was constructed, and a radiomics score (Rad-score) was calculated by using the radiomics signature-based formula. A clinical radiomics nomogram was then built by incorporating the Rad-score and significant clinical features. The diagnostic performance of the three models was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

Of the 106 patients with CD, 37 exhibited MH after 26 weeks of infliximab (IFX) treatment. The area under the ROC curve (AUC) of the clinical radiomics nomogram for distinguishing MH from non-MH, which was based on the disease duration and Rad-score, was 0.880 (95% confidence interval [CI]: 0.809-0.943) in the training cohort and 0.877 (95% CI: 0.745-0.983) in the testing cohort. Decision curve analysis (DCA) confirmed the clinical utility of the clinical radiomics nomogram.

CONCLUSIONS

This is a preliminary study suggesting that this CTE-based radiomics model has potential value for predicting MH in CD patients. A nomogram constructed by combining radiomics signatures and clinical features can help clinicians select appropriate therapeutic strategies for CD patients.

KEY POINTS

• The disease duration (odds ratio (OR) = 0.969, 95% confidence interval (CI) = 0.943-0.995, p = 0.021) was an independent predictor of MH in the clinical model. • The AUC of the radiomics model constructed by the five radiomics features was 0.846 (95% CI: 0.759-0.921) in the training cohort and 0.817 (95% CI: 0.665-0.945) in the testing cohort for differentiating MH from non-MH. • The AUC of the clinical radiomics nomogram was 0.880 (95% CI: 0.809-0.943) in the training cohort and 0.877 (95% CI: 0.745-0.983) in the testing cohort for distinguishing MH from non-MH.

The Impact of Intestinal Ultrasound on the Management of Inflammatory Bowel Disease: From Established Facts Toward New Horizons

Intestinal ultrasound (IUS) plays a crucial role as a non-invasive and accurate tool to diagnose and assess inflammatory bowel disease (IBD). The rationale for using IUS in Crohn’s disease (CD), a transmural disease, is widely acknowledged. While the use of IUS in ulcerative colitis (UC), a mucosal disease, is often underestimated, but, recently, it is increasingly expanding. In the context of a treat-to-target approach, the role of IUS is shifting toward a monitoring tool for predicting response to therapy. Hence, adjusting therapeutic strategies based on IUS response could reduce the burden related to endoscopy and speed the decision process with the ultimate goal to alter the natural course of IBD. Assessment of bowel wall thickness (BWT) is the most reliable IUS measure. However, the development of validated and reproducible sonographic scores to measure disease activity and the identification of parameters of therapeutic response remain relevant issues to implement the daily adoption of IUS in clinical practice. Accordingly, this review focuses on the current literature investigating the impact of IUS on CD with emphasis on the concept of transmural healing (TH) and the main related advantages. We further explore new insights on the role of IUS in UC and its clinical implications.

Serum Leucine-Rich Alpha-2 Glycoprotein in Quiescent Crohn's Disease as a Potential Surrogate Marker for Small-Bowel Ulceration detected by Capsule Endoscopy

Background: Small bowel (SB) lesions in quiescent Crohn’s disease (CD) are sometimes not identified by clinical activity or existing markers. We investigated the usefulness of a novel biomarker, leucine-rich α2-glycoprotein (LRG), for screening for the presence of SB ulcerative lesions detected by small-bowel capsule endoscopy (SBCE). Methods: We examined patients with a Crohn’s Disease Activity Index (CDAI) value < 150 and a C-reactive protein (CRP) value < 0.5 mg/dL with SB or SB colonic CD. The presence of small-bowel ulcerative lesions (≥0.5 cm) was grouped by SBCE results, and we then compared the groups’ LRG value to establish a cutoff value for screening for the presence of lesions. Results: In 40 patients with CD, the LRG values differed significantly between the patients with and without SB ulcerative lesions (Ul + 14.1 (2.1−16.5) μg/mL vs. Ul − 12.3 (9.3−13.5) μg/mL; p = 0.0105). The respective cutoff LRG values for the presence of SB ulcerative lesions was 14 μg/mL (areas under the ROC curve 0.77), with sensitivity 63.6%, specificity 82.8%, positive predictive values 58.3%, negative predictive values 85.7%, and accuracy 78%. Conclusion: These results indicate that LRG may be useful in predicting the presence of SB inflammation associated in patients with CD with CRP < 0.5 mg/dL and CDAI < 150, and in selecting patients for SBCE.

Apex Score: Predicting Flares in Small-Bowel Crohn's Disease After Mucosal Healing

BACKGROUND

Optimal strategies for using small-bowel capsule endoscopy (SBCE) in established small-bowel Crohn's disease (CD) remain uncertain. Mucosal healing (MH) has emerged as a valuable predictor of a flare-free disease. We aimed to evaluate the occurrence of disease flare on patients with small-bowel CD and MH, as well as to create a score identifying patients in higher risk for this outcome.

METHODS

We analyzed consecutive patients submitted to SBCE for assessment of MH and included those where MH was confirmed. The incidence of disease flare was assessed during follow-up (minimum 12 months). A score predicting disease flare was created from several analyzed variables.

RESULTS

From 47 patients with MH, 12 (25.5%) had a flare (versus 48.3% in excluded patients without MH; p = 0.01). Age ≤ 30 years (OR  = 70; p  = 0.048), platelet count ≥ 280 × 10³/L (OR  = 12.24; p  =  0.045) and extra-intestinal manifestations (OR  =  11.76; p  =  0.033) were associated with increased risk of CD flare during the first year after SBCE with MH. These variables were used to compute a risk-predicting score-the APEX score-which assigned the patients to having low (0-3 points) or high-risk (4-7 points) of disease flare and had excellent accuracy toward predicting disease relapse (AUC  =  0.82; 95%CI 0.64-0.99).

CONCLUSION

Patients with small-bowel CD and MH were not free of disease flares on the subsequent year, despite presenting lower rates when compared to those without MH. The APEX score demonstrated excellent accuracy at stratifying patients relapse risk and guiding further therapeutic options for patients achieving MH.

Artificial intelligence for endoscopy in inflammatory bowel disease

Inflammatory bowel disease (IBD), with its 2 subtypes, Crohn's disease and ulcerative colitis, is a complex chronic condition. A precise definition of disease activity and appropriate drug management greatly improve the clinical course while minimizing the risk or cost. Artificial intelligence (AI) has been used in several medical diseases or situations. Herein, we provide an overview of AI for endoscopy in IBD. We discuss how AI can improve clinical practice and how some components have already begun to shape our knowledge. There may be a time when we can use AI in clinical practice. As AI systems contribute to the exact diagnosis and treatment of human disease, we should continue to learn best practices in health care in the field of IBD.

Identification of Ulcers and Erosions by the Novel Pillcam™ Crohn's Capsule Using a Convolutional Neural Network: A Multicentre Pilot Study

BACKGROUND AND AIMS

Capsule endoscopy is a central element in the management of patients with suspected or known Crohn's disease. In 2017, PillCam™ Crohn's Capsule was introduced and demonstrated to have greater accuracy in the evaluation of extension of disease in these patients. Artificial intelligence [AI] is expected to enhance the diagnostic accuracy of capsule endoscopy. This study aimed to develop an AI algorithm for the automatic detection of ulcers and erosions of the small intestine and colon in PillCam™ Crohn's Capsule images.

METHODS

A total of 8085 PillCam™ Crohn's Capsule images were extracted between 2017 and 2020, comprising 2855 images of ulcers and 1975 erosions; the remaining images showed normal enteric and colonic mucosa. This pool of images was subsequently split into training and validation datasets. The performance of the network was subsequently assessed in an independent test set.

RESULTS

The model had an overall sensitivity and specificity of 90.0% and 96.0%, respectively. The precision and accuracy of this model were 97.1% and 92.4%, respectively. In particular, the algorithm detected ulcers with a sensitivity of 83% and specificity of 98%, and erosions with sensitivity and specificity of 91% and 93%, respectively.

CONCLUSION

A deep learning model capable of automatically detecting ulcers and erosions in PillCam™ Crohn's Capsule images was developed for the first time. These findings pave the way for the development of automatic systems for detection of clinically significant lesions, optimizing the diagnostic performance and efficiency of monitoring Crohn's disease activity.

Mucosal Healing in Crohn's Disease: Bull's Eye or Bust? The "Relative" Con Position

BACKGROUND

Crohn's disease is a progressive inflammatory bowel disease. Persistent untreated inflammation can cumulatively result in bowel damage in the form of strictures, fistulas, and fibrosis, which can ultimately result in the need for major abdominal surgery. Mucosal healing has emerged as an attractive, yet ambitious goal in the hope of preventing long-term complications.

SUMMARY

Clinical remission is an inadequate measure of disease activity. Noninvasive markers such as fecal calprotectin, CRP, or small bowel ultrasound are useful adjunct tools. However, endoscopic assessment remains the cornerstone in building a treatment plan. Achieving complete mucosal healing has proved to be an elusive goal even in the ideal setting of a clinical trial.

KEY MESSAGES

Aiming for complete mucosal healing in all patients may result in overuse of medications, higher costs, and potential side effects of aggressive immunosuppressive treatment. More practical goals such as relative or partial healing, for example, 50% improvement in inflammation and reduction in size of ulcers, ought to be considered, particularly in difficult-to-treat populations.

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

BACKGROUND

Capsule endoscopy (SBCE) has developed a relevant role in patients with established Crohn's Disease (CD). However, evaluation of the impact in clinical management has been scarce.

AIMS

To evaluate therapeutic impact of SBCE in an 11-year real-life cohort of known CD patients.

METHODS

Retrospective single center study including all patients with established CD submitted to SBCE procedure from 01/01/2008 to 31/12/2019. Patency capsule was used in selected patients. Small bowel mucosal inflammation was quantified using Lewis score. Therapeutic impact was defined as a change in CD-related treatment recommended based on SBCE results. Patients were assigned to four groups regarding SBCE indication: staging, flare, post-op and remission.

RESULTS

From the 432 SBCE performed 87.5% were conclusive. Active disease was present in 63.7 of patients; 41.6% mild inflammation and 21.9% moderate-to-severe activity. A change of management was guided by SBCE in 51.3% of procedures: 199 (46.1%) escalation and 23 (5.3%) de-escalation, with significant changes in all groups. Escalation increased with disease activity: 57.8% in mild and 89.5% in moderate-to-severe disease. De-escalation was conducted in 13.9% procedures with mucosal healing and 1.1% with mild disease.

CONCLUSION

SBCE is a useful tool for guiding therapeutic management in CD patients both for treatment escalation and de-escalation.

Assessment of a new score for capsule endoscopy in pediatric Crohn's disease (CE-CD)

Background and study aims  Two scores have been implemented to standardize capsule endoscopic (CE) findings in patients with Crohn's disease (CD): Lewis score (LS) and Capsule Endoscopy Crohn's Disease Activity Index (CECDAI). Both have limitations and are not well validated in the pediatric population. The aim of our study was to assess a new score (capsule endoscopy - Crohn's disease index, CE-CD) in pediatric patients with CD and to compare it to preexisting scores. Patients and methods  This was a double-center, retrospective study involving pediatric subjects with CD who underwent CE. Correlation analyses between CE-CD, endoscopy scores and noninvasive markers of disease activities were performed. The ability of different CE scores to predict clinical and endoscopic outcomes was evaluated with regression and survival analyses. Results  A total of 312 subjects were analyzed. The CE-CD score showed a moderate (Pearson's r = 0.581, P  < 0.001) and strong (r = 0.909, P  < 0.001) association with LS and CECDAI, respectively. CE-CD was a statistically significant predictor of hospitalization (hazard ratio [HR]1.061), treatment escalation (HR 1.062), steroid therapy (HR 1.082), clinical (HR 1.064) and endoscopic (HR 1.060) relapse over the twenty-four months ( P  < 0.001). Subjects with mucosal inflammation according to CE-CD (CE-CD ≥ 9) had worse outcomes compared to patients without inflammation (CE-CD < 9) (Log rang test < 0.001). Conclusions  The CE-CD score is a simple, reliable, reproducible, and predictive score for evaluation of small bowel inflammation in pediatric patients with CD. Prospective validation is needed to confirm the applicability of this new index in clinical practice.

Role of capsule endoscopy in inflammatory bowel disease: Anything new?

Capsule endoscopy (CE) is a recently developed diagnostic method for diseases of the small bowel that is non-invasive, safe, and highly tolerable. Its role in patients with inflammatory bowel disease has been widely validated in suspected and established Crohn’s disease (CD) due to its ability to assess superficial lesions not detected by cross-sectional imaging and proximal lesions of the small bowel not evaluable by ileocolonoscopy. Because CE is a highly sensitive but less specific technique, differential diagnoses that can simulate CD must be considered, and its interpretation should be supported by other clinical and laboratory indicators. The use of validated scoring systems to characterize and estimate lesion severity (Lewis score, Capsule Endoscopy Crohn’s Disease Activity Index), as well as the standardization of the language used to define the lesions (Delphi Consensus), have reduced the interobserver variability in CE reading observed in clinical practice, allowing for the optimization of diagnoses and clinical management strategies. The appearance of the panenteric CE, the incorporation of artificial intelligence, magnetically-guided capsules, and tissue biopsies are elements that contribute to CE being a promising, unique diagnostic tool in digestive tract diseases.

Implications of artificial intelligence in inflammatory bowel disease: Diagnosis, prognosis and treatment follow up

Driven by the tremendous availability of data, artificial intelligence (AI) using deep learning has emerged as a breakthrough computer technology in the last few decades and has recently been acknowledged by the Task Force on AI as a golden opportunity for research. With its ability to understand, learn from and build on non-linear relationships, AI aims to individualize medical care in an attempt to save time, cost, effort and improve patient’s safety. AI has been applied in multiple medical fields with substantial progress made in gastroenterology mainly to facilitate accurate detection of pathology in different disease processes, among which inflammatory bowel disease (IBD) seems to drag significant attention, specifically by interpreting imaging studies, endoscopic images and videos and -to a lesser extent- disease genomics. Moreover, models have been built to predict IBD occurrence, flare ups, persistence of histological inflammation, disease-related structural abnormalities as well as disease remission. In this article, we will review the applications of AI in IBD in the present medical literature at multiple points of IBD timeline, starting from disease prediction via genomic assessment, diagnostic phase via interpretation of radiological studies and AI-assisted endoscopy, and the role of AI in the evaluation of therapy response and prognosis of IBD patients.

Scoring systems in clinical small-bowel capsule endoscopy: all you need to know!

Capsule endoscopy (CE) emerged out of the pressing clinical need to image the small bowel (SB) in cases of midgut bleeding and provide an overall comfortable and reliable gastrointestinal (GI) diagnosis 1. Since its wider adoption in clinical practice, significant progress has been made in several areas including software development, hardware features and clinical indications, while innovative applications of CE never cease to appear 2 3. Currently, several manufacturers provide endoscopic capsules with more or less similar technological features 4. Although there is engaging and continuous academic and industry-fueled R&D, promising furtherment of CE technology 4 5, the current status of clinical CE remains that of by and large an imaging modality. Clinical relevance of CE images is cornerstone in the decision-making process for medical management. In one of the larger to date SB CE studies, 4,206 abnormal images were detected in 3,280 patients 6. Thus, CE leads to the identification of a large amount of potential pathology, some of which are pertinent (or relevant) while some (probably the majority) are not.

Soon artificial intelligence (AI) is likely to carry out several roles currently performed by humans; in fact, we are witnessing only the first stages of a transition in the clinical adoption of AI-based solutions in several aspects of gastroenterology including CE 7. Until then though, human-based decision-making profoundly impacts patient care and – although not suggested in the updated European Society of Gastrointestinal Endoscopy (ESGE) European curriculum 8 9 – it should be an integral part of CE training. Frequently, interpretation of CE images by experts or at least experienced readers differs. In a tandem CE reading study, expert review of discordant cases revealed a 50 % (13/25 discordant results) error rate by experienced readers, corresponding (in 5/13 cases) to ‘over-classification’ of an irrelevant abnormality 10. Another comparative study showed an ‘over-classification’ of such irrelevant abnormalities in ~10 % of CE readings 11. One thing which has been for a while on the table – in relation to optimizing and/or standardizing CE reporting and subsequent decision-making – is the need for reproducible scoring systems and for a reliable common language among clinicians responsible for further patient’s management.

Over the years, several of these scoring systems were developed while others appear in the wake of software and hardware improvements aiming to replace and/or complement their predecessors. This review presents a comprehensive account of the currently available classification/scoring systems in clinical CE spanning from predicting the bleeding potential of identified SB lesions (with emphasis on vascular lesions), and the individual rebleeding risk; scoring systems for the prediction of SB lesions in patients with obscure gastrointestinal bleeding (OGlB), having the potential to improve patient selection and rationalize the use of enteroscopy, with better allocation of resources, optimized diagnostic workflow and tailored treatment. This review also includes scores for reporting the inflammatory burden, the cleansing level that underscores confidence in CE reporting and the mass or bulge question in CE. Essentially, the aim is to become a main text for reference when scoring is required and facilitate the inclusion of -through readiness of access- one of the other in the final report.

Automated Detection of Crohn's Disease Intestinal Strictures on Capsule Endoscopy Images Using Deep Neural Networks

BACKGROUND AND AIMS

Passable intestinal strictures are frequently detected on capsule endoscopy [CE]. Such strictures are a major component of inflammatory scores. Deep neural network technology for CE is emerging. However, the ability of deep neural networks to identify intestinal strictures on CE images of Crohn's disease [CD] patients has not yet been evaluated.

METHODS

We tested a state-of-the-art deep learning network for detecting CE images of strictures. Images of normal mucosa, mucosal ulcers, and strictures of Crohn's disease patients were retrieved from our previously described CE image bank. Ulcers were classified as per degree of severity. We performed 10 cross-validation experiments. A clear patient-level separation was maintained between training and testing sets.

RESULTS

Overall, the entire dataset included 27 892 CE images: 1942 stricture images, 14 266 normal mucosa images, and 11 684 ulcer images [mild: 7075, moderate: 2386, severe: 2223]. For classifying strictures versus non-strictures, the network exhibited an average accuracy of 93.5% [±6.7%]. The network achieved excellent differentiation between strictures and normal mucosa (area under the curve [AUC] 0.989), strictures and all ulcers [AUC 0.942], and between strictures and different grades of ulcers [for mild, moderate, and severe ulcers-AUCs 0.992, 0.975, and 0.889, respectively].

CONCLUSIONS

Deep neural networks are highly accurate in the detection of strictures on CE images in Crohn's disease. The network can accurately separate strictures from ulcers across the severity range. The current accuracy for the detection of ulcers and strictures by deep neural networks may allow for automated detection and grading of Crohn's disease-related findings on CE.

The utility of faecal and urine biomarkers for small bowel diseases

PURPOSE OF REVIEW

Small bowel diseases pose a unique diagnostic and management challenge and often requires tertiary specialist referral. The use of biomarkers may provide a cheap, noninvasive tool to assess the small bowel in terms of diagnosis, offering a better way to triage referrals and select patients for early management. This review looks at the most recent evidence behind the use of several faecal and urine biomarkers for small bowel diseases.

RECENT FINDINGS

Faecal calprotectin shows the most promise, with evidence to support its role in predicting relapse postsurgery and monitoring treatment response in patients with Crohn's disease. A faecal calprotectin less than 50 μg/g may also be used as a cut-off to triage further investigation. Faecal lactoferrin also appears promising as a marker of small bowel inflammation. A positive faecal immunohistochemistry test precapsule may help to prioritize referrals for obscure bleeding.

SUMMARY

The use of biomarkers in the diagnosis and management of small bowel disease is still controversial and remains unclear. More studies are required to further develop their potential and before societal guidelines can be developed to direct their appropriate use in clinical practice.

Rediscovering histology: what is new in endoscopy for inflammatory bowel disease?

The potential of endoscopic evaluation in the management of inflammatory bowel diseases (IBD) has undoubtedly grown over the last few years. When dealing with IBD patients, histological remission (HR) is now considered a desirable target along with symptomatic and endoscopic remission, due to its association with better long-term outcomes. Consequently, the ability of endoscopic techniques to reflect microscopic findings in vivo without having to collect biopsies has become of upmost importance. In this context, a more accurate evaluation of inflammatory disease activity and the detection of dysplasia represent two mainstay targets for IBD endoscopists. New diagnostic technologies have been developed, such as dye-less chromoendoscopy, endomicroscopy, and molecular imaging, but their real incorporation in daily practice is not yet well defined. Although dye-chromoendoscopy is still recommended as the gold standard approach in dysplasia surveillance, recent research questioned the superiority of this technique over new advanced dye-less modalities [narrow band imaging (NBI), Fuji intelligent color enhancement (FICE), i-scan, blue light imaging (BLI) and linked color imaging (LCI)]. The endoscopic armamentarium might also be enriched by new video capsule endoscopy for monitoring disease activity, and high expectations are placed on the application of artificial intelligence (AI) systems to reduce operator-subjectivity and inter-observer variability. The goal of this review is to provide an updated insight on contemporary knowledge regarding new endoscopic techniques and devices, with special focus on their role in the assessment of disease activity and colorectal cancer surveillance.